4290*24290*2INFECTION

CONTROL QUESTIONS
Question 1
The nurse is caring for a client who is receiving the first dose of a newly prescribed intravenous
antibiotic. Which finding observed by the nurse would indicate an allergic reaction?
A Development of oral thrush
B A decrease in heart rate from 80 to 72
C Development of swelling in the lips
D An increase in systolic blood pressure from 102 to 115

Question Explanation
CORRECT ANSWER is C
Rationale: A sign of allergic reaction is swelling of the lips, mouth, and tongue. Other symptoms
include the development of tachycardia and hypotension. Oral thrush, or candidiasis, is a yeast
infection that can develop when a client is taking antibiotics.

Question 2
The charge nurse is observing a newly hired nurse use a fire extinguisher for a small fire in a
client’s room. Which action by the newly hired nurse would require intervention by the charge
nurse?
AAiming the hose at the top of the fire
B Pulling out the fire extinguisher’s safety pin
C Squeezing the handle to discharge material onto the fire
D Sweeping the hose from side to side until the fire is extinguished

Question Explanation
ANSWER is A
Rationale: Correct technique for use of a fire extinguisher includes pulling out the safety pin,
aiming the hose at the base of the fire, squeezing the handle to discharge the material, and
sweeping the hose from side to side. It requires intervention if the nurse is observed aiming the
hose at the top of the fire instead of the base.

Question 3
A nurse is providing teaching to a client who reports mild hearing impairment associated with
aging. Which action will promote client understanding of the instructions?
A Repeating the instructions to the client several times
B Sitting at eye-level in front of the client
C Speaking very loudly to the client
D Providing all instructions to the client in writing

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Question Explanation
Correct answer is B
Rationale: Clients with a hearing impairment benefit from lip reading and facial cues. Sitting
close enough to the client will promote effective communication. Repeating the instructions
several times may not guarantee understanding. Lack of client feedback may require rewording
of the instructions. Speaking very loudly to the client does not promote effective communication.
Clients with a hearing impairment benefit from visual cues, not a higher pitched voice. Providing
all instructions to the client in writing does not promote therapeutic communication. The nurse
should not assume the client is unable to communicate.

Question 4
A nurse is reviewing the medical record for a client with a urethral stricture. Which prescription
should the nurse clarify with the healthcare provider?
A Monitor intake and output
B Schedule a pelvic ultrasound
C Obtain a urine sample
D Insert an indwelling catheter

Question Explanation
Correct Answer is D
Rationale: A urethral stricture is a narrowing of the urethra that restricts the flow of urine from
the bladder. Insertion of an indwelling catheter may cause further trauma to the urethra if the
stricture has not been dilated. Strict intake and output is not an invasive procedure and cannot
cause harm to the client. A pelvic ultrasound is an expected diagnostic procedure to visualize the
volume of urine present in the bladder. A urinalysis is an expected prescription to assess for
signs of infection or blood in the urine.

Question 5
The nurse is reviewing the plan of care with a client who has a prescription to remain supine for
24 hours following a procedure. Which statement should the nurse make to the client regarding
positioning?
A “Keep your knees flexed.”
B “Place a pillow under your legs.”
C “Rotate your hips side to side to relieve pressure.”
D “Raise your arms over your head to stretch.”

Question Explanation
Correct Answer is B
Rationale: When caring for a client with a prescription for the supine position, the nurse should
implement interventions to prevent pressure injuries. The supine position increases pressure on
the client’s heels and coccyx. To alleviate this pressure, the nurse should instruct the client to
keep a pillow under their legs, this will float the heels off the bed and prevent pressure.
Instructing the client to keep knees flexed will increase pressure on heels. Raising arms above
the head does not reduce pressure. Rotating hips can increase pressure.

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Question 6
A nurse is implementing seizure precautions for a client with tonic-clonic seizures. Which action
should the nurse take?
A Raise all side rails on the bed
B Instruct client to ambulate slowly to the restroom
C Ensure patency of the saline lock
D Position the overbed table in front of the client

Question Explanation
Correct Answer is C
Rationale: Clients with tonic-clonic seizures are at risk for injury due to rhythmic jerking of the
extremities and changes in breathing patterns. The nurse should ensure intravenous access is
patent in case pharmacologic treatment is required. Raising all of the siderails is considered a
restraint. Clients should be instructed to call for assistance with ambulation. The client may fall
and injure themselves during a seizure. Positioning the overbed table in front of the client can
cause injury if the client experiences a seizure.

Question 7
A nurse is verifying a prescription for an intravenous antibiotic on the client’s electronic medical
record. Before administering the medication, which action will the nurse perform first?
A Disinfect the injection port on the intravenous line
B Program the infusion pump with the prescribed rate
C Flush the intravenous line with normal saline
D Scan the bar code on the client’s wristband

Question Explanation
Correct Answer is D
Rationale: Client identification should occur before performing interventions. The client’s bar
code can be used as one identifier. Two identifiers are required. Disinfecting the injection port
should be done after the client is identified. Programming the infusion pump is a step performed
after the nurse verifies the client’s identity. Flushing the intravenous line with normal saline is
considered medication administration and cannot occur until the client has been properly
identified.

Question 8
The charge nurse is required to recommend a client that can be discharged in the next hour due to
a disaster plan activation. The nurse should recommend which client for discharge?
A A client post-laparoscopic cholecystectomy with a prescription for a soft diet
B A client with a comminuted pelvic fracture who is taking oral analgesics
C A client with atelectasis on oxygen via nasal cannula
D A client with a foot ulcer who is receiving intravenous antibiotics

Question Explanation
Correct Answer is A

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Rationale: A postoperative client who is tolerating oral intake is considered stable for discharge.
A laparoscopic cholecystectomy is minimally invasive, and clients are usually discharged within
a day. A client with a comminuted pelvic fracture cannot be mobilized until treated. A client with
atelectasis who requires oxygen therapy is not stable for discharge within an hour. A client
receiving intravenous antibiotics is not ready for discharge. Intravenous therapy requires care
management collaboration prior to discharge.

Question 9
The nurse is making client care assignments during a facility disaster drill. Which action by the
nurse indicates correct understanding of assignments during a disaster?
A Assigning a nursing administrator to care for clients in the post-anesthesia care unit
B Assigning a nurse on the medical-surgical floor to perform triage on disaster victims in the
emergency department
C Assigning a critical care nurse to care for emergent clients in the emergency department
D Assigning unlicensed assistive personnel to monitor a group of clients on a medical-surgical
floor

Question Explanation
Correct Answer is C
Rationale: Mass casualty events often require nurses to practice outside of their normal daily
duties. Nursing administrators may be assigned to client care on units; however, they should be
assigned to stable, predictable clients. Clients who are immediately post-operative in the post-
anesthesia unit are in critical condition and should not be assigned to the nursing administrator.
Nurses on the medical-surgical floor may be assigned to care for stable clients in the emergency
department so that emergency room nurses can perform triage on critical patients. Critical care
nurses may be reassigned to care for critical patients in the emergency department. Unlicensed
assistive personnel cannot perform regular nursing assessments or interventions even in a
disaster situation and should not be assigned to monitor or manage a group of medical-surgical
clients.

Question 10
The nurse is providing an in-service to the nursing staff on needlestick prevention using needle-
based safety systems. Which of the following actions should the nurse demonstrate when placing
the syringe with a needle in the sharps container?
A Recap the needle using the one-handed method
B Immediately engage the safety shield
C Leave the needle uncapped
D Remove the used needle using a needle clipper

Question Explanation
Correct Answer is B
Rationale: Needle based safety systems have a one-handed safety mechanism built into the
device. They should be engaged immediately after use. If the needle does not have a safety
device, the safest way to dispose of a used needle is to immediately place it in a sharps disposal
container. If a sharps disposal container isn’t immediately available, recap the needle. Do not
bend or break the needle and never remove a hypodermic needle from the syringe by hand.
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Recapping should be performed using the one-handed technique. Needle clippers make syringes
unusable by clipping off the needle and are not used by nurses.

Question 11
The nurse is interviewing an older adult client in the outpatient clinic about home safety. Which
statement by the client indicates the need for intervention?
A “My toilet has a raised seat on it.”
B “I like to keep the lighting low because it hurts my eyes.”
C “I wear non-slip socks when I am walking around the house.”
D “My son installed a handrail next to my toilet.”

Question Explanation
Correct Answer is B
Rationale: Low lighting increases the risk of falling, therefore the nurse should educate the client
on the need to increase light brightness or add lighting to the home. A raised toilet seat, non-slip
socks, and handrails are all appropriate safety devices.

Question 12
The nurse is educating a client who has age related macular degeneration on home safety
practices. Which of the following statements is appropriate?
A “Ask for written instructions for your medications.”
B “Keep lights in your home dim to avoid glare.”
C “Color-code the controls on your kitchen appliances.”
D “Watch television with closed captions.”

Question Explanation
Correct Answer is C
Rationale: Color-coding kitchen appliance controls helps to ensure that the client is able to
operate the appliances safely. An example of this is stove burner knobs; turning on the incorrect
burner increases the risk of burns and fire. Lights should be bright, and written materials such as
medication education and closed captions may be difficult for the client to read and should be
avoided.

Question 13
The nurse is assessing a client’s room for safety hazards. Which finding observed by the nurse
would increase the client’s risk for falls?
A The client’s side rails are raised on all sides of the bed.
B The client has a nonskid mat in the shower.
C The bed exit alarm is activated on the client’s bed.
D The client’s ambulatory aid is next to the client’s bed.

Question Explanation
Correct Answer is A
Rationale: Raising all side rails on a bed has been shown to increase the risk of client falls
because clients may become entrapped and unable to get out of bed. If a client is at risk for falls,

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side rails are often not used at all and beds are fully lowered, and padding is placed on the floor
along the sides of the bed. Nonskid mats in the shower, bed exit alarms, and keeping client
ambulatory aids within easy reach are all correct techniques to reduce the risk of falls.

Question 14

A dayshift nurse administered insulin aspart to a client at 0730. The nightshift nurse calls stating
they forgot to document the administration of the same medication to the client at 0630. Which
action does the nurse perform next?
A Provide the client with a cup of juice.
B Fill out an incident report.
C Check the client’s capillary blood glucose.
D Notify the healthcare provider.

Question Explanation
Answer is C
Rationale: The nurse's priority action is to assess the client for hypoglycemia due to the
administration of a double dose of insulin. Insulin aspart is a rapid-acting insulin that can
decrease glucose levels. Providing the client with a cup of juice is an intervention for correcting
hypoglycemia. The nurse must first assess the client’s glucose level. Filling out an incident
report is important for quality improvement. However, it is not the priority action. Notifying the
healthcare provider is important. However, the nurse must first assess the client’s condition.

Question 15
A charge nurse is performing the daily check of the code cart on the unit. Which finding will the
nurse report immediately for further inspection?
A The oxygen tank is empty
B The defibrillator charging light is off
C One of the wheels on the cart does not lock
D The last inspection is not signed

Question Explanation
Correct Answer is B
Rationale: A defibrillator should always be fully charged in case of emergencies. Drained
batteries can result in equipment failure. The oxygen tank is required for transport. However, the
tank can be replaced with a full tank from the unit. The wheel locks prevent the crash cart from
moving. Although the wheel needs to be inspected, it is not a priority action. Inspection
signatures are important for quality improvement and documentation. However, ensuring the
defibrillator is charged is the priority.

Question 16
The nurse is caring for a client receiving an intravenous infusion using a smart pump when a
system error begins alarming. Which action by the nurse will reduce the risk of injury to the
client?
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A Tag the device for maintenance and remove it from the unit
B Power down and restart the pump to clear the error
C Reposition the tubing in the infusion device to clear the alarm
D Place the plug in a red outlet to reduce the incidence of an energy surge

Question Explanation
Answer is A
Rationale: Electrical equipment can present a safety hazard to both the patient and health care
practitioner when safety measures are ignored. IV infusion equipment has the potential to
experience software and system errors that can result in delayed infusions, over-infusion, under-
infusion, or failed infusions. These errors can lead to serious injury and death. When system
errors occur, the best action is to remove the device from service until it has been serviced.
System errors are not caused by poor tubing placement and are not prevented by placing the plug
in a generator outlet.

Question 18
The charge nurse is observing a staff nurse perform a sterile dressing change for a client with
sacral wound. Which action by the staff nurse while wearing sterile gloves would require the
charge nurse to intervene?
A The nurse uses a sterile cotton-tipped swab to clean the wound edges.
B The nurse takes a sterile gauze pad and places it in the wound.
C The nurse picks up a gauze pad soaked in sterile saline to cleanse the wound.
D The nurse pulls up the clean sheet over the client's perineum for better draping.

Question Explanation
Correct Answer is D
Rationale: Touching the clean sheet with sterile gloves will contaminate the gloves. The draping
should be completed before the sterile gloves are put on. Touching sterile objects with sterile
gloves does not result in contamination.

Question 19
The nurse is planning care for a client with methicillin-resistant staphylococcus aureus
pneumonia. Which type of precaution should the nurse implement for this client?
A Airborne precautions
B Droplet precautions
C Contact precautions
D Standard precautions

Question Explanation
Correct Answer is C
Rationale: Contact precautions involve the use of barrier protection (e.g. gloves, mask, gown, or
protective eyewear as appropriate) whenever direct contact with any of the body fluids is
expected. When determining the type of isolation to use, one must consider the mode of
transmission. The hands of personnel continue to be the principal mode of transmission for
methicillin-resistant staphylococcus aureus (MRSA). Because the organism is limited to the

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sputum in this example, precautions are taken if contact with the patient’s sputum is expected.
Standard precautions are not enough to prevent transmission. Droplet and airborne precautions
are not needed since the bacteria is not floating in the air.

Question 20
A nurse is assisting a healthcare provider with a sterile procedure and prepares to pour a solution
onto a piece of sterile gauze. In what order should the nurse perform the following steps when
pouring sterile solution? Place the steps in order, and all steps are to be used.

1. Pour 1 to 2 mL into a receptacle.

2. Place the bottle cap face-up on a clean surface.
3. Pour the solution onto the gauze.
4. Perform hand hygiene.
5. Pick up the bottle with the label facing toward the palm.
6. Remove the bottle cap.
A 4, 6, 2, 5, 1, 3
B 6, 2, 3, 1, 5, 4
C 3, 5, 4, 2, 6, 1
D 2, 4, 1, 3, 6, 5

Question Explanation
ANSWER is A
Rationale: When pouring a sterile solution onto a sterile field, the nurse should perform hand
hygiene, remove the bottle cap, place the bottle cap face-up on a clean surface, pick up the bottle
with the label facing toward the palm, pour 1 to 2 mL into a receptacle, and pour the solution
onto the gauze.

Question 21
The nurse is caring for a client who has an allergy to shellfish. Which of the following products
should the nurse avoid when caring for this client?
A Iodine
B Chlorhexidine
C Alcohol
D Lidocaine

Question Explanation
Correct Answer is A
Rationale: Clients with shellfish allergies may have a cross-reaction with products that contain
iodine, including Betadine. These products should be avoided to prevent an allergic reaction in
the client. Lidocaine, alcohol, and chlorhexidine are not known to cause allergic reactions in
clients with shellfish allergies.

Question 22
The nurse is assessing an older adult client for risk factors associated with falls. Which of the
following should the nurse identify as increasing the risk of falls?

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A Having a history of urinary tract infections
B Taking an opioid analgesic for pain
C Living in a home that has wall-to-wall carpeting
D Taking a daily antiplatelet medication

Question Explanation
Correct Answer is B
Rationale: Factors that increase the risk for falls in older adults include medication use such as
opioid analgesics which can cause confusion and drowsiness, as well as diuretic use, which can
cause orthostatic hypotension leading to dizziness. Antiplatelet medications are not associated
with an increased fall risk, rather an increased bleeding risk. A history of a UTI will not increase
the risk of falls, however, a current UTI with urinary frequency or urgency could increase an
older adult client’s risk of falls. Clients are at an increased risk of falls in houses with throw rugs,
which could be tripping hazards.

Question 23
The nurse is providing teaching about car seats to the parents of a 30-pound child. Which of the
following should be included in the teaching?
A “The buckled chest clip should be 1 inch below the armpit level of the child.”
B “A child can safely ride in the front seat while in a booster seat.”
C “The child can be placed in a forward-facing car seat with a harness.”
D “The car seat can move side-to-side 1-2 inches after being secured.”

Question Explanation
Correct Answer is C
Rationale: A child of 30 pounds can sit in a forward-facing car seat or booster. The buckled clip
needs to be at the armpit not below. Children cannot ride it the front seat, regardless of weight.
All seats should be securely fastened and not be able to move at all.

Question 24
The nurse is teaching a group of clients at the community center about burn prevention for
children. Which of the following should be included in the teaching?
A “The handles of the pots on the stove must be turned inward.”
B “The hot water tank should be set at 150 degrees.”
C “Infants can be bathed in the kitchen sink.”
D “Electrical outlets do not need to be covered until the infant is crawling.”

Question Explanation
Correct Answer is A
Rationale: Turning the handles in will limit the risk of the child reaching up and pulling a hot pot
onto themselves. Hot water tanks should be set at 120 degrees or less to decrease likelihood of
scalding. Bathing in the sink increases the risk that the infant will turn the hot water on.
Electrical outlets should be covered to prevent anything from being inserted into it.

Question 25

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The nurse is caring for a pediatric client who is experiencing a febrile seizure. Which action
should the nurse take first?
A Administer anticonvulsant medication
B Protect the child’s head from injury
C Loosen any clothing around the neck
D Apply a cooling blanket over the client

Question Explanation
Correct Answer is B
Rationale: Protecting the child from injury would be the highest priority action. Seizure activity
may cause the child to have involuntary movements which could result in hitting their head.
Loosening the clothing will help maintain the airway but would not be done first. The cooling
blanket can help reduce the fever but would not be done first. Administering anticonvulsant
medication would not happen first.

Question 26
A charge nurse is assigning a room to a client with a history of moderate Alzheimer’s. The
charge nurse will assign the client to a room in which area of the unit?
A Next to the client activity room
B At the end of the hallway
C In front of the elevator
D Across from the medication room

Question Explanation
Correct Answer is D
Rationale: Clients with moderate Alzheimer’s may have personality and behavioral changes that
lead them to wander and get lost. Medication rooms are frequently used by nurses. This
placement ensures frequent visual checks of the client. Assigning the client to a room at the end
of the hallway is not appropriate. Most stairwells are at the end of hallways and can be an area
for the client to escape. A room in front of the elevator is not appropriate for a client with
Alzheimer’s. Assigning the client next to an activity room provides overstimulation. Noise
should be kept to a minimum.

Question 27
A nurse is reviewing new prescriptions for a client with suspected meningitis. The client has a
history of atrial fibrillation and is taking warfarin for disease management. Which prescription
should the nurse clarify?
A CT scan of the head
B Blood cultures
C Lumbar puncture
D MRI of the spine

Question Explanation
Answer is C

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Rationale: The nurse should clarify the lumbar puncture order. Clients who are on anticoagulant
medications are at risk of bleeding. A lumbar puncture may cause bleeding that can compress the
spinal cord. Obtaining a blood culture is not contraindicated in a client taking anticoagulant
medications. The nurse should apply direct pressure after the venipuncture. A computerized
tomography (CT) scan of the head and a magnetic resonance imagining (MRI) of the spine are
not invasive and will not affect the client taking anticoagulants.

Question 28
The nurse has attended a staff education conference about assessing for factors that impact a
client’s ability to ambulate. Which of the following statements by the nurse indicates a need for
further teaching?
A “The length of time a client has been in bed may impact the ability to ambulate without
assistance.”
B “The client should be medicated right before they attempt to ambulate.”
C “Clients should be assessed for the ability to understand directions prior to attempting
ambulation.”
D “Client’s range-of-motion ability should be assessed prior to attempting ambulation.”

Question Explanation
Answer is B
Rationale: Several factors influence a client’s ability to balance and ambulate safely. It requires
further teaching if the nurse states that narcotics will improve balance and safety. While it is
important to address pain levels and ensure comfort prior to ambulation, several medications,
such as narcotics, sedatives, and tranquilizers may cause drowsiness, dizziness, weakness, and
orthostatic hypotension and can hinder the client’s ability to walk safely. The length of time a
client is in bed can cause weakness and impair ability to transfer and ambulate. Clients should
be assessed for the ability to understand directions during ambulation with or without assistive
devices to ensure safe transfers. Limitations in range-of-motion or lower extremity strength may
hinder ability to balance and transfer and may require assistive devices as needed.

Question 29
The nurse has taught a client about measures to reduce the risk of repetitive stress injuries.
Which of the following statements by the client indicates the need for further teaching?
A “Varying the types of sports that I play may reduce the risk of acquiring a repetitive stress
injury.”
B “I will limit the amount of time I use electrical tools each week to reduce repetitive vibration to
my joints.”
C “Frequent lifting of heavy objects will increase muscle strength and reduce my risk of
repetitive stress injuries.”
D “I will ensure that I have running shoes with proper padding in the soles to reduce impact on
the joints in my legs.”

Question Explanation
Answer is C
Rationale: Repetitive stress injuries are caused by sports, occupations, and hobbies that cause
repetitive motion, causing strain on the joints and tendons. Frequent lifting of heavy objects
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increases the risk of repetitive stress injuries and requires further teaching. Varying the types of
sports that are played can reduce the risk of acquiring a stress injury due to using the same
motion frequently when training often for one particular sport (i.e., tennis elbow). Clients that
use electrical tools that vibrate either for hobbies or for work are at risk for injury and these tools
should be limited, if possible. Proper padding in running shoes and allowing for rest each week
will reduce the risk of running-related stress injuries.

Question 30
The nurse has collected a stool specimen from a client with antibiotic associated
diarrhea. Clostridium difficile is suspected. What action should the nurse take to transport the
specimen to the lab?
A Place the specimen in a small biohazard bag.
B Wear gloves and an isolation gown when walking to the lab.
C Wipe the exterior of the collection cup with a disinfectant wipe.
D Place the client’s label on the cap of the collection cup.

Question Explanation
Correct answer is A
Rationale: Personal protection equipment (PPE) should be removed inside or just outside of the
client’s room. It is not worn in the hallway. Send or transport the specimen to the laboratory in a
biohazard bag immediately or within the optimal time from collection as indicated by facility
policy and guidelines. Avoid contact with soaps, detergents, and disinfectants as these may affect
test results. The identification label should be attached to the cup so that when the lid is removed,
the specimen remains labeled.

Question 31
The nurse is caring for a client who is undergoing internal radiation therapy. Which of the
following actions by the nurse is appropriate to ensure safety?
A Encouraging the client to ambulate in the hallway
B Following airborne isolation precautions while in the client’s room
C Discarding any dislodged implants into a sharps container
D Prohibiting visitation from children

Question Explanation
Correct answer is D
Rationale: For the client undergoing internal radiation therapy, the nurse should prohibit
visitation from children or pregnant individuals. The client should remain in their own private
room during ambulation. Airborne precautions are not necessary, but radiation shielding
protective equipment should be used. If an implant is dislodged, it should be discarded into a
radiation safe container; sharps containers do not protect from radiation.

Question 32
The nurse is teaching the parents of a toddler-age client about protective measures to reduce the
risk of unintentional poisoning at home. Which of the following actions, if identified by the
parent, indicates the need for further teaching?

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A Attaching plastic hooks to cabinet doors
B Placing poison warning stickers on toxic substances
C Reusing empty containers to store different substances
D Storing cleaning agents and medications in locked cabinets

Question Explanation
Correct answer is C
Rationale: It requires further teaching if the parent reuses empty containers to store different
substances. All substances should be kept in their original containers in the event of
unintentional ingestion to alert the poison control center. It indicates a correct understanding of
protective measures if the parent attaches plastic hooks to cabinets to keep them securely closed,
stores medications and cleaning agents in locked cabinets, and places poison warning stickers on
toxic substances.

Question 33
The nurse is documenting an occurrence in which the nurse identified that the wrong site was
marked by the surgeon prior to the procedure being performed. Which type of practice error
should the nurse document as having occurred?
A An adverse event
B A near-miss event
C A sentinel event
D A root cause analysis

Question Explanation
Correct answer is B
Rationale: A near-miss event is the identification of any event or situation that might have
resulted in client harm, but the harm did not occur due to timely intervention by healthcare staff.
The nurse should document the identification of the wrong surgical site marking prior to the
actual surgery as a near-miss. Near-misses should be documented as they occur so that root cause
analyses can be performed to identify human factors that could be avoided to prevent a similar
situation from occurring. An adverse event and a sentinel event occur when actual harm or death
is inflicted on a client due to healthcare errors.

Question 34
A staff nurse is assisting the unit charge nurse with narcotic counts. The staff nurse notices the
charge nurse becomes nervous when several discrepancies in the counts are found. Which action
should the staff nurse take?
A Stop the count and notify the unit manager.
B Continue the count and offer therapeutic statements to the charge nurse.
C Complete the count and document the discrepancies.
D Pause the count and find another staff nurse to assist the charge nurse.

Question Explanation
Correct answer is A

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Rationale: It is the nurses’ responsibility to report narcotic discrepancies and behaviors indicative
of substance abuse. The nurse should stop the count and notify a supervisor. Offering therapeutic
statements to the charge nurse does not address the behavior change when discrepancies are
found. Completing the count makes the staff nurse liable for the discrepancies. Pausing the count
and finding another staff nurse does not address the issue of the charge nurse’s reaction to the
discrepancies.

Question 35
A nurse is providing education to a client with diabetes type 2 on using a blood glucose monitor
at home. Which client statement indicates an understanding of the teaching?
A “I will keep the used lancets on the counter until I can dispose of them properly.”
B “I will do the quality control test every time I use the glucose monitor.”
C “I will place the test strips in a plastic bag when I travel.”
D “I will write the date I opened the test strips on the container.”

Question Explanation
Correct Answer is D
Rationale: Expired test strips can produce inaccurate results. Writing the date on the bottle
prevents test strips from being used beyond their expiration date. Quality control tests do not
need to be performed every time the glucose monitor is used. The nurse should instruct the client
to perform the quality control test as recommended by the device manufacturer. Test strips
should be kept in their original container. Light and moisture can affect their functionality.
Lancets should be disposed of immediately after use. Exposed lancets can cause a needlestick
injury.
Question 36
The nurse is caring for a pediatric client a new diagnosis of cancer. The parent appears to be
quite angry and has made threats towards staff members. Which of the following actions will
reduce the risk of workplace violence while maintaining a caring environment?
A Call security to stand outside the client’s room.
B Ignore the parent’s behavior while providing care.
C Tell the parent that these feelings are inappropriate.
D Remain close to the doorway when talking with the parent.

Question Explanation
Correct Answer is D
Rationale: Remaining close to the doorway allows the nurse to leave the room for assistance in
case the parent becomes physically violent. While security may be notified of the potential need
for their assistance, standing outside the room is likely to increase the anger of the parent.
Ignoring the parent’s behavior or telling them it is inappropriate does not validate the feelings
that they are experiencing and decreases the nurse’s awareness of safety concerns.

Question 37
The nurse is providing staff education on reducing hospital acquired infections by eliminating
potential reservoirs of infection. Which of the following statements should be included in the
teaching?

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A “Client bedrails should be disinfected regularly using hospital approved wipes.”
B “It is a good idea to wear gloves when touching door handles.”
C “Documentation areas are cleaned less often than client rooms.”
D “Soiled linens should remain in the client’s laundry bin until discharge.”

Question Explanation
Correct answer is A
Rationale: Research has shown that one of the biggest reservoirs of infection is the client’s
bedrails. These must be thoroughly sterilized between patients. Gloves are a potential source of
infection. If someone is wearing gloves and touches a reservoir then touches the door handle, the
door handle becomes a reservoir. Clients, visitors, healthcare providers, and facility staff may
touch door handles multiple times each day. Office supplies, computer mice, and keyboards are
all potential sources of infection and need to be diligently cleaned. Linen bags should be brought
directly to the soiled utility room.

Question 38
The nurse is reviewing the communicable disease policy about what information needs to be
provided to the health department. Which statement by the nurse indicates the need for additional
education about the policy?
A “The results of testing should be provided.”
B “I will need to report the onset of symptoms.”
C “HIPAA prevents the reporting of personal information.”
D “Patient information such as name, age, and gender are reported.”

Question Explanation
Correct Answer is C
Rationale: This type of required reporting uses personal identifiers and enables the states to
identify cases where immediate disease control and prevention are needed. Each state has its own
laws and regulations defining what diseases are reportable. The list of reportable diseases varies
among states and over time. HIPPA does not apply to reportable diseases.

Question 39
The nursing supervisor is working in an acute care facility following an earthquake. The building
has lost water supply and is on generator power. Which patients should the nursing supervisor
evacuate first?
A Ventilator dependent adults in the ICU
B Ambulatory adults on the medical unit
C Ambulatory children in the pediatric unit
D Non-ventilator dependent adults in the ICU

Question Explanation
Correct answer is A
Rationale: Evacuation decisions after No Advanced Warning Events such as earthquakes are
based on building integrity, infrastructure, and environmental factors. If there is a potential or
immediate threat to staff or clients, an assessment must be made to immediately evacuate or wait

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and reassess. Once evacuation is determined, triage is based on the availability of critical
resources. In this case, the loss of power and water makes movement of acutely ill clients the
priority. The other clients may be evacuated subsequently.

Question 40
The infection control nurse is evaluating a staff member putting on personal protective
equipment (PPE) before entering the room of a client who is on droplet isolation. Which item
should the staff member put on first?
A Gown
B Mask
C Gloves
D Face shield

Question Explanation
Correct Answer is A
Rationale: When putting on PPE, the first item to put on is the gown, followed by the mask, face
shield, and then gloves.

Question 41
The nurse is assessing a client for allergies prior to a scheduled magnetic resonance image (MRI)
with contrast. Which of the following statements by the client requires follow-up?
A “I take a daily antihistamine for nasal congestion due to pet dander.”
B “I get itchy when I put iodized salt on my food.”
C “I had a reaction in the past when I received blood products.”
D "I have an air purifier in my bedroom for dust-mite allergies."

Question Explanation
Correct answer is B
Rationale: Clients who are undergoing diagnostic testing with contrast medium should be
assessed for allergies to iodine-containing food such as shellfish, cabbage, kale, and iodized salt,
which could cause an adverse reaction. Allergies to pet dander, dust mites, and a previous blood
transfusion reaction do not place the client at an increased risk of an adverse reaction to the
contrast medium.

Question 42
The nurse is teaching a group of parents about measures to reduce the incidence of unintentional
poisoning in toddlers. Which of the following statements by a parent indicates a need for further
teaching?
A “I will carefully evaluate the products my child’s toys are made of to reduce the likelihood that
they contain lead.”
B “I will keep houseplants on the ground to ensure they do not get knocked over and cause
injury.”
C “I will never leave my child unsupervised around standing water sources.”
D “All household chemicals will be kept on a top shelf, out of reach from my child.”

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Question Explanation
Correct answer is B
Rationale: Major causes of unintentional injury in toddlers are accidental poisoning due to
ingesting toxic substances, such as plants, chemicals, and medications. Additional causes include
exposure to lead in toys, paint, and ceramic dishes as well as drowning. The nurse should follow
up if the parent states that houseplants should be kept on the ground. Toddlers are curious and
often stick objects in their mouths, including plants, which can sometimes be poisonous if
ingested. Plants should be kept out of reach of toddlers.

Question 43
A nurse is providing care to a client experiencing substance withdrawal. Which prescription by
the healthcare provider requires clarification?
A Implement seizure precautions.
B Keep client NPO.
C Initiate cardiac monitoring.
D Ambulate ad lib.

Question Explanation
Correct answer is D
Clinical manifestations of substance withdrawal include tremors, irritability, and unsteady gait.
These manifestations increase the risk for falls. A prescription for ambulation as desired requires
clarification. Substance withdrawal is one of the main risk factors for seizure activity. Seizure
precautions are indicated. A nothing by mouth (NPO) order is indicated for a client experiencing
substance withdrawal. Nausea and vomiting are common manifestations. Substance withdrawal
can cause tachycardia and elevated blood pressure. Cardiac monitoring is indicated.

Question 44
The nurse is planning care for a client who is paralyzed on the right side. Where should the nurse
place the signaling device?
A On the left side of the bed near the client's hand
B Near the pillow on the right side
C Across the client’s chest
D Attached to the bed

Question Explanation
Correct answer is A
Any items the client needs to use must be place on the unaffected side. Placing them anywhere
else or on the affected or paralyzed side will not allow the client to use them. Attaching the
signaling device to the bed may be out of reach for the client.

Question 45
The nurse is providing teaching to client on the use of range of motion exercises while on
bedrest. Which statement made by a client indicates the need for further teaching?
A “I will move each joint through the full range at least 3 times.”
B “I should raise my leg with my foot 6 inches off the bed.”

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C “I can move the joint until I feel resistance.”
D “I will hold my leg when someone rotates the joint.”

Question Explanation
Correct Answer is D
Rationale: Active range of motion exercises are movements that the client does independently.
The client should be instructed to perform the active range of motion exercises. The nurse should
instruct the client to perform the movement until resistance is felt. When exercising a joint, the
movement should be done at least 3 times. When performing leg exercises, the client should lift
the foot about 6 to 12 inches off the bed. Passive range of motion exercises are done with
someone performing the exercise.

Question 46
A nurse is preparing to assess a newly admitted client. Which action should the nurse take first?
AExplains the purpose of the assessment.
B Checks the client’s wristband.
C Obtains a health history.
D Places the client in a supine position.

Question Explanation
Correct Answer is B
Rationale: The nurse should ensure proper identification of the client before providing care. The
client’s wristband will confirm name, date of birth, and medical record number. Explaining the
purpose of the assessment is important. However, the nurse should ensure care is being provided
to the correct client. Obtaining a health history should precede a physical assessment. However,
the nurse must ensure the health history is being obtained from the correct client. Placing the
client in a supine position is not a priority action. The nurse must first identify the client.

Question 47
A nurse attends a training on activation of the hospital incident command system (HICS). Which
personnel role does the nurse identify as being responsible for rapidly evaluating clients to
determine priorities for treatment?
A Public information officer
B Triage officer
C Hospital incident commander
D Charge nurse

Question Explanation
Correct answer is B
Rationale: A triage officer is responsible for evaluating clients and determining the priority for
treatment. A public information officer is a person who serves as a liaison between the media
and the hospital. The hospital incident commander is the person who assumes overall leadership
when the emergency plan is implemented. The charge nurse is responsible for coordinating staff
roles in the assigned unit.

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Question 48
The nurse is participating in the implementation of a hospital’s disaster response plan. Which of
the following indicates correct understanding of disaster planning?
A All hospital staff must receive training on identifying signs of bioterrorism activities within the
community.
B All hospital staff must receive training on handling of hazardous materials and
decontamination.
C Annual drills are required and should include community-wide resources with a simulation of
a large influx of clients.
D The hospital pharmacy is required to stockpile antibiotics and nerve agent antidotes in the
event of a bioterrorist attack.

Question Explanation
Correct Answer is C
Rationale: All facilities are required to carry out internal and external disaster drills, one of
which includes implementing community-wide resources and simulation of a large influx of
clients in the event of a disaster. Typically, nurses, emergency department physicians and other
medical providers are required to receive training on handling hazardous materials,
decontamination and recognizing patterns of illness that indicate potential bioterrorism in the
community. While it is ideal for pharmacies to stockpile antidotes to nerve agents and
antibiotics, this is not a federal requirement, although resources are becoming more available for
facility pharmacies to obtain these medications.

Question 49
The occupational health nurse is teaching a client about measures to reduce the risk of carpal
tunnel syndrome. Which of the following should the nurse include in the teaching?
A “Geometrically designed keyboards may assist with reducing strain on your fingers and
wrists.”
B “Lower your chair height so that your wrists are flexed.”
C “Take frequent breaks from keyboards to perform other finger motions.”
D “Stretch your fingers and wrists in the morning before work.”

Question Explanation
Correct answer is A
Rationale: Carpal tunnel syndrome is the most common repetitive stress injury. Clients should be
taught proper ergonomics to reduce the risk of developing carpal tunnel syndrome, including
stretching wrists frequently during the day while at work and typing, adjusting the chair height so
that elbows are at a 90-degree angle without flexion of the wrists. Clients should be taught to
take frequent breaks from keyboards in addition to typing on keyboards found on cellphones and
handheld devices. A geometrically designed keyboard may reduce strain on fingers and wrists as
well as adjustable height desks to allow for alterations in positions throughout the day.

Question 50
The nurse is performing a dressing change for a client who has an abdominal wound healing by
secondary intention. There is a moderate amount of sanguineous drainage on the old dressing.
How should the nurse dispose of this dressing?
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A Place in the client’s regular trash bin
B Discard in a red biohazard waste bin
C Flush the dressing down the client’s toilet
D Call environmental services to remove the waste

Question Explanation
Answer is B
Rationale: A red bag marked BIOHAZARD is used to dispose of trash that contains liquid or
semiliquid blood or other potentially infective material (OPIM), trash contaminated with blood
or OPIM that would release these substances if compressed, and trash that is caked with dried
blood or OPIM and is capable of releasing these materials during handling. Therefore, it is
inappropriate to place the dressing in the client’s trash bin. Dressings are not flushed down the
toilet. It is unnecessary to call environmental services for this task.

Question 51
The charge nurse observes a staff nurse carrying soiled linen in the hallway from a client who is
receiving chemotherapy. Which statement by the charge nurse would be most appropriate?
A “Soiled linens should be held away from the body and placed in a linen cart or bag before
leaving the room.”
B “Soiled linens should be left in the client’s room to prevent the spread of biohazardous and
infectious materials.”
C “Linens should be changed weekly to prevent exposure to cytotoxic agents.”
D “Linens should be held closely to reduce the risk of any biohazardous or infectious materials
from becoming airborne.”

Question Explanation
Correct answer is A
Rationale: Blood and body fluids are contaminated with cytotoxic drugs or metabolites for about
3 to 5 days after a dose. Therefore, the nurse should wear appropriate PPE when handling
patients’ clothing, bed linens, or excreta. Linens should be placed in a specially labeled linen cart
or plastic bag before being taken to the soiled utility room. It is important that meticulous
hygiene is administered to the patient undergoing chemotherapy to help prevent infection.
Therefore, linens should be changed as needed. Linens should be held away from the body to
prevent contamination of the nurse's clothing.

Question 52
The nurse is caring for a client with severe osteoarthritis. Which of the following home
interventions should the nurse recommend to promote client safety?
A Avoid the use of analgesics prior to activity.
B Perform exercise regimen at the end of the day.
C Use an assistive device for ambulation.
D Increase intake of high calorie foods.

Question Explanation

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Correct answer is C
Rationale: Assistive devices allow a client with severe osteoarthritis to ambulate safely.
Strenuous activity such as exercise should be planned for times when the client is in the least
amount of pain, often this is in the morning hours. Analgesics are recommended prior to periods
of significant activity. Increasing caloric intake does improve the safety of a client with
osteoarthritis.

Question 53
The home health nurse is assessing a client’s home for safety hazards. Which finding observed
by the nurse would increase the client’s risk for carbon monoxide poisoning?
A Client uses a wood-burning stove to heat the home.
B Client keeps their electric car stored in the garage.
C Client keeps a charcoal grill for cooking on the back patio.
D Client has a gasoline powered lawnmower stored in an outdoor shed.

Question Explanation
Correct answer is A
Rationale: Carbon monoxide is an odorless, colorless gas that is toxic, and prolonged exposure
can lead to brain damage or death. Risk factors for carbon monoxide poisoning include using
gasoline-powered vehicles, lawnmowers, barbeques, and wood-burning units or stoves inside the
home; therefore, a wood-burning stove places the client at an increased risk. The risk for carbon
monoxide poisoning is reduced if these units are not in use in enclosed spaces.

Question 54
A nurse is performing an equipment check in a client’s room. Which finding requires
intervention?
A The sequential compression device sleeves inflate and deflate.
B The vital signs machine is connected to an outlet next to the window.
C The portable monitor charging indicator light is on.
D The excess infusion pump electrical cord is tied in a knot.

Question Explanation
Correct answer is D
Rationale: Electric cords should not be bent or twisted as this can cause the wires inside the cord
to break. The nurse should loosen the cords. Outlets next to windows are not a safety hazard. The
nurse should ensure electric cords are not near water sources. The charging light for heart
monitors and defibrillators should be on, indicating that the batteries are charging. Sequential
compression devices provide pressure to the leg in time increments. Inflation and deflation of the
device is an expected finding.

Question 55
The nurse is transporting a client in a motorized hospital bed when the cord becomes trapped
under the wheel. The cord is visibly damaged. Which of the following actions is appropriate?
A Have the client remain in the unplugged bed until it is repaired
B Wrap the cord in electrical tape and continue to use the bed

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C Exchange the bed and leave it in the hallway for repair
D Tag the bed for repair and remove it from the patient care area

Question Explanation
Correct answer is D
Rationale: Electrical equipment can present a safety hazard to both the patient and health care
practitioner when safety measures are ignored. Electrical cords that are bent or twisted may have
broken wires inside. Make certain that electric cords are not in a position to be trapped as beds
are raised or lowered. This can strip insulation covering the electric wires. The bed should be
removed from use and appropriately tagged for repair.

Question 56
The nursing supervisor is working in a hospital that is in the path of a hurricane. Which client
would be appropriate for immediate discharge?
A The client with nondisplaced tibia fracture that has been immobilized
B The client with lymphoma receiving induction IV chemotherapy
C The client with heart failure who is receiving 8 liters of oxygen
D The client who had an appendectomy with a paralytic ileus

Question Explanation
Correct answer is A
Rationale: Medically unstable and unpredictable critical care patients are not candidates for
discharge. Stable clients who need assistance are the second priority and, therefore, not
discharged until the lowest priority clients are discharged. Ambulatory clients who need no
assistance are the first clients to be safely discharged and relocated. The lowest acuity client here
is the tibia fracture as this injury does not require surgical intervention. Clients who are receiving
high flow oxygen, IV medication, and experiencing complications should not be discharged.

Question 57
The nurse is performing hand hygiene before providing care to a group of clients. The nurse
should identify that the use of alcohol-based hand sanitizer would be contraindicated in which of
the following clients?
A The client with a positive Methicillin-resistant Staphylococcus aureus (MRSA) infection
B The client receiving treatment for Clostridium difficile
C The client who has a history of Mycobacterium tuberculosis
D The client that developed a Escherichia coli urinary tract infection

Question Explanation
Correct answer is B
Rationale: Alcohol-based hand sanitizers are an alternate way to perform hand hygiene.
However, the nurse should use soap and water when caring for clients with Clostridium difficile,
which is a gram-positive, spore-forming bacteria that is not killed with alcohol. The nurse can
use alcohol-based hand sanitizers with clients who have other nosocomial infections.

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Question 58
The nurse educator is reviewing the policy about needlestick injuries with a group of staff nurses.
Which action should the nurse take first following a needlestick from a contaminated needle?
A Put the needle in a biohazard bag for testing
B Report to the Emergency Department
C Clean the site with soap and water
D Make an appointment to see the healthcare provider

Question Explanation
Correct Answer is C
Rationale: The puncture site and skin should be washed thoroughly with soap and water. Then
the nurse should follow the next steps in the facility-specific protocol for when a needlestick
occurs. Once the nurse has reported the incident to the supervisor, the nurse will be directed to
seek immediate treatment.

Question 59
The nurse is planning care for a client who is receiving a hematopoietic stem cell transplant.
Which actions should the nurse take?
A Schedule open visiting hours with client’s family
B Monitor the client’s vital signs once a shift
C Provide the client with a pitcher of crushed ice
D Keep client care equipment in the room

Question Explanation
Correct answer is D
Rationale: Clients who are receiving stem cell transplants are at high risk for infection. The nurse
should plan interventions that prevent infection. The nurse should keep all client care equipment
in the room and use dedicated equipment to prevent the spread of infection. The nurse will limit
the visitors to the client to prevent exposure. The nurse should provide fresh water, replacing it
every hour. The nurse should monitor the client’s vital signs every four hours.

Question 60
The nurse is adding sterile solution from an open container onto a prepared sterile field. Which
action should the nurse take?
A Pour the sterile solution from a height of five inches
B Place the cap of the sterile solution on the table with edges down
C Pour the sterile solution immediately after opening the container
D Apply sterile gloves before opening the sterile solution container

Question Explanation
Correct answer A
Rationale: When adding sterile solution to prepared sterile field, the nurse should maintain the
sterility of the solution and the field by pouring the solution 4 to 6 inches above the sterile
container. When using a sterile solution container that has been opened, the nurse should place
the cap with edges up and pour out solution lipping the bottle edges before pouring the solution

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onto the sterile field. The nurse will apply sterile gloves after pouring the sterile solution to
prevent contamination.

Question 61
The nurse is assessing a client for the risk of allergic reactions to products commonly used in the
healthcare setting. Which of the following statements by the client requires follow-up?
A “I have an air purifier in my home for allergies to pet dander.”
B “I take a daily antihistamine due to dust-mite allergies.”
C “I avoid eating bananas because they make me itchy.”
D "I have a family history of anaphylaxis due to bee stings.”

Question Explanation
Correct answer is C
Rationale: Clients should be assessed for risk of allergic reactions to products commonly used in
the healthcare setting, such as iodine, adhesive tape, and latex. A sign of allergic reaction
includes itching after eating a product. Allergies to foods such as bananas, kiwis and avocados
are known to also cause allergic reactions to latex in clients, therefore itching after ingesting
bananas may indicate risk of allergic reaction to latex. Allergies to pet dander, dust mites and a
family history of allergies to bee venom do not increase the client’s risk of allergic reaction to
common healthcare products.

Question 62
A community health nurse is educating a group of clients on burn safety. Which client is at a
higher risk for burns?
A A client with peripheral arterial disease
B A client with chronic kidney disease
C A client with a traumatic brain injury
D A client with diabetic nephropathy

Question Explanation
Correct answer is A
Rationale: Clients with peripheral arterial disease have decreased blood flow and sensitivity to
the lower extremities. Clients with decreased sensation to the feet can suffer burns without
realizing the injury. Decreased sensation is not an expected finding for a client with chronic
kidney disease. Clients with a traumatic brain injury are at a high risk for falls and seizures.
Diabetic nephropathy is damage to the kidneys due to elevated blood glucose levels. Diabetic
nephropathy does not result in decreased sensory perception.

Question 63
The nurse is providing teaching about car seats to a client who is a first-time parent to a
premature infant. Which information should the nurse include in the teaching?
A use a convertible car seat with a covering
B Select a car seat with less than 5 ½ inch distance from the crotch strap to the seat back
C Choose a car seat that does not recline
D Pick a car seat that has head padding built into the head rest

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Question Explanation
Correct answer is B
Rationale: An infant-only car seat should be used for preterm infants since convertible car seats
are designed for full-term infants. Use a car seat with a distance of fewer than 5½ inches from
the crotch strap to the seatback. This reduces the potential for your baby to slump forward.
Infants should be in car seats that recline to keep the airway open. No head padding is
recommended since the padding may push the infant's head forward.
Concepts tested

Question 64
The home health nurse is conducting a safety visit with the family of a toddler who is crawling.
Which statement by the parent would require follow-up by the nurse?
A “We use a thermometer to test the temperature of the bath water.”
B “A gate was installed in the entryway to the kitchen.”
C “There are coverings placed over all electrical outlets.”
D “Any furniture with sharp edges we cover with a blanket.”

Question Explanation
Correct answer is D
Rationale: Checking the water temperature reduces the risk of burns. Toddlers are unsteady and
can fall easily on unsecured rugs. Toddlers put everything in their mouths so small objectives are
a choking hazard. Covering the electrical outlets will prevent them from placing items in the
outlet.
Concepts tested

Question 65
The nurse is walking a client to the bathroom who has a history of seizures. The client states
“My vision seems to be distorted.” What action should the nurse take first?
A Return the client to bed
B Take the client to the bathroom
C Assess the client’s medication history
D Call the emergency response team

Question Explanation
Correct answer is A
Rationale: The patient is reporting signs and symptoms of an aura, which is a warning sign
before a seizure. Returning the client to bed will reduce the likelihood of injury. Calling the
response team and checking the history would not be the first actions. Continuing to the
bathroom is not an appropriate action, as the client is experiencing difficulty with ambulation.
Concepts tested

Question 66
A nurse is providing care to a client with chronic constipation. The client is on neutropenic
precautions. Which prescription should the nurse clarify?
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A High-fiber diet
B Abdominal x-ray
C Digital disimpaction
D Ambulate ad lib

Question Explanation
Correct answer is C
Rationale: The nurse should clarify the prescription for digital removal of feces. Digital
disimpaction can damage the mucosa along the rectal wall and increase the risk of infection. A
client with neutropenia is immunosuppressed. A high-fiber diet is recommended for clients with
chronic constipation and does not affect a client with neutropenia. An abdominal x-ray is not
invasive and can help visualize blockage of the intestines. Ambulation increases peristalsis and is
encouraged for clients with constipation. Ambulation is not contraindicated for a client with
neutropenia.
Concepts tested

Question 67
The nurse is performing client care in response to an external disaster in the community. Which
of the following actions should the nurse take first?
A Evaluate clients for airway patency and effectiveness of breathing
B Assess clients for uncontrolled bleeding and apply pressure as indicated
C Evaluate clients for disability and immobilize the cervical spine as indicated
D Assess for exposure to hazardous materials and observe the client for injury

Question Explanation
Correct Answer is A
Rationale: The primary survey during a disaster response is performed to detect life-threatening
injuries, which consists of checking for airway-breathing-circulation, disability, exposure, and
then facilitation of family. The nurse should first assess clients for airway patency and quality of
breathing, followed by the other actions.
Concepts tested

Question 68
The charge nurse is observing a newly hired nurse assess the client’s ability to ambulate while
transferring from a supine position in bed. Which of the following actions by the newly hired
nurse requires intervention?
A Assisting the client to sit upright with legs dependent on side of bed for 10 seconds
B Assessing for upper and lower extremity weakness prior to standing by the side of the bed
C Assisting the client to stand by the side of the bed for at least 1 minute
D Assessing the client for dizziness or a sudden increase in heart rate prior to ambulation

Question Explanation
Correct Answer is A
Rationale: When assisting clients to transfer from a supine position to ambulate, clients should
be moved slowly and closely monitored for orthostatic hypotension and any weakness. It

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requires intervention if the nurse has the client sit and dangle the legs for 10 seconds. Clients
should sit at the side of the bed for at least 1 minute for assessment of possible dizziness or vital
sign changes. It is correct for the nurse to assess for extremity weakness prior to attempting to
stand, assisting the client to stand for at least 1 minute prior to ambulation, and to assess the
client for dizziness.
Concepts tested

Question 6 9
The nurse is providing education on prevention of repetitive stress injuries to an adult client who
does virtual learning. Which of the following statements should be included in the teaching?
A “Lean back against the office chair while sitting at the computer.”
B “Make the desktop higher than elbow height.”
C “Use a mousepad with a wrist rest.”
D “Float the wrists above the keyboard.”

Question Explanation
Correct Answer is D
Rationale: Repetitive strain injury (RSI) is a general term used to describe the pain felt in
muscles, nerves, and tendons caused by repetitive movement and overuse. The condition mostly
affects the forearms and elbows, wrists and hands, and neck and shoulders. Leaning back against
a desk chair can cause poor posture with hyperextension of the neck. Proper posture is essential
to preventing RSI. The desktop should be at or below the level of the elbows to reduce shoulder
strain. The wrists should be floating above all surfaces. A wrist rest can cause or worsen carpal
tunnel syndrome.
Concepts tested

Question 70
The nurse is planning care for a client with a diagnosis of cancer who has received the first dose
of intravenous chemotherapy. Which type of precautions should the nurse implement for this
client?
A Place the client on contact isolation
B Wear a gown and gloves when handling linens and body fluids
C Place incontinence pads in the regular trash bin
D Maintain a distance of at least 3 feet from the client

Question Explanation
Correct Answer is B
Rationale: Chemotherapy drugs are present in the waste and body fluids of clients for 3 to 5 days
after administration. Nurses involved in handling chemotherapeutic agents may be exposed to
low doses of the agents by direct contact, inhalation, or ingestion. Therefore, PPE should be
worn when handling the client’s linens. Incontinence pads should be placed in chemotherapy
waste bins. Distancing is required with radiation implants and not chemotherapy.
Concepts tested

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Question 71
The nurse is completing a home health visit for a client who uses a wheelchair. Which of the
following findings indicate the need for home modification?
A Low countertops in the bathrooms
B A walk-in shower
C Upper cabinets in the kitchen are empty
D Uneven flooring in the home

Question Explanation
Correct Answer is D
Rationale: For the client who uses a wheelchair, having uneven flooring can be a significant
safety issue and modifications are warranted. Lowered countertops and walk-in style showers are
both appropriate. Not utilizing the upper cabinets in the home may be appropriate and is not a
safety concern.
Concepts tested

Question 72
The nurse is teaching a client about fire safety in the home. Which of the following statements by
the client indicates the need for further teaching?
A “I will change the batteries in smoke alarms on special days, such as the first of the year.”
B “I will keep my fire extinguishers in locations that are most prone to fires, such as the
kitchen.”
C “In the event of a fire, I will open all the windows in my house.”
D “In the event of a fire, I will move through smoke-filled areas with my head as close to the
floor as possible.

Question Explanation
Correct Answer is C
Rationale: It requires further teaching if the client states that they will open all windows and
doors during a fire. The client should be taught to contain the fire, if possible, by closing
windows and doors, which deprives the fire of oxygen. It is correct for the client to change
smoke alarm batteries annually and doing so routinely on a special day helps clients to remember
to do so. Fire extinguishers should be kept in locations that are prone to fires, such as the kitchen
or near grills. In the event of a fire, clients should move with their heads as close to the ground as
possible to prevent smoke inhalation.
Concepts tested

Question 73
The nurse has attended a staff education conference about incident reporting. Which of the
following statements by the nurse indicates a need for further teaching?
A “An incident report should be submitted for a client who fell after receiving an opioid
analgesic.”
B “Any type of medication error requires the submission of an incident report.”
C “An incident report should be submitted when a client has an allergic reaction to a newly
prescribed antibiotic.”

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D “Any time a prescription is written for the wrong client, an incident report should be
submitted.”

Question Explanation
Correct Answer is C
Rationale: An incident report is an agency record of an accident or unusual occurrence in the
healthcare setting, which can be used to help prevent future incidents or accidents. It is the
correct understanding of incident reporting if the nurse states that a client fall, medication error,
and an incorrect prescription that is written for a client require incident reports. These are all
considered errors or adverse/preventable events and should be reported to identify strategies to
reduce human error and adverse events in the future. Clients may have unknown allergies to
certain medications, and this requires prompt treatment of the allergy depending on severity as
well as documentation in the medical record of the allergy, however, this is not considered an
actual accident that requires incident reporting.
Concepts tested

Question 74
The nurse is documenting an occurrence in which the incorrect mole was removed from a
client’s leg. Which type of practice error should the nurse document as having occurred?
A A sentinel event
B A near-miss event
C A never-event
D An unpreventable event

Question Explanation
Correct Answer is C
Rationale: The nurse should document the incorrect removal of a client’s mole as a never-event.
Never-events are defined by the Joint Commission as surgeries on the wrong body part, foreign
objects placed in the client after surgery, and mismatched blood transfusions. A sentinel event is
one in which serious injury or death occurred due to errors. A near-miss event is the
identification of any event or situation that might have resulted in client harm, but the harm did
not occur due to timely intervention by healthcare staff. An unpreventable event is one in which
death or client injury would occur in the absence of a medical error.
Concepts tested

Question 75
A nurse walks into a client’s room and hears the unlicensed assistive personnel (UAP) telling the
client, “If you continue to use that call bell for no reason, I am going to restrain you.” What
action does the nurse take?
A Reprimand the UAP in the client’s room
B Instruct the UAP to make frequent rounds on the client
C Educate the UAP on the indication for restraints
D Report the UAP’s statement to the unit manager

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Question Explanation
Correct Answer is D
Rationale: The statement made by the unlicensed assistive personnel (UAP) is considered
assault. Threatening statements to a client should be reported to a supervisor. Reprimanding the
UAP in the client’s room is not professional behavior. Instructing the UAP to make frequent
rounds on the client does not address the threatening statement. Educating the UAP on the use of
restraints is indicated when medically necessary and does not address the threatening statement.
Concepts tested

Question 76
A nurse attended a training session on how to use a powered stand-assist lift to transfer a client to
a chair. Which action by the nurse indicates correct use of the device?
A Places the sling under the client’s arms
B Instructs the client to place the feet on the ground
C Holds the client’s hands when standing
D Manually turns the handle to lift the client

Question Explanation
Correct Answer is A
Rationale: Placing the sling under the client’s arms is a correct method. The sling should be
placed around the client’s back and under the arms to support the torso during lifting. The feet
should be placed on the footrests of the lift to support the weight during transfers. The nurse
should instruct the client to place the hands on the lift handles. The powered stand-assist lift is
designed to lift the client without assistance from the nurse.
Concepts tested

Question 77
The nurse is working in the newborn nursery when an unfamiliar person in scrubs comes to the
nursery door and requests to bring a newborn to the parents’ room. What action by the nurse is
appropriate?
A Verify the hospital identification badge
B Call security to the unit immediately
C Check with the parents to verify the request
D Ask the person if they are in the float pool

Question Explanation
Correct Answer is A
Rationale: Each member of the hospital staff should have an identification badge clearly
displayed. The nurse should look at the identification of anyone trying to transport a newborn as
this is one way to prevent infant abduction. The individual may have legitimate reasons for being
on the unit, so it is not appropriate to immediately call security, nor is it appropriate to take the
person at their word.
Concepts tested

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Question 78
The nurse is conducting a compliance survey to identify adherence to infection control practices.
While observing handwashing, which of the following findings would require intervention?
A Artificial nails are scrubbed using a brush for 30 seconds.
B Handwashing occurs for at least 15 seconds.
C Wrists are included in the washing.
D Soap is rinsed off from the wrist down to the fingertips.

Question Explanation
Correct Answer is A
Rationale: A nurse with artificial nails may harbor a large number and variety of microbes under
the nails. The CDC and WHO both have recommendations regarding the avoidance of artificial
nails in healthcare settings. Handwashing should occur for at least 15 seconds, include the wrists,
and rinse water proximal to distal.
Concepts tested

Question 79
The nurse is instructing a group of unlicensed assistive personal in the correct use of personal
protective equipment. Which statement by the UAP indicates understanding of the correct
protocol?
A “I only need to wear a mask during influenza season.”
B “I will wear gloves when performing hygiene care.”
C “I should wear a personal protective gown when assisting with meals.”
D “I have to put on the protective equipment when entering the room.”

Question Explanation
Correct Answer is B
Rationale: Gloves should be worn for all contact with blood and body fluids, nonintact skin, and
mucous membranes for handling soiled items during hygiene care. Masks are worn when
exposed to airborne and droplet respiratory disorders, such as tuberculosis or Covid-19, and can
be worn any time of year. Gowns should be worn during procedures that are likely to cause
splashes of blood or body fluids. Protective equipment is put on before entering a room.
Concepts tested

Question 80
The nurse is caring for a client with a history of falls. The nurse observes the client attempting to
get out of bed unassisted. Which safety device should the nurse implement for this client?
A Apply soft wrist restraints
B Raise all bed side rails
C Initiate a pressure bed alarm
D Set up an enclosure tent

Question Explanation
Correct Answer is C

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Rationale: When planning care for a client with a history of falls who is observed attempting to
get out of bed unassisted, the nurse should implement safety devices that prevent injury.
Restraints, such as wrist restraints, enclosure tents, and side rails, are physical devices that can
limit the client’s movement. The nurse should attempt less restrictive safety devices, such as
pressure bed alarms. A pressure bed alarm is a safety device that alerts staff if the client attempts
to get out of bed.
Concepts tested

Question 81
A nurse is implementing fall precaution strategies for a client who is visually impaired. Which
action would be an appropriate action for the nurse to take?
A Replace the call light with a touch pad call switch
B Place the bed in the lowest position
C Apply non-slip socks on the client
D Activate the position-sensitive bed alarm

Question Explanation
Correct Answer is A
Rationale: Clients who are visually impaired are unable to see all of the buttons on the call light.
Replacing the call light with a touchpad call switch enables the client to easily call for assistance.
Placing the bed in the lowest position is a fall prevention strategy. However, this intervention
benefits all clients regardless of impairment. Applying non-slip socks on the client will prevent a
fall while ambulating. The nurse should perform actions specific to the client’s impairment.
Activating the position-sensitive bed alarm is a fall prevention strategy. However, bed alarms are
beneficial for clients who have cognitive impairments and cannot understand instructions.
Concepts tested

Question 82
The nurse is discharging a newborn from the hospital. Upon inspection of the car, which of the
following is the correct use of the infant car seat?
A The car seat is positioned in the front seat.
B The car seat is forward facing in the back seat.
C The car seat is secured in the back seat by the door.
D The car seat is rear facing in the center of the back seat.

Question Explanation
Correct Answer is D
Rationale: The safest place for a car seat is the middle of the rear seat. Rear-facing seats are used
for infants less than 20 lbs. Infants should never be placed in the front seat. Infant carriers are not
the same as car seats.
Concepts tested

Question 83
The nurse is providing room orientation to a client who is newly admitted. When instructing the
client how to alert the staff, which statement should the nurse make?

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A “You can call the client care station with your phone.”
B “Let us know when you need something during hourly rounding.”
C “Use the call light device when you need assistance.”
D “You can call the hospital operator to have the staff paged.”

Question Explanation
Correct Answer is C
Rationale: The best communication tool for clients to use is the call light. The hospital operator
directs calls to the correct unit or provides announcements regarding emergencies. Hourly
rounding is when staff visually observes clients and provides basic care, such as bathroom visits.
Clients should still alert staff if needed and not wait for the rounding schedule. Calling the client
care station may delay in alerting the staff.
Concepts tested

Question 84
The nurse is teaching a client who just had a leg cast removed about ways to strength the calf
muscle to reduce the stress due to inactivity. Which of the following statements by a client
indicates a need for further teaching?
A “I will need to do the exercise 2 to 3 times a week to build strength.”
B “I should do 8 to 12 repetitions of each exercise.”
C “I will need to do several sets for each exercise daily.”
D “The faster I move through the exercises, the sooner my muscle strength will return.”

Question Explanation
Correct Answer is D
Rationale: Isometric exercises are used for strengthening muscles without moving the joint.
These can be used for maintaining strength in immobilized muscles in casts or traction. It is
recommended that clients should do the exercises consistently two or three times a week to build
strength. The nurse should instruct the client to perform the eight to 12 repetitions of each
exercise for one to three sets. Clients should move slowly through each exercise to help build
muscle strength. Moving too quickly can increase stress and damage the muscle.
Concepts tested

Question 85
A nurse is preparing to obtain a blood specimen from a client. Which action should the nurse
take?
A Labels the tubes before the specimen is obtained
B Writes the client’s information directly on the tube
C Places a client label on the biohazard bag prior to transport
D Asks the client to state their name and date of birth

Question Explanation
Correct Answer is D
Rationale: The nurse should identify the client by asking them to state their name and date of
birth. Ensuring client identification prevents the nurse from mistakenly obtaining blood from the

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incorrect client. The tube should not be labeled until after the blood specimen is collected.
Writing the information directly on the tube can smudge and does not ensure proper
identification of the specimen. Placing a client label on the biohazard bag does not ensure proper
identification if the specimen is separated from the bag upon analysis.
Concepts tested

Question 86
During a disaster activation, a nurse is tasked with recommending the most stable client for
discharge within the hour. Which client should the nurse recommend?
A A client with newly diagnosed diabetes type II who requires medication teaching
B A client post-bowel resection who has a new colostomy appliance
C A client with an ankle fracture who uses crutches for ambulation
D A client with a sacral wound who is receiving negative pressure wound therapy

Question Explanation
Correct Answer is C
Rationale: A client with an ankle fracture who requires crutches is the most stable client for
discharge. The client can ambulate with an assistive device. A client who needs medication
assistance for a newly diagnosed disease is not appropriate for discharge. The client requires a
case management consult. A client who has had major surgery is not the most appropriate client
for discharge. A new colostomy requires extensive client education. A client on negative
pressure wound therapy (NPWT) is not an appropriate client for discharge within an hour.
Arrangements for home use of NPWT is a lengthy approval process.
Concepts tested

Question 87
An emergency department (ED) charge nurse is receiving training on providing assignments to
unit nurses who are floated to the ED during a disaster activation. Which assignment is
appropriate for a nurse from an orthopedic unit?
A A client who had a myocardial infarction with continuous cardiac monitoring
B A client with end stage renal disease who is receiving hemodialysis
C A client with a femur fracture who is placed in skin traction
D A client who had acute respiratory failure with mechanical ventilation

Question Explanation
Correct Answer is C
Rationale: The charge nurse should assign a client that closely matches the nurses’ competencies.
A client on skin traction is an appropriate client to assign to an orthopedic nurse. Skin traction is
applied to clients who have fractures. A client who requires cardiac monitoring is not an
appropriate client to assign to an orthopedic nurse. Cardiac monitoring requires telemetry
training. Taking care of a client on hemodialysis requires specialized training. Providing care to a
client on mechanical ventilation is an advanced competency for critical care nurses.
Concepts tested

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Question 88
The nurse is participating in the planning of a facility’s annual disaster drills. Which of the
following indicates correct understanding of disaster planning?
A A mass casualty event involves management of the disaster by the facility using local
resources.
B An internal disaster plan requires a strategy for evacuation and relocation of clients.
C A facility must plan disaster drills for all potential external natural disasters regardless of
geographic location.
D A facility should plan active shooter drills primarily if gun violence is prevalent in the
surrounding community.

Question Explanation
Correct Answer is B
Rationale: Facilities require annual drills for both internal and external disasters. Internal
disaster plans always require a strategy for safely evacuating and relocating clients. A mass
casualty event differs from a multi-casualty event in that it is broader in scope and typically
overwhelms local medical capabilities, requiring collaboration with numerous healthcare
facilities and possibly state, regional, and federal assistance. Facilities are required to plan drills
for natural disasters but may choose disasters that are prevalent in their region, such as
avalanches near mountains or hurricanes near the ocean. All facilities should plan active shooter
drills, regardless of geographic location or prevalence of gun violence in the surrounding
community
Concepts tested

Question 89
The nurse is caring for a client with lower extremity paralysis who uses a wheelchair and is non-
weight bearing. Which of the following actions will promote a safe transfer to the wheelchair?
A Obtain a mechanical lift
B Use a two-person assist
C Use a slide board
D Have the client stand and pivot

Question Explanation
Correct Answer is A
Rationale: The Occupational Safety and Health Administration recommends a no-lift policy for
all health care facilities. They advise using patient handling aids and mechanical lifting
equipment for patients who are unable to assist in their transfer. The use of mechanical lifts and
other patient handling devices reduces the risk of injury to nurses and clients. Patients who are
unable to bear partial weight or full weight or who are uncooperative should be transferred using
a full-body sling lift with two caregivers. This client is non-weight bearing and therefore, is a
candidate for a lift and not for stand and pivot or any other means.
Concepts tested

Question 90
The nurse is caring for a client who uses oxygen at home. Which of the following statements by
the client warrants additional assessment by the nurse?
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A “I keep my spare tanks in the bedroom closet.”
B “I use a beeswax- based moisturizer when my nose gets dry.”
C “I keep the oxygen concentrator outside of the bathroom when I shower.”
D “I wear my oxygen when I’m preparing our dinner.”

Question Explanation
Correct Answer is D
Rationale: Clients should always maintain at least two meters (approx. 6 feet) between a fire and
a portable oxygen concentrator and accessories. This includes gas stovetops. Clients may need to
wear oxygen when showering or bathing, but it is important the concentrator itself does not get
wet. Extension tubing can be used to facilitate this. Clients will have spare tanks at home in case
of power failure. They should be stored in a secure location away from open flame and heat.
Concepts tested

Question 91
The nurse is teaching a client who is newly diagnosed with diabetes type I about needle disposal.
Which statement should the nurse include in the teaching?
A “Sharps with safety mechanisms can be discarded directly into regular trash.”
B “Put used sharps in a strong, plastic container that has a lid.”
C “Plastic containers that are full of sharps should not be placed in the regular trash.”
D “Sealed containers must be dropped off at a local acute care facility.”

Question Explanation
Correct Answer is B
Rationale: Clients should be taught to put used sharps in a strong, plastic container. When the
container is 3/4 full, put the lid on, seal it with tape, and label “do not recycle.” It is then
acceptable to put the container in the household trash or bring it to a drop-off location such as a
hospital, pharmacy, health department, or police or fire station. Sharps that retract after use
should be disposed of like all other sharps.
Concepts tested

Question 92
The nurse is teaching a client about protective measures to reduce the risk of electrical shock
while using medical devices. Which of the following statements by the client indicates the need
for further teaching?
A “I will repair any frayed or damaged equipment cords with electrical tape.”
B “I will place protective covers over wall outlets around my younger children.”
C “I will use only grounded outlets and plugs to power my medical equipment.”
D “I will avoid overloading outlets with too many appliances at a time.”

Question Explanation
Correct Answer is A
Rationale: It indicates the need for further teaching if the client states they will repair frayed or
damaged electrical cords with electrical tape. Devices that indicate damage should not be used
and should be evaluated and repaired by an electrician. It indicates a correct understanding of the

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use of protective equipment to reduce electrical shock by placing protective covers on electrical
outlets around children, to use only grounded outlets, and to avoid overloading outlets with too
many appliances.
Concepts tested

Question 93
A nurse has administered 5 ml of intravenous hydralazine to a client. As the multi-dose
medication vial is discarded, the nurse notes the prescription was to administer 2 ml. Which
action does the nurse perform first?
A Inform the charge nurse
B Take the client’s blood pressure
C Notify the healthcare provider
D Check the client’s respirations

Question Explanation
Correct Answer is B
Rationale: Hydralazine is a vasodilator used in the treatment of hypertension. Upon noticing the
dosage error, the nurse should immediately assess the client’s condition by taking vital signs.
Hydralazine decreases blood pressure. Informing the charge nurse and notifying the healthcare
provider are important actions to manage the client’s condition after the error. However,
assessing the client is the priority. Checking the client’s respirations will not evaluate the effects
of hydralazine.
Concepts tested

Question 94
A nurse is inspecting equipment in a client’s restroom for safety. Which finding requires
intervention by the nurse?
A A commode chair without the pan is in the shower area.
B The toilet has a raised seat with armrests.
C The nurse call pull cord is wrapped around the handrail.
D A rubber mat is spread out underneath the sink.

Question Explanation
Correct Answer is C
Rationale: Nurse-call pull cords in the shower should be hanging low enough for the client to
pull in case of a fall. The nurse should unwrap the cord from the handrail. A commode chair
provides support to a client with a physical disability or weakness while taking a shower. The
pan is not necessary in the shower. A raised seat with armrests on the toilet provides support and
decreases the risk of falls. A rubber mat prevents the client from slipping and falling on wet
surfaces.
Concepts tested

Question 95
A nurse is performing a bladder scan on a female client with history of a hysterectomy. Which
action by the nurse indicates correct use of the ultrasound bladder scanner?

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A Selects ‘female’ as the biological sex on the screen
B Applies ultrasound gel above the level of the umbilicus
C Points the directional icon on the scanner head toward the client’s head
D Presses the scanner head upward toward the abdomen

Question Explanation
Correct Answer is C
Rationale: The directional icon on the scanner head should be pointing toward the client’s head
to mimic the client’s anatomical placement and obtain an accurate measurement. The nurse
should select ‘male’ as the biological sex with clients who have a history of a hysterectomy due
to the absence of the uterus. Ultrasound gel should be placed above the pubic symphysis, at the
level of the bladder. The scanner head should be pointed down towards the coccyx to obtain an
accurate read.
Concepts tested

Question 96
The nurse is caring for a client who is receiving a continuous infusion of norepinephrine. The
infusion pump battery is not charging even though the pump is plugged in. Which of the
following actions is appropriate?
A Continue to use the pump
B Replace it with another pump that has been charging properly.
C Inform the maintenance department that it will need to be serviced after the client is
discharged
D Restart the pump

Question Explanation
Correct Answer is B
Correct Answer Rationale: The client is on a vasopressor to support hemodynamic stability. If
the power were to fail or the client would need to leave the room, the pump would not continue
to function and the client would not receive a life sustaining treatment. The pump should be
replaced now while the situation isn’t critical. The nurse should not attempt to troubleshoot
software or mechanical failures.
Concepts tested

Question 97
The nurse is teaching a client newly diagnosed with HIV about virus transmission. Which
statement by the client would indicate to the nurse the need for further teaching?
A "I should avoid cooking for my family.”
B "I will notify all of my sexual partners.”
C “I am going to wear a medical alert bracelet.”
D "I can still use the community gym."

Question Explanation
Correct Answer is A

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Rationale: HIV is transmitted through direct contact with bodily fluids, such as unprotected sex
or sharing of used needles. HIV is not transmitted through casual contact, such as preparing food
or using shared gym equipment. Clients who are newly diagnosed with HIV should be instructed
to contact previous sexual partners.
Concepts tested

Question 98
The nurse has provided strategies to a client about infection prevention. Which of the following
statements by the client indicates the need for further teaching?
A “I will use antimicrobial soap and hot water to wash my hands.”
B “I will wash all raw fruits and vegetables before eating.”
C “My fingernails should be cut short and clean.”
D “Sharing my toothbrush is not a good practice.”

Question Explanation
Correct Answer is A
Rationale: Antimicrobial soap is not needed for routine handwashing and can lead to resistant
organisms. Raw fruits and vegetables can carry infectious organisms and should be washed
before eating. Fingernails should be cut and clean to prevent harboring of organisms. The nurse
should instruct the client to avoid sharing personal grooming items, such as toothbrushes.
Concepts tested

Question 99
The nurse is planning care for a group of assigned clients. Which action by the nurse would
require the use of sterile gloves?
A Placement of a peripheral IV
B Insertion of an indwelling urinary catheter
C Administration of prescribed rectal medication
D Performing perineal hygiene care

Question Explanation
Correct Answer is B
Rationale: Surgical asepsis is used for procedures that require sterile technique. Sterile
technique is required for procedures that could introduce infectious agents to the client, such as
placement of an indwelling urinary catheter, wound dressing change, or preparing injectable
medications. Medical asepsis or clean technique is used for procedures such as placement of a
peripheral IV, administering a rectal medication, or performing hygiene care.
Concepts tested

Question 100
The nurse working with an unlicensed personal assistant (UAP) to care for a client who has soft,
bilateral wrist restraints placed. Which task should the nurse delegate to the UAP?
A Evaluate the client’s ability to move fingers.
B Observe the client’s capillary refill time.
C Assist the client during mealtimes.

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D Maintain documentation of restraint criteria.

Question Explanation
Correct Answer C
Rationale: A client who is in soft wrist restraints will require an assessment of skin and
circulation and maintain documentation on restraint criteria, which is the responsibility of the
nurse. The nurse can delegate to the UAP assisting the client to the bathroom and with eating and
drinking.
Concepts tested

Question 101
The charge nurse is observing a newly hired nurse respond to a fire in a client’s room. Which of
the following actions by the newly hired nurse requires intervention?
A Evacuating clients who are in immediate danger
B Using a fire extinguisher with a sweeping motion at the base of the fire
C Opening the doors to client rooms and hallways to allow smoke to escape
D Reporting fire details and location to the agency's emergency response system

Question Explanation
Correct Answer is C
Rationale: Correct response during a fire is to use the RACE protocol: rescue, alarm, confine,
and extinguish. It is correct for the nurse to evacuate clients in immediate danger, report details
of the fire to the emergency response system, and use the fire extinguisher if the fire is small
enough to extinguish. The nurse should not open doors to client rooms and hallways; the correct
action is to close the doors in order to confine the fire.
Concepts tested

Question 102
A nurse is providing injury prevention strategies to a client with hemiparesis. Which intervention
will decrease the risk of environmental injury?
A Performing passive range of motion to the affected extremities
B Placing the wheelchair at the foot of the bed
C Using a sliding board to transfer from bed to chair
D Securing the affected arm in a sling while ambulating

Question Explanation
Correct Answer is C
Rationale: Clients with hemiparesis are unable to move one side of their body. Using a sliding
board to transfer from bed to chair decreases the risk of falls. Performing passive range of
motion to the affected extremities promotes muscle tone but does not directly prevent injury.
Placing a wheelchair at the foot of the bed increases the risk of falls. Wheelchairs should be
placed close to the client on the unaffected side. Securing the affected arm in a sling decreases
the weight of the extremity and prevents shoulder injuries.
Concepts tested

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Question 103
A nurse is providing care to a client with a wound to the left heel. The wound is open and has
eschar tissue on the surface. Which prescription from the healthcare provider will the nurse
clarify?
A Apply negative pressure wound therapy
B Teach toe touch weight bearing to the left lower extremity
C Irrigate wound twice a day
D Position with pressure off left lower extremity

Question Explanation
Correct Answer is A
Rationale: Negative pressure wound therapy (NPWT) promotes wound closure and healing.
NPWT should not be applied over eschar tissue as it can promote additional bacterial growth.
Eschar tissue is dead tissue that should be removed prior to application of NPWT. Toe touch
weight bearing is an acceptable mobility prescription for a client with a wound to the heel.
Irrigation is an expected treatment to clean an open wound and remove surface bacteria. Pressure
offloading is an expected treatment for wounds to the heel area. Decreasing pressure increases
circulation to the area and promotes wound healing.
Concepts tested

Question 104
The nurse is reviewing the plan of care for a client with a head injury who has a prescription for
seizure precautions. Which action should the nurse take?
A Place the bed in high position
B Keep restraints at the bedside
C Keep suction equipment at the bedside
D Remove all pillows from the client’s bed

Question Explanation
Answer Correct is C
Rationale: A client with a head injury has an increased risk for seizures. A head injury and
seizure can cause airway obstruction and breathing impairment. Oxygen and suctioning may be
needed to keep the airway open, so it should be available at the bedside. The bed needs to be in
the lowest position possible, and a pillow should be underneath the patient’s head to protect it
from injury. The use of restraints would not protect the client from injury related to a seizure and
could cause musculoskeletal damage.
Concepts tested

Question 105
A nurse is assigned a client with Parkinson’s disease experiencing delirium. Which room is best
indicated for this client?
A A room adjacent to an ante room
B A room facing the elevator
C A room with multiple windows
D A semi-private room

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Question Explanation
Answer Correct is C
Rationale: Clients with Parkinson’s may experience neurological changes leading to delirium.
Delirium results in impaired judgment, the inability to focus, and disorientation. A room with
multiple windows helps the client with time orientation. A room with an adjacent ante room
further isolates the client. Ante rooms are indicated for clients with organism precautions. A
room facing the elevator and a semi-private room will produce too much noise and visual stimuli
for a client with delirium
Concepts tested

Question 106
A nurse is asked to recommend one of her assigned clients for discharge due to a disaster plan
activation. Which client will the nurse recommend for discharge
A A client with a platelet count of 70,000/mm³ and history of systemic lupus erythematosus
B A client with a potassium level of 6.2 mEq/L and history of kidney disease
C A client with a PaO₂ of 55 mmHg and history of chronic obstructive pulmonary disease
D A client with a hemoglobin level of 10 g/dL and history of chronic anemia

Question Explanation
Correct Answer is D
Rationale: A client with a hemoglobin of 10 g/dL is the most stable client for discharge. The
normal hemoglobin level is 12 to 18 g/dL. A hemoglobin level of 10 g/dL is not uncommon with
chronic anemia. A client with a low platelet count is not appropriate for discharge.
Thrombocytopenia can lead to uncontrolled bleeding. A potassium level of 6.2 mEq/L is not a
safe discharge. The normal potassium level is 3.5 to 5.0 mEq/L. Hyperkalemia can cause cardiac
arrhythmias. A client with a partial pressure of oxygen (PaO₂) level of 55 mmHg is not a stable
client for discharge. Hypoxemia can lead to decreased tissue perfusion.
Concepts tested

Question 107
The nurse is responding to a fire on the unit. Which of the following actions by the nurse
requires intervention?
A Opening all the doors and windows on the unit
B Discontinuing oxygen for all clients who can breathe without it
C Directing ambulatory clients to walk to a safe location
D Moving bedridden clients by stretcher to a safe area

Question Explanation
Correct Answer is A
Rationale: It requires intervention if the nurse is observed opening the doors and windows to
allow smoke to escape. Proper response during a fire is to confine the fire by closing doors and
windows to reduce the amount of oxygen feeding the fire. Oxygen is flammable, therefore all
clients who can breathe without oxygen should have their oxygen removed. Nurses should direct
all ambulatory clients to walk to a safe location and focus on moving bedridden clients either in
their bed, on a stretcher, or carrying them with two staff on a blanket.
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Concepts tested

Question 108
The nurse has attended a staff training program about recognition of personal risks while
responding to external disasters. Which of the following statements by the nurse indicates a need
for further training?
A “Disaster sites should be assessed for the potential to cause injury due to structural collapse.”
B “Responders to a terrorist attack are at a reduced risk of becoming a target of a secondary
attack.”
C “Exposure to contagious diseases and natural hazards may occur while responding to
disasters.”
D “Responders should always be aware of the risk of interpersonal violence in unsecured areas.”

Question Explanation
Correct Answer is B
Rationale: Responders to external and internal disasters must be aware of the personal risks
involved. It requires additional training if the nurse states that responders are at reduced risk of
becoming the target of a secondary terrorist attack. Responders to potential terrorist attacks must
always be vigilant of a second attack, which is aimed at harming first responders. Disaster sites
should be assessed for potential structural collapse, which can cause injury to responders.
Responders should take appropriate personal protective equipment if possible, based on
contagious or natural hazards that may be encountered, and should be vigilant about personal
safety and security regarding violence in unsecured areas.
Concepts tested

Question 109
The nurse is providing education to a client who works on an assembly line about preventing
repetitive stress injuries. Which of the following statements should be included in the teaching?
A “Use a footrest at the workstation.”
B “Use the lunch period to elevate the legs.”
C “Twist at the waist when possible.”
D “Limit the amount of walking done during the work shift.”

Question Explanation
Correct Answer is A
Rationale: Prolonged standing can lead to lower back repetitive stress injuries. Using a footrest
reduces intravertebral disc stress by preventing excessive lordosis. Frequent work breaks should
be used to reduce back stress instead of a single, prolonged break. Workers should pivot instead
of twisting at the waist. Walking is encouraged to promote venous return and circulation and
reduce tension.
Concepts tested

Question 110
The nurse is caring for a client who is receiving prescribed cytotoxic chemotherapy. Which
safety precautions should the nurse implement with this client?

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A Wear gown, gloves, and face shield when handling body fluids for 3 to 5 days after the last
dose
B Require visitors to wear gowns and gloves while in the room
C Adhere to universal precautions when changing IV tubing every 2 to 4 hours
D Dispose of contaminated needles, syringes, vials, and ampules in red biohazard containers

Question Explanation
Correct Answer is A
Rationale: Blood and body fluids are contaminated with drugs or metabolites for about 3 to 5
days after a dose. Therefore, the nurse should wear appropriate PPE when handling patients’
clothing, bed linens, or excreta. Gloves alone may be inadequate in protecting the nurse from
exposure to cytotoxic agents. Visitors are not required to wear a gown and gloves when in the
room. Dispose of contaminated materials (e.g., needles, syringes, ampules, vials, IV tubing, and
bags) in puncture-proof containers labeled “Warning: Hazardous Material.” Chemotherapy waste
containers are typically yellow in color.
Concepts tested

Question 111
The nurse is caring for a client who is receiving internal radiation therapy. Which of the
following actions by the nurse is appropriate for reducing radiation exposure?
A Limit exposure to 60 minutes per day
B Have visitors keep 6 feet away from the client
C Wear a gown and gloves when caring for the client
D Measure radiation omitted using a radiation survey meter

Question Explanation
Correct Answer is B
Rationale: The goal is to deliver safe, efficient care in the shortest amount of time. Exposure for
the nurse, health care provider, and visitors should be limited to 30 minutes per 8-hour shift.
Visitors should keep a distance of at least 6 feet. A gown and gloves would protect against
exposure to cytotoxic agents used in chemotherapy, but not radiation. Lead would be used for
this purpose. Radiation survey meters are used for disasters involving potential radiation
exposure, but not for radiation therapy. Healthcare providers may wear dosimeters to measure
exposure.
Concepts tested

Question 112
The nurse is teaching an older adult client about measures to reduce incidence of falls in the
home. Which of the following statements by the client indicates a need for further teaching?
A “I will plan on having grab bars installed in my shower.”
B “ I should plan on removing my wall-to-wall carpeting in my home.”
C “I will install nightlights in my hallways and bathrooms.”
D “I should remove clutter from the floor in my living areas.”

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Question Explanation
Correct Answer is B
Rationale: The client requires further teaching if the client states that wall-to-wall carpeting
needs to be removed. The nurse should teach the client that loose rugs are tripping hazards and
should be removed. Wall-to-wall carpeting is not known to increase fall risks in clients. Clients
should be taught to remove clutter from living areas, provide adequate lighting at night, and
install grab bars in showers to reduce the risk of falling
Concepts tested

Question 113
The nurse has attended a staff education conference about incident reporting. Which of the
following statements by the nurse indicates a need for further teaching?
A “An incident report should be submitted when a client develops drowsiness after receiving a
prescribed opioid analgesic.”
B “A medication that is given to a client at the wrong dosage requires the submission of an
incident report.”
C “A procedure that is started on the wrong client requires the submission of an incident report.”
D “An incident report should be submitted for a client who fell after receiving a sedative.”

Question Explanation
Correct Answer is A
Rationale: An incident report is an agency record of an accident or unusual occurrence in the
healthcare setting, which can be used to help prevent future incidents or accidents. It is the
correct understanding of incident reporting if the nurse states that a client fall, medication error,
and incorrect procedure on a client require incident reports. These are all considered errors or
adverse/preventable events and should be reported to identify strategies to reduce human error
and adverse events in the future. Clients may experience side effects to certain medications, and
this requires monitoring and possible treatment depending on the severity, however, this is not
considered an actual accident that requires incident reporting.
Concepts tested

Question 114
A nurse is assisting a respiratory therapist with tracheal suctioning on a client. The nurse
observes the respiratory therapist break sterile technique multiple times when preparing the
equipment. What initial action does the nurse take?
A Provide the respiratory therapist with a new suction kit
B Tell the respiratory therapist that sterile technique was breached
C Document the respiratory therapist's error in the client’s record.
D Inform the respiratory therapist’s supervisor about the incident

Question Explanation
Correct Answer is A
Rationale: A break in sterile technique is considered negligent care. The nurse should provide the
respiratory therapist with a new suction kit to prevent client harm. Telling the respiratory
therapist that the sterile technique was breached should be discussed outside of the client’s room.
Documentation of a procedural error should not be part of the client’s medical record. Informing
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the respiratory therapist’s supervisor about the incident is indicated for quality improvement
purposes. However, this action should occur after the nurse verifies infection control during the
procedure.
Concepts tested

Question 115
A nurse is providing education to a client post-knee surgery on safe use of a continuous passive
motion (CPM) machine. What will the nurse include in the teaching?
A "Position the knee where the CPM machine bends.”
B “Check the range of motion settings every other day.”
C “Set the degree of flexion where it feels the most comfortable.”
D “Remove any padding between your knee and the CPM machine.”

Question Explanation
Correct Answer is A
Rationale: The client’s leg should be positioned so the affected joint is in line with the bend of
the continuous passive motion (CPM) machine. This promotes proper flexion of the joint. The
cycle and range of motion settings should be checked at least every 8 hours to ensure the degree
of flexion is as prescribed. The degree of flexion should be set according to the provider’s
prescription. The CPM machine should be well padded to avoid skin integrity issues.
Concepts tested

Question 116
The nurse at an ambulatory care clinic is participating in an active shooter drill. The shooter is
rapidly approaching the nurse’s location. Which of the following responses is best?
A Immediately evacuate the building
B Hide in a room with no windows
C Attack the shooter at the head and neck
D Call Emergency Services

Question Explanation
Correct Answer is B
Rationale: The best action in an active shooter situation is to run. However, if the shooter is
rapidly approaching the room you are in, the best strategy is to hide as soon as possible.
Attacking the shooter is the final option. Emergency Services are notified by those who are not
in immediate danger.
Concepts tested

Question 117
The charge nurse working at the nurse’s station overhears a conversation between a new
graduate nurse and an unfamiliar employee who is wearing appropriate identification. The
employee is asking for the security code to enter the medication room. Which of the following
statements should the charge nurse make?
A “Only nursing staff is permitted in the medication room.”
B “I will need to know the reason for your access to the medication room.”

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C “I will enter the code to the medication room for you.”
D “Someone will need to be in the medication room with you.”

Question Explanation
Correct Answer is B
Rationale: Organizations must ensure the medications are secure – meaning protected from
unauthorized access, tampering, theft, or diversion. Medication rooms are accessed by authorized
personnel, which can include pharmacists, pharmacy technicians, nurses, and other licensed
personnel. Therefore, it is inappropriate to teach the nurse that only nursing staff members are
authorized to be in the room. However, the individual needs to be vetted to determine if they are
included in the individuals with approved access. It is not an effective use of time to supervise an
authorized individual as they complete their work. While the employee may need regular access
to the room, it may not be appropriate to provide the code until further information can be
obtained.
Concepts tested

Question 118
The nurse is preparing to obtain vital signs for assigned clients and notes an available blood
pressure machine right outside of a room on contact isolation for Clostridium difficile. What is
the appropriate action?
A Find the client’s nurse and ask if the machine has been in the room
B Take the machine and begin the assessments
C Clean the machine with bleach wipes before starting
D Use alcohol-based hand sanitizer before moving the machine

Question Explanation
Correct Answer is C
Rationale: C. difficile is a gram-positive, anaerobic, spore-forming bacterium that is a common
cause of diarrhea. It is not killed by alcohol-based hand-rubs. Washing hands frequently is an
important infection control intervention. Regardless, washing hands before touching dirty
equipment would not prevent the nurse from transferring C. difficile to another surface. The
appropriate action is to proactively disinfect the machine using a bleach-based disinfecting wipe.
Finding the nurse is nonproductive, as they may not have left the machine there or may not
remember if it was cleaned.
Concepts tested

Question 119
The nurse is preparing a sterile field for a bedside procedure. Which action should the nurse
take?
A Leaving the room after the sterile field is set up for less than 1 minute to check orders
B Opening sterile supplies away from the body and above the waist
C Putting on sterile gloves by touching the inside of both gloves
D Touching the sterile field within 2 inches of the outer edge

Question Explanation

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Correct Answer is B
Rationale: Opening sterile supplies and/or instruments away from their bodies ensures that the
components of the sterile field remain sterile. Nurses should never leave the sterile field
unattended, as this automatically deems the field contaminated. Sterile gloves should be applied
by only touching the inside of the first hand to don the glove, followed by using the newly sterile
gloved hand to only touch the outside of the second glove to apply. Nurses should not touch the
sterile field except the outer 1-inch edges of that field while considered unsterile.
Concepts tested

Question 120
The charge nurse observes a new staff nurse who is changing a sterile dressing. After removing
the dirty dressing, the nurse removes the gloves and dons a new pair of sterile gloves before
setting up the sterile field. What is the most appropriate action for the charge nurse to take?
A Inform the staff nurse that sterile gloves are not needed to remove the old dressing
B Hand the nurse a new pair of sterile gloves
C Discuss the dressing change technique with the nurse at the bedside
D Inform the nurse of the need to wash her hands after removal of the dirty dressing and gloves

Question Explanation
Correct Answer is D
Rationale: The nurse should wash her hands after removing the soiled dressing and before
donning the sterile gloves to clean and dress the wound. Not doing so compromises client safety
and should be brought to the immediate attention of the nurse. Nonsterile gloves are adequate to
remove the old dressing. A new pair of sterile gloves is not needed at this time. Discussion of the
nurse’s techniques should occur outside of the client’s room.
Concepts tested

Question 121
The nurse has attended a staff education conference about electrical safety in the healthcare
setting. Which of the following statements by the nurse indicates the need for further teaching?
A “Plugs should be removed from the wall outlet by pulling from the cord.”
B “All electrical equipment should be checked for fraying or other signs of damage before use.”
C “Electrical equipment should not be used near wet areas such as sinks and showers.”
D “Electrical cords should be kept coiled or taped to the ground to prevent damage and tripping
hazards.”

Question Explanation
Correct Answer is A
Rationale: It indicates a correct understanding of electrical safety if the nurse states that cords
should be kept coiled or taped to the ground to prevent tripping and damage to the cords, to
avoid the use of electrical equipment around wet areas since water is an electrical conductor, and
to check cords for fraying and signs of damage, which could increase the risk of electrical shock
to the user. Plugs should be removed from the wall outlet by pulling from the plug, not the cord,
as this could cause damage to both the outlet and the device, increasing the risk of electrical
shock.
Concepts tested
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Question 122
A nurse is reviewing prescriptions for a client with a deep vein thrombosis to the right lower
extremity (RLE). Which prescription should the nurse clarify?
A Apply graduated compression stocking to the RLE
B Massage the RLE as needed
C Perform range of motion exercises to the RLE
D Elevate the RLE above the level of the heart

Question Explanation
Correct Answer is B
Rationale: A deep vein thrombosis is a blood clot that forms within a vein and obstructs blood
flow. The goal of treatment is to increase circulation to the extremity once anticoagulant therapy
is initiated. Massaging the affected extremity is contraindicated, as it can dislodge the blood clot
and cause obstruction of other vessels. Applying graduated compression stockings is an expected
treatment. Compression stockings increase the velocity of blood flow and improve valve
function in the veins. Range of motion exercises are encouraged and improve muscle tone and
circulation to the extremity. Elevating the affected extremity above the level of the heart
increases venous blood flow.
Concepts tested

Question 123
The nurse is preparing a client who is non-verbal for a lumbar puncture. The nurse instructs the
client to remain still during the procedure. Which information should the nurse provide to the
client on how to communicate with staff during the procedure?
A Shake their head back and forth
B Raise hand above head
C Squeeze the nurse’s hand
D Use a finger to tap on the bed

Question Explanation
Correct Answer is C
Rationale: Clients are instructed not to move during the procedure. Any movement can cause the
needle to shift. The nurse helps keep the client in the proper alignment and provides support.
Squeezing the nurse’s hand requires little movement by the client; the other methods require
significant movement.
Concepts tested

Question 124
The nurse is caring for a client with an inner ear infection who is experiencing vertigo. Which
intervention would protect the client from injury?
A Monitor the client for falls
B Document vital signs
C Speak to the client on the unaffected side
B Provide medication for nausea

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Question Explanation
Correct Answer is A
Rationale: Some clients may experience vertigo, a sensation of spinning, with inner ear
infections. Clients with vertigo will report feeling dizzy, which could lead to falls and cause
injury. Monitoring for falls will protect the client from injury. Vertigo can also cause nausea and
is treated with medication but does not cause injury. Clients may also have hearing loss, which is
not an injury, related to vertigo, so speaking to the client on the unaffected side will make sure
the client understands the instructions. Documenting vital signs will allow assessing of trends
with vertigo but will not prevent injury.
Concepts tested

Question 125
The nurse is teaching a client who uses a wheelchair for mobility about reducing pressure
injuries. Which exercise should the nurse include in the teaching?
A Wheelchair push-ups
B Leg lifts
C Ankle rolls
D Shoulder lifts

Question Explanation
Correct Answer is A
Rationale: When sitting in a wheelchair, the majority of the bodyweight is on the pelvis and the
buttocks. These are bony areas that can have skin breakdown if the pressure is not relieved.
Wheelchair push-ups take pressure off the bony areas. The other exercises will maintain muscle
tone but will not take pressure off the buttocks and pelvis.
Concepts tested

Question 126
The nurse has attended a staff training program about nursing roles during disasters. Which of
the following statements by the nurse indicates the need for further training?
A “Nurses may be responsible for activating notification systems to call in nurses who are not
scheduled to work.”
B “General staff nurses should be assigned to perform triage for incoming clients to determine
level of severity of injuries.”
C “Critical care nurses should be prepared to determine clients who are stable enough for
transfer to ensure adequate beds for critically ill clients.”
D “Administrative nurses may have roles reassigned to provide care for stable clients on the
unit.”

Question Explanation
Correct Answer is B
Rationale: Mass casualty events such as disasters require nurses to assume roles outside of
normal daily operations. Typically, general staff nurses will be assigned to discharge stable
clients or care for stable clients in the emergency department to allow emergency department
nurses to perform triage and critical care duties as needed for disaster victims. Nurses should be
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prepared to activate notification systems to increase nursing staff available to care for victims.
Critical care nurses should discharge stable clients to medical-surgical units to allow for space
for victims who are unstable. Administrative nurses may be reassigned outside of their regular
roles to care for stable clients with predictable outcomes.
Concepts tested

Question 127
The nurse is performing triage on clients during a facility disaster drill. Which of the following
indicates correct understanding of disaster triage?
A Classifying a client with a pneumothorax as emergent
B Classifying a client with a cervical spinal cord injury as urgent
C Classifying a client with an open femur fracture as non-urgent
D Classifying a client with a scalp laceration as expectant

Question Explanation
Correct Answer is A
Rationale: In mass casualty disaster situations, triage focuses on doing the greatest good for the
greatest number of people. Therefore, when resources are severely limited, some clients who
have very extensive critical injuries who would otherwise receive massive resuscitation efforts
(cervical cord injury, head injuries, massive burns), may be classified as expectant, or black-
tagged and allowed to die or not be treated. Clients with airway compromise or shock are
classified as emergent and are seen immediately. Clients with open fractures or wounds should
be classified as urgent and seen within 30 minutes to 2 hours. Clients with abrasions or
contusions should be classified as non-urgent and can be seen after 2 hours or when other more
urgent clients have been attended to.
Concepts tested

Question 128
The nurse is assessing the client’s ability to perform proper use of a cane while ambulating.
Which of the following actions by the client requires intervention?
A Stepping with the weaker leg after moving the cane
B Holding the cane on the client’s stronger side of the body
C Looking down at the cane while moving the legs forward
D Maintaining the top of the cane at the level of the hip

Question Explanation
Correct Answer is C
Rationale: It indicates proper use of a cane to move the cane first, followed by the weaker leg,
and then the stronger leg, which provides a constant wide base of support. The client should hold
the cane on the stronger side of the body and maintain the cane at the level of the hip. Clients
should be instructed to stand up straight and look forward, not down at the cane, to reduce the
risk of falling.
Concepts tested

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Question 129
A nurse is preparing to move a client up in bed. The client is unable to assist in repositioning and
assistance is obtained. Which action demonstrates use of ergonomic principles?
A Twist at the waist while lifting the client
B Raise the bed to the nurse's working height
C Keep the feet close together
D Lift and move in an uncoordinated fashion

Question Explanation
Correct Answer is B
Rationale: Twisting at the waist, keeping the feet close together when lifting and moving, and
performing uncoordinated lifting and moving all increase the risk of back injuries in nurses.
Raising the bed height reduces lower back strain.
Concepts tested

Question 130
A nurse is caring a client who was admitted for diarrhea and has been diagnosed with a
Clostridium difficile infection (CDI). To reduce the risk of transmission, which action should the
nurse take?
A Perform frequent hand hygiene with alcohol- based hand sanitizer
B Clean shared equipment with standard disinfecting wipes
C Move the client to a negative pressure room
D Place dirty linens directly into the soiled linen cart

Question Explanation
Correct Answer is D
Rationale: C. diff is a spore-forming, gram-positive anaerobic bacillus. It is a common cause of
antibiotic-associated diarrhea (AAD). C. diff is shed in feces so any surface, device, or material
that becomes contaminated with feces could serve as a reservoir. C. diff spores can also be
transferred to patients via the hands of healthcare personnel who have touched a contaminated
surface or item. Use contact precautions for patients with CDI. Because alcohol does not kill C.
diff spores, the use of soap and water is more effective than alcohol-based hand hygiene. Bleach-
based wipes should be used for cleaning surfaces and shared equipment. The linens of a client
with C. diff diarrhea may be contaminated and should be immediately placed in the soiled linen
cart. Do not lay dirty linens on any surface.
Concepts tested

Question 131
The nurse is educating a client who has diabetes mellitus on home safety. Which of the following
statements by the nurse is appropriate?
A “Store used needles for later use.”
B “Keep a spare vial of insulin in the refrigerator.”
C “You don’t need to check your glucose if your diabetes is well-controlled.”
D “Don’t wear shoes while inside your home.”

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Question Explanation
Correct Answer is B
Rationale: Having a backup vial of insulin in the refrigerator is a safe practice if the current vial
becomes lost or damaged. Used needles should be discarded in a sharp-safe container. Glucose
levels are important to assess regardless of how well the client’s condition is controlled. The
client should wear well-fitting shoes as often as possible, even indoors, to prevent foot injury.
Concepts tested

Question 132
The nurse is teaching the parents of an infant client about protective measures to reduce injuries
at home. Which of the following actions, if identified by the parent, indicates the need for further
teaching?
A Placing covers over electrical outlets
B Using guard gates on stairs and windows
C Setting the water heater maximum temperature to 140°F
D Maintaining the crib slats no greater than 2.5 inches apart

Question Explanation
Correct Answer is C
Rationale: It requires further teaching if the parent states that the water temperature maximum
should be set at 140°F. It is recommended that the temperature maximum be set at 120°F to
minimize the risk of scalding burns during baths. It is the correct understanding of protective
measures to place covers over electrical outlets to reduce risk of electrical shock, to use guard
gates on stairs and windows to reduce risk of falling, and to maintain crib slats no greater than
2.5 inches apart.
Concepts tested

Question 133
The nurse is documenting an occurrence in which a client fell during a transfer and resulted in an
intracerebral hemorrhage and death. Which type of practice error should the nurse document as
having occurred?
A A sentinel event
B A near-miss event
C A never-event
D An unpreventable event

Question Explanation
Correct Answer is A
Rationale: The nurse should document the death of a client following a fall during a transfer on
the unit as a sentinel event. A sentinel event is one in which serious injury or death occurred due
to errors. Never-events are defined by the Joint Commission as surgeries on the wrong body part,
foreign objects placed in the client after surgery, or mismatched blood transfusions. A near-miss
event is the identification of any event or situation that might have resulted in client harm, but
the harm did not occur due to timely intervention by healthcare staff. An unpreventable event is
one in which death or client injury would occur in the absence of a medical error.
Concepts tested
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Question 134
A nurse is assisting a client out of bed. As the client begins to stand, the bed moves back, and the
client falls to the ground. The nurse notes the brakes on the bed were not activated. Which
priority action does the nurse perform?
A Informs the charge nurse
B Assists the client back to bed
C Locks the brakes on the bed
D Assesses the client for injury

Question Explanation
Correct Answer is D
Rationale: Assisted falls to the ground can still result in client injury. The nurse should assess the
client for injuries prior to performing other interventions. Informing the charge nurse is an
important action for the coordination of care. However, ensuring client safety is the priority.
Assisting the client back to bed should occur after the nurse ensures there are no injuries from
the fall. Locking the brakes on the bed will prevent a future fall. However, this action is not the
priority.
Concepts tested

Question 135
A nurse is preparing a client for a 12-lead electrocardiogram. Which anatomical site indicates
correct placement of the electrodes?
A Fourth intercostal space, left sternal border, to obtain lead V3
B Left midaxillary line, third intercostal space, to obtain lead V6
C Fifth intercostal space, left midclavicular line, to obtain lead V4
D Right sternal border, second intercostal space, to obtain lead V1

Question Explanation
Correct Answer is C
Rationale: An electrocardiogram monitors the electrical activity of the heart. The placement of
leads is important to obtain accurate readings. Lead V4 provides information on the anterior
myocardial wall. The electrode should be placed in the 5th intercostal space (ICS), left
midclavicular line. The 4th ICS, left sternal border, corresponds with lead V2. Lead V6 requires
an electrode to be placed on the left midaxillary line, 5th ICS. Lead V1 is obtained by placing an
electrode on the right sternal border, 4th ICS.
Concepts tested

Question 136
The nurse is obtaining vital signs on a stable client using an electronic blood pressure cuff. The
cuff begins to inflate, but the machine is making an unusual sound. The client states that it is
painfully tight. Which of the following actions is appropriate?
A Remove the cuff from the client and take note of which device is defective
B Remove the device from service and call biomedical services to provide maintenance
C Obtain the blood pressure with the device and then report the issue to the charge nurse

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D Ask another nurse to assist in troubleshooting the device and obtain the blood pressure

Question Explanation
Correct Answer is B
Rationale: Obtaining accurate vital signs is essential to quality nursing care. When a BP machine
is not operating correctly, the data it provides may not be reliable and there is a risk of harm to
the client if any intervention is based on an inaccurate BP. The device should be removed from
service until it can be checked for accuracy and safety and, if needed, repaired.
Concepts tested

Question 137
The nurse is caring for clients on the medical unit when the “Code Red” alert is announced over
the intercom. The unit is not close to the fire’s point of origin. Which of the following actions is
appropriate?
A Close the double doors to the unit
B Assist all clients to the far end of the unit
C Use the elevators to begin the evacuation
D Relocate clients to a unit on a higher floor

Question Explanation
Correct Answer is A
Rationale: Upon activation of a code red, nurses who are not in proximity to the fire should first
close all doors and keep patients and visitors in their rooms with the doors closed. Elevators may
be unsafe, and clients would be evacuated using the stairwell. Clients are not relocated to higher
floors during fires. Evacuation will occur horizontally, and then laterally, if there is immediate
danger due to fire, smoke, chemical release, structural failure, or a similar condition.
Concepts tested

Question 138
The nurse working in pediatrics is admitting a client with a diagnosis of measles. Which of the
following transmission-based precautions should be instituted?
A Airborne
B Contact
C Droplet
D Reverse

Question Explanation
Correct Answer is A
Rationale: The client with measles should be placed on airborne precautions. Patients with
measles should remain in Airborne Precautions for 4 days after the onset of rash (with the onset
of rash considered to be Day 0). Standard precautions should be adhered to, as is the case for all
patients. Reverse isolation is designed for immunosuppressed clients.
Concepts tested

Question 139
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A nurse has attended a conference about communicable diseases. Which statement by the nurse
indicates the need for further teaching?
A “I only need to report diseases associated with children.”
B “I should review the infection control policies.”
C “I need to report suspected communicable disease to the infection control department.”
D “I need to use the correct isolation precautions for the disease.”

Question Explanation
Correct Answer is A
Rationale: The nurse should be aware of the infection control policies for their organization. The
CDC recommends that all suspected communicable diseases be reported to the health department
via the infectious disease department. Staff members need to use the appropriate infection
control precautions for all communicable diseases. All communicable diseases need to be
reported, not just those associated with children.
Concepts tested

Question 140
The infection control nurse is evaluating the infection prevention procedures on the unit. Which
of the following observed by the nurse would require intervention?
Question 20 Answer Choices
A The nurse puts on a mask, a gown, and gloves before entering the room of a client on strict
isolation.
B A client with active tuberculosis is asked to wear a mask when he leaves his room to go to
another department for testing.
C A nurse with open, weeping lesions on the hands puts on gloves before giving direct client
care.
D Staff are not wearing gloves when feeding clients in the common dining area.

Question Explanation
Correct Answer is C
Rationale: Persons with exudative lesions or weeping dermatitis should not give direct client care
or handle client-care equipment until the condition resolves; this helps prevent the spread of any
pathogens. There is no need to wear gloves when feeding a client. However, universal
precautions (treating all blood and body fluids as if they are infectious) should be observed in all
situations. A client with active tuberculosis should be on respiratory precautions. Having the
client wear a mask when leaving his private room is appropriate to prevent exposure to others.
Strict isolation requires the use of a mask, a gown, and gloves.
Concepts tested

Question 141
The nurse has attended a staff education conference about internal radiation therapy safety.
Which of the following statements by the nurse indicates a need for further teaching?
A “Caregivers should maintain a 3-foot distance from clients with radiotherapy implants unless
providing direct client care.”

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B “Visitors should be limited to 30-minute visits each day to reduce time exposed to radiation.”
C “Portable lead shields are effective in reducing caregiver exposure to radiation during client
care.”
D “Caregivers and visitors who may be pregnant should not enter the room of clients undergoing
internal radiation therapy.”

Question Explanation
Correct Answer is A
Caregivers and visitors are at risk of excessive radiation exposure when caring for clients who
are undergoing internal radiation therapy for cancer treatments because these patients are
emitting radiation during treatment. Proper safety precautions to reduce exposure include
limiting time, increasing distance from the client, and implementing shielding. The correct
distance that should be maintained is at least 6 feet from the client to reduce exposure to
radiation. Visitors and staff should limit their time with the client to 30 minutes, pregnant staff
and visitors should not enter the room due to potential risk to the fetus, and lead shields should
be implemented to provide a barrier to radiation exposure.
Concepts tested

Question 142
The nurse is caring for a client with a prescription for seizure precautions. The nurse should
implement which action?
A Apply soft restraints on the client’s upper extremities
B Move the client closer to the nursing station
C Provide only paper dishes with meals
D Keep the client’s bed in the low position

Question Explanation
Correct Answer is D
Maintaining the bed in the low position will decrease the chance of injury from a fall during a
seizure. Moving a client closer to the nursing station is for a client who is confused but does not
prevent injury from a seizure. Restraints are used to keep a client safe from self-harm. Providing
paper dishes is an action related to suicide precautions but not seizures.
Concepts tested

Question 143
A charge nurse on a stroke unit receives a request for several client admissions. Which client will
the charge nurse assign to a room in front of the nurses’ station?
A A client with dysphagia
B A client with hemianopsia
C A client with expressive aphasia
D A client with agnosia

Question Explanation
Correct Answer is B

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Hemianopsia is vision loss in one or both eyes. Decreased sensory perception increases the
client’s risk for falls. Expressive aphasia is difficulty with speaking or finding the correct words
to verbally communicate. Clients with expressive aphasia benefit from picture-based
communication boards. Dysphagia is difficulty swallowing. Precautions related to dysphagia
include elevating the head of the bed and assisting the client with meals. Agnosia is the inability
to recognize familiar objects, people, or places. Clients with agnosia are still able to comprehend
safety instructions.
Concepts tested

Question 144
A nurse is admitting a client from the emergency department diagnosed with an ischemic stroke.
The client has right hemiplegia and facial drooping. Which admitting prescription should the
nurse clarify?
A Continuous pulse oximetry
B Mechanical soft diet
C Bed rest
D Neurological checks every hour

Question Explanation
Correct Answer is B
A client with an ischemic stroke and visible signs of paralysis is at risk for dysphagia. Clients
should be evaluated by a speech-language pathologist (SLP) prior to feeding to avoid aspiration.
Continuous pulse oximetry is indicated for clients with an ischemic stroke to monitor
oxygenation. Bed rest promotes safety until the client can be evaluated by physical therapy.
Frequent neurological checks are expected for a client with an ischemic stroke. The nurse should
notify the healthcare provider of any changes.
Concepts tested

Question 145
During a disaster activation plan, a nurse is tasked with recommending the most stable client for
discharge. Which of the assigned clients will the nurse recommend?
A A client with tuberculosis who is on airborne precautions
B A client with a perirectal abscess who requires daily wound care
C A client with an external fixator to the left lower extremity who is homeless
D A client with pancreatic cancer who is post-operative Whipple procedure

Question Explanation
Correct Answer is B
A client with a perirectal abscess who requires daily wound care is the most stable client. Wound
care can be taught to the client’s family or caregiver prior to discharge. A client with tuberculosis
on airborne precautions is not appropriate for discharge. Community spread is possible if the
client is discharged without proper treatment. Clients with invasive devices such as a fixator are
at a high risk for infection. A client who is homeless requires a consult from case management
and social work. A client who had a Whipple procedure is not stable for discharge. A Whipple
procedure is a complex surgery that requires extensive medical management.
Concepts tested
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Question 146
The nurse is triaging clients during an external disaster. Which of the following clients should
the nurse see first?
A The client who has a respiratory rate of 36 and has asymmetrical chest expansion
B The client who has full-thickness burns extending over 75% of the body
C The client who has an open femur fracture with palpable distal pulses
D The client with a scalp laceration who has a moderate amount of bleeding from the site

Question Explanation
Correct Answer is A
In mass casualty disaster situations, triage focuses on doing the greatest good for the greatest
number of people. Therefore, when resources are severely limited, some clients who have very
extensive critical injuries who would otherwise receive massive resuscitation efforts (cervical
cord injury, head injuries, massive burns), may be classified as expectant, or black-tagged and
allowed to die or not be treated. Clients with airway compromise or shock are classified as
emergent and seen immediately, such as the client who is exhibiting a potential pneumothorax.
Clients with open fractures or wounds should be classified as urgent and seen within 30 minutes
to 2 hours. Clients with abrasions or contusions should be classified as non-urgent and can be
seen after 2 hours or when other more urgent clients have been attended to.
Concepts tested

Question 147
The nurse is participating in a disaster drill in which clients must be discharged to make room for
unstable victims. Which of the following clients would require intervention by the nurse?
A The client who is ambulatory and was admitted 2 days ago for observation for lightheadedness
and palpitations
B The client who requires assistance with a walker and is awaiting diagnostic testing for possible
lung cancer
C The client who is on bed rest and had a cardiac catheterization 2 hours ago for evaluation of
chest pain.
D The client who is awaiting transfer to a rehabilitation facility following a minor stroke

Question Explanation
Correct Answer is C
It may be necessary during disaster situations for nurses to determine clients who are stable
enough for discharge to make room for unstable victims. Clients who should be considered for
discharge include those who are admitted for observation and are not bedridden, those who are
having diagnostic evaluations and are not bedridden, and those who could be cared for in another
health care facility, such as long-term care or rehabilitation. The client who just underwent
cardiac catheterization for chest pain must be monitored closely for complications related to the
procedure and the workup for chest pain and is not suitable for discharge.
Concepts tested

Question 148

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A nurse is caring for a client who has left-sided weakness and is being transported to radiology
by wheelchair. Which of the following actions should the nurse plan to take when transferring
the client from bed?
A Raise the bed to the nurse's working height
B Use a gait belt when assisting the client
C Assist the client by lifting under the arms while they stand
D Place the chair on the client's right side

Question Explanation
Correct Answer is B
For a bed-to-chair transfer, the bed should be in its lowest position to prevent client injury. Using
a gait belt will help prevent injury to the client and nurse and allows the nurse to have a firm grip
on the client as needed. During any patient-transferring task, if any caregiver is required to lift
more than 35 lb of a client’s weight, consider them to be fully dependent and use assistive
devices for the transfer. The wheelchair should be on the client’s strong side.
Concepts tested

Question 149
The nurse is providing teaching about system internal radiation to a client diagnosed with thyroid
cancer who will be treated with radioactive iodine. Which of the following statements will the
nurse include in the teaching?
A “You may return to work immediately.”
B “Avoid airplane travel after your treatment.”
C “It is safe to sleep in the same bed as your spouse.”
D “Limit the amount of fluids you drink for several days.”

Question Explanation
Correct Answer is B
I-131 (radioactive iodine) is used to treat thyroid cancer. Clients are asked to follow some
radiation precautions after treatment in order to limit radiation exposure to others, especially
pregnant women and children. Radiation detection devices used at airports or in federal buildings
may pick up even very small radiation levels. Therefore, travel should be avoided if possible.
Clients should sleep in a separate bed (6 feet of separation) for 1-11 days, depending on dosing.
Clients cannot return to work immediately, as they need to remain socially distanced. Fluids are
encouraged in the first 2-3 days after treatment.
Concepts tested

Question 150
The nurse is performing an initial home assessment for a client who is at risk for falls. Which of
the following findings indicates the need for client education?
A Night light plug-ins present in each room
B Raised toilet seats in the bathrooms
C Shower chair present in the client’s bathroom
D Throw rugs on the flooring surfaces

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Question Explanation
Correct Answer is D
The presence of throw rugs increases the risk for falls, and they should be removed. Night lights,
raised toilet seats, and shower chairs are all appropriate devices to help reduce the risk of falling.
Concepts tested

Question 151
The nurse is teaching the parents of a toddler-age client about home safety. Which of the
following statements by the parent indicates the need for further teaching?
A “I will place hot cooking pans on the back burner of the stove with handles pointed inward.”
B “I will ensure my houseplants are kept very low to the ground or on the floor.”
C “I will keep all objects with sharp edges, such as knives, out of my child’s reach.”
D “I will keep all cleaning solutions and medicines in a locked cabinet.”

Question Explanation
Correct Answer is B
The nurse should provide additional teaching if the parent states that houseplants should be
placed on the floor. Toddlers are curious and often stick objects into their mouths, including
plants, which could cause unintentional poisoning. Houseplants should be kept out of reach and
off surfaces that could cause them to get knocked over. It indicates a correct understanding of the
teaching if the client keeps pots on the back burner of the stove, keeps sharp objects out of the
client's reach, and keeps all cleaning solutions in a locked cabinet.
Concepts tested

Question 152
The home-health nurse is assessing the client’s home for fire hazards. Which of the following
findings requires intervention?
A An iron facing upright on the ironing board
B The use of the oven as storage space for food items
C The use of an ashtray on the porch to smoke outside
D Smoke alarms installed on every floor of the house

Question Explanation
Correct Answer is B
It requires intervention if the client is using the oven as storage space for food items, as this can
create a fire hazard if the oven is turned on accidentally. If the client continues to smoke,
smoking should occur outside of the house and away from oxygen, and cigarettes should be
disposed of in an ashtray. It is correct for smoke alarms to be installed on every floor of the
house and for an iron to be placed in an upright position (never facing down) on an ironing
board.
Concepts tested

Question 153
The nurse has attended a staff education conference about incident reporting. Which of the
following statements by the nurse indicates a need for further teaching?
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A “A healthcare provider should submit an incident report if an injury to a client is witnessed,
even if they were not involved in the incident.”
B “An incident report should be submitted when a client refuses a prescribed medication.”
C “An incident report should be submitted if the wrong client receives a chest x-ray.”
D “A nurse should submit an incident report if they recognize, after the fact, that a previous
nurse performed a medication error.”

Question Explanation
Correct Answer is B
An incident report is an agency record of an accident or unusual occurrence in the healthcare
setting, which can be used to help prevent future incidents or accidents. It is the correct
understanding of incident reporting if the nurse states that all healthcare workers should submit
an incident report if an injury is witnessed, regardless of their involvement in the incident. It also
demonstrates a correct understanding of incident reporting if an incident report is submitted if a
client receives a wrong diagnostic treatment. Nurses should also submit an incident report if it is
determined that an error occurred on a previous shift, even if they were not the ones to make the
error. It indicates a need for further teaching if an incident report is submitted for a client who
refuses medications. Clients have the right to refuse medical treatments at any time and the
healthcare provider should be notified, however, this is not considered an adverse event that
requires reporting.
Concepts tested

Question 154
An oncology nurse arrives to the unit and notes the staffing assignment indicates “float to ICU.”
What action does the nurse take?
A Prepare to receive report
B Clarify the duties to be performed
C Refuse the assignment
D Contact the chief nursing officer

Question Explanation
Correct Answer is B
Floating to another unit does not indicate that the nurse will be expected to perform outside of
their scope of practice. The nurse should clarify what duties are expected before accepting the
assignment. The nurse should not receive report and assume care of the clients before knowing
what duties are expected. Refusal of an assignment should not occur until the nurse evaluates the
expected duties are within the scope of practice. Contacting the chief nursing officer does not
follow the chain of command for reporting staffing concerns.
Concepts tested

Question 155
A nurse is providing education to a client on the safe use of a breast pump. Which client
statement indicates the need for further teaching?
A “I will inspect the cord of my electric breast pump for any exposed wires.”
B “I will turn off the breast pump before removing my breast shield.”

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C “I will gradually increase the speed setting on my breast pump.”
D “I will clean the breast pump at the end of every day.”

Question Explanation
Correct Answer is D
Breast pumps should be sanitized after every use to avoid the risk of infection. Electric breast
pumps require a power source and should be inspected with every use. Exposed wires increase
the risk of electric shock. The breast pump should be turned off before attempting to break the
seal between the breast and the shield to avoid tissue injury. A gradual increase in the speed of
the breast pump ensures comfort and decreases the risk of tissue injury.
Concepts tested

Question 156
The nurse is providing staff education on security measures in the newborn nursery. All the
babies in the unit have electronic tags attached to their umbilical cord clamps. What information
about these tags will the nurse include in the training?
A A sensor activates an alarm if the newborn is taken out of the unit.
B The newborn’s identification can be quickly identified using the tag.
C Medication administration is performed after the tag’s barcode is scanned.
D The parent’s identification band is matched to the umbilical tag.

Question Explanation
Correct Answer is A
Prevention of infant abductions has been successful through a combination of increased security
measures in hospitals, including video cameras and alarm devices, and education of staff and
parents about precautions to take while in the hospital. Umbilical tags have electronic sensors
that will activate audible alarms if the baby is taken outside of the unit. Newborn identification is
done using an ID bracelet. Medication administration may utilize barcode scanning, but this is
not done using the umbilical tag. The parent’s identification band is matched to the arm or ankle
ID bracelet.
Concepts tested

Question 157
A home health nurse is working in a neighborhood with a high crime rate. What procedures
should the nurse follow to reduce safety risks?
A Have local law enforcement accompany the nurse for the shift
B Schedule visits during the daytime
C Conduct visits as quickly as possible
D Develop relationships with other residents in the neighborhood

Question Explanation
Correct Answer is B
Visiting during the day is safer. It is not an effective use of law enforcement to have them follow
the nurse throughout the shift. Visits should not be rushed but should be done efficiently. It is

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potentially unsafe, as well as impractical, to develop relationships with other residents unless
they have an association with the client.
Concepts tested

Question 158
The nurse is planning care for a pediatric client with rubeola. Which type of precautions should
the nurse implement for this client?
A Contact
B Droplet
C Airborne
D Neutropenic

Question Explanation
Correct Answer is C
Rubeola is transmitted by air with infectious aerosolized particles, which are micro-droplets that
suspend in the air and travel greater distances. Airborne precautions would require the use of an
N95 mask in addition to the gown and gloves. Droplet precautions are implemented for clients
with respiratory infections that suspend in larger droplets, which do not suspend in the air and
travel less than 3 feet. Contact precautions would require direct contact with the organism such
as stool with E. coli. Bloodborne precautions are for diseases transmitted by blood, such as
hepatitis. Neutropenic precautions are for clients with low WBCs.
Concepts tested

Question 159
The operating nurse is monitoring sterile procedures during a client’s surgery. Which of the
following observed by the nurse would require intervention?
A The surgeon holds the instruments above the waist.
B The instruments in the sterile field are at least two inches from the edge.
C Blood-soaked gauze is placed on the sterile field.
D The sterile field is always in the view of the staff.

Question Explanation
Correct Answer is C
The role of the nurse in the operating room is to monitor and maintain the sterile fields. The
nurse will also evaluate that OR staff maintain sterility during the procedure. Contamination of
the sterile field, such as from used equipment, visibly soiled supplies, or someone crossing the
sterile field, requires the nurse to intervene. To maintain sterility, instruments and supplies
should be kept above waist level. The sterile field should be in constant view of staff to prevent
unwitnessed contamination. A sterile field has a border of two inches from the edge that is not
sterile.
Concepts tested

Question 160

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The nurse is planning care for a group of assigned clients. Which client would be most
appropriate for the nurse to request a prescription for physical restraints?
A The client with a history of falls who uses a walker with ambulation
B The client with dementia who keeps pulling on the inserted nasogastric tube
C The client with a decrease in visual acuity who is touching the IV site
D The client with incontinence who is attempting to get out of bed

Question Explanation
Correct Answer is B
Restraints are physical devices that can limit the client’s movement and are used to keep the
client safe from injury. The nurse should attempt to use alternatives to restraints, such as provide
the client with a bedside commode, bed alarms for fall risks, and communicating with the client
about interventions. Restraints are used when alternative interventions are unable to keep the
client safe from harm, such as to maintain placed tubes or prevent injury to staff.
Concepts tested

Question 161
A pre-school nurse is providing education to parents on poisoning prevention. Which statement
made by a parent indicates the need for further teaching?
A “I have my furnace professionally inspected each year.”
B “I keep the poison control center phone number on the counter.”
C “I always store my cleaning products underneath the sink.”
D “I dispose of medications in the trash mixed with coffee grounds.”

Question Explanation
Correct Answer C
Rationale: Poisoning prevention in children includes keeping toxic chemicals out of reach.
Storing cleaning products underneath the sink is not safe unless a cabinet has a safety latch.
Furnaces should be professionally inspected each year to ensure good ventilation and proper
escape of combustion byproducts. The poison control center phone number should be kept within
reach at all times in case of accidental ingestion. Disposing medications mixed with coffee
grounds or cat litter discourages children from ingesting substances.
Concepts tested

Question 162
The nurse is providing education at a prenatal class about car seat safety. Which client statement
indicates understanding of the use of the car seat?
A “I can use the car seat that my mom used for me when I was a child.”
B “My infant can ride in a rear-facing seat in the front seat of my car.”
C “I will make sure that the car seat is secured with the safety belt.”
D “I will make sure my car seat is fastened upright.”

Question Explanation
Correct Answer is C

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Rationale: When installing a car seat, follow the manufacturer's instructions on how to secure the
seat with the car’s seat belt. After 10 years, car seats are considered expired. Car seats should not
be placed in the front seat due to the risk of airbag deployment. Infant seats need to be in a semi-
reclining position to prevent their chin from falling on their chest to maintain an open airway.
Concepts tested

Question 163
The nurse is assessing a client who is 2 days post-operative from coronary artery bypass graft
surgery and is sitting up in a chair. The nurse observes that the client is cold to the touch, appears
pale, and is reporting dizziness. Which intervention should the nurse take first to prevent injury
to the client?
A Apply oxygen at 2 liters.
B Check the client’s vital signs.
C Put the client back in bed.
D Call the healthcare provider.

Question Explanation
Correct Answer is B
Rationale: When caring for a client who becomes dizzy in a chair, the nurse should first assess
the client’s vital signs. Assessing blood pressure and heart rate can evaluate if the client can
safely be moved back to the bed. If the client is hypotensive or bradycardia, the nurse will
require additional assistance to safely move the client. The nurse should assess the SP02 before
administering oxygen. The nurse will call the healthcare provider once the client is stable.
Concepts tested

Question 164
A nurse is preparing to administer intravenous medication to a client. Which action by the nurse
ensures the medication is administered to the correct client?
A Asks the client to state their name and date of birth
B Verifies the medication has a client label
C Checks the medication against the prescription and the MAR
D Ensures the client has an identification wristband

Question Explanation
Correct Answer is A
Rationale: Proper identification of a client requires two identifiers. The client’s name and date of
birth are two commonly used identifiers. Verifying the medication has a client label should be
performed before dispensing the medication. This process does not ensure it is administered to
the correct client. Checking the medication against the prescription and the medication
administration record is one of the three checks of medication administration. However, this does
not ensure that the medication is administered to the correct client. Ensuring the client has an
identification wristband does not guarantee the information printed on the wristband is correct.
Concepts tested

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Question 165
The nurse has attended a staff training program about nursing roles during disasters. Which of
the following statements by the nurse indicates a correct understanding of the training?
A “Nurses should be prepared to work on different units during a disaster.”
B “General staff nurses should be assigned to perform triage for incoming clients to determine
level of severity of injuries.”
C “Nurses who are not scheduled to work should remain at home during a disaster.”
D “A nurse should expect to perform duties outside the nursing scope of practice during a
disaster.”

Question Explanation
Correct Answer is A
Rationale: Nurses should be prepared to perform roles outside of their regular duties during a
disaster, however this does not include acting out of scope for nursing practice. General staff
nurses should be assigned to care for stable clients in the emergency department, thus allowing
emergency department nurses to perform critical triage duties. Nurses who are not scheduled to
work should be ready to report to their facility to assist with any duties that may be needed.
Concepts tested

Question 166
The nurse has attended a staff training program about client triage during a disaster. Which of the
following statements by the nurse indicates a correct understanding of the training?
A “Clients with injuries such as airway obstruction or shock should be classified as emergent
and seen immediately.”
B “Clients with injuries such as open fractures or large wounds should be classified as nonurgent
and can generally be seen in more than 2 hours.”
C “Clients experiencing abrasions and contusions should be classified as expectant and may not
be treated.”
D “Clients with massive head trauma, extensive burns, or high cervical spinal cord injury should
be classified as urgent and should be seen within 30 minutes to 2 hours.”

Question Explanation
Correct Answer is A
Rationale: In mass casualty disaster situations, triage focuses on doing the greatest good for the
greatest number of people. Therefore, when resources are severely limited, some clients who
have very extensive critical injuries who would otherwise receive massive resuscitation efforts
(cervical cord injury, head injuries, massive burns), may be classified as expectant, or black-
tagged and allowed to die or not be treated. Clients with airway compromise or shock are
classified as emergent and seen immediately. Clients with open fractures or wounds should be
classified as urgent and seen within 30 minutes to 2 hours. Clients with abrasions or contusions
should be classified as nonurgent and can be seen after 2 hours or when other more urgent clients
have been attended to.
Concepts tested

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Question 167
The nurse is assessing the client’s ability to perform proper use of crutches while ambulating.
Which of the following actions by the client requires intervention?
Question 7 Answer Choices
A Placing crutches at a 6-inch distance in front of the feet.
B Maintaining the back in straight alignment and eyes gazing forward.
C Maintaining the weight of the body on the axilla during movement.
D Placing the crutches 6-inches out laterally on either side of the feet.

Question Explanation
Correct Answer is C
Rationale: Correct technique for crutch walking includes placing the crutches at a 6-inch distance
both in front of the feet as well as 6 inches out laterally on either side of the feet to maintain a
wide base of support. The client should maintain the back in straight alignment and look
forward, not down, while ambulating to reduce the risk of falls. It requires intervention if the
client is maintaining the weight of the body on the axilla instead of the wrists, as this can cause
radial nerve injury and eventually crutch palsy, causing weakness of the muscles of the forearm,
wrist, and hand.
Concepts tested

Question16 8
The homecare nurse is caring for a client on home oxygen. Which of the following findings
requires an immediate further assessment?
A An ashtray is present on the side table.
B The heating system in the home is natural gas forced air.
C The oxygen concentrator is plugged into a surge protector.
D Replacement air filters are present on the kitchen counter.

Question Explanation
Correct Answer is A
Rationale: Oxygen is combustible, so clients should not smoke while using oxygen. The
presence of an ashtray should alert the nurse that this may be occurring. Oxygen concentrators
may be plugged into surge protectors, and it is recommended to change the filter every 6 months
to 1 year based on usage. The use of natural gas for the household heater is not a risk to the client
on home oxygen.
Concepts tested

Question 169
The nurse is caring for a client diagnosed with prostate cancer who is prescribed oral
cyclophosphamide. Which of the following actions should the nurse take when caring for the
client on this medication?
A Instruct the client to wear gloves when picking up the medication.
B Crush the medication before administration.
C Inform the client that any unused medication should be flushed down the toilet.
D Advise the client to take the medication with food.

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Question Explanation
Correct Answer is A
Rationale: Oral cyclophosphamide is a cytotoxic medication that is used for many cancers.
Clients may self-administer these medications at home and, therefore, they may be used outside
of an oncology unit. However, this does not mean the drug is safer via the oral route. Gloves
should always be worn when handling the medication. If gloves are not worn by the client, teach
them to tip tablets and capsules from their container/blister pack directly into a disposable
medicine cup. Oral chemotherapeutics should not be crushed. These medications should be
disposed of as cytotoxic waste according to the local waste disposal regulatory guidelines.
Cytoxan should be taken on an empty stomach unless irritation occurs.
Concepts tested

Question 170
The nurse is completing a home health visit for a client who experiences right sided-weakness
due to a previous cerebrovascular accident. Which of the following statements by the nurse is an
appropriate safety recommendation?
A “Use a long-handled bath brush while showering.”
B “Using a bedside commode will cause further loss of mobility.”
C “Avoid using your weak side for self-care practices.”
D “Only complete range of motion activities with assistance.”

Question Explanation
Correct Answer is A
Rationale: The client who experiences hemiplegia will benefit from modified self-care devices,
such as a long-handled shower brush. These devices reduce the risk of falls and injuries. Using a
bedside commode may be necessary and will not cause mobility loss. The client should use the
affected side as much as possible. The client should complete range of motion activities with the
caregiver but can do these activities independently as well.
Concepts tested

Question 171
The nurse is teaching the parents of a toddler-age client about protective measures to reduce
injuries at home. Which of the following actions, if identified by the parent, indicates the need
for further teaching?
A Placing covers over electrical outlets
B Installing screens on windows and balconies
C Obtaining a bed with high railings
D Keeping plastic bags stored in a secured container

Question Explanation
Correct Answer is C
Rationale: It indicates the need for further teaching if the parent states that they will obtain a bed
with high railings for toddlers. Toddlers are prone to climbing and it is recommended to obtain a
low bed without railings at this age to prevent falls and climbing-related injuries. It is the correct
understanding of protective measures to place covers over electrical outlets, to install screens on

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windows and balconies to prevent falls, and to keep plastic bags in a secure storage container out
of reach to prevent suffocation.
Concepts tested

Question 172
The nurse is documenting an occurrence in which a surgical tool was left in a client’s abdomen
following a procedure. Which type of practice error should the nurse document as having
occurred?
A A never-event
B A sentinel event
C A near-miss event
D An unpreventable event

Question Explanation
Correct Answer is A
Rationale: The nurse should document the retention of a surgical object in a client following a
procedure as a never-event. Never-events are defined by the Joint Commission as surgeries on
the wrong body part, foreign objects placed in the client after surgery, and mismatched blood
transfusions. A sentinel event is one in which serious injury or death occurred due to errors. A
near-miss event is the identification of any event or situation that might have resulted in client
harm, but the harm did not occur due to timely intervention by healthcare staff. An
unpreventable event is one in which death or client injury would occur in the absence of a
medical error.
Concepts tested

Question 173
A nurse is admitting a client after an intravenous pyelogram. The nurse notes an allergy to
shellfish on the client’s medical record. Which action does the nurse perform next?
A Provides oral fluids to the client.
B Assesses the client’s airway.
C Monitors client’s urinary output.
D Checks the client’s intravenous line.

Question Explanation
Correct Answer is B
Rationale: An intravenous pyelogram uses contrast media to examine the urinary structures on an
x-ray. Contrast media is contraindicated in clients with an allergy to iodine. Clients with an
allergy to shellfish may also have a cross allergy to iodine. The nurse should assess the client for
signs and symptoms of an allergic reaction. Providing oral fluids and monitoring the client’s
urinary output are important actions after the procedure. However, these actions are not the
priority. Checking the client’s intravenous line assesses for patency after contrast media is
injected. However, the priority is to assess the client for an allergic reaction to the contrast.
Concepts tested

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Question 174
A nurse is inspecting medical equipment in a client’s room. Which finding
requires immediate intervention?
A The sharps container is halfway full.
B The bed is connected to the wall with a three-prong electric plug.
C The vital signs machine is unplugged.
D There is a water spill behind the infusion pump.

Question Explanation
Correct Answer is D
Rationale: Electrical cords for equipment should be kept away from water sources. The nurse
should ensure the water spill is cleaned to avoid the risk of electrocution. A sharps container that
is halfway full does not require immediate attention. A three-prong plug is recommended to
provide a ground for electrical equipment. An unplugged vital signs machine can drain the
battery. However, reconnecting the machine is not the priority action.
Concepts tested

Question 175
A nurse is instructing an unlicensed assistive personnel (UAP) on how to take manual blood
pressure on a client. Which action by the nurse indicates correct use of the blood pressure
equipment?
A Selects a cuff with a bladder length that is 60% of the arm’s circumference
B Lines up the arrow on the cuff with the radial artery
C Closes the valve on the bulb by turning it counterclockwise
D Centers the deflated cuff 1 inch above the brachial artery

Question Explanation
Correct Answer is D
Rationale: The deflated cuff should be centered 1 inch above the brachial artery to allow room
for the stethoscope diaphragm to placed. The length of the cuff bladder should be 80% of the
arm’s circumference to obtain an accurate measurement. The arrow on the cuff should line up
with the brachial artery, not the radial. The valve closes when it is turned clockwise.
Concepts tested

Question 176
The charge nurse is working on the medical floor when the fire alarm goes off. The fire is on the
same floor, but on the other side of the fire doors. Which of the following preparations should
the nurse take first?
A Assign a nurse to be responsible for manning the oxygen shut-off valve
B Plan to evacuate all clients vertically
C Remove all equipment from the hallways
D Implement the R.A.C.E. program

Question Explanation
Correct Answer is A

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Rationale: In the event of an emergency that would potentially allow oxygen to escape into the
immediate area or room intensifying a fire hazard, oxygen and medical gas should be shut off.
Clients may shelter in place unless there is an immediate threat to health and safety. Equipment
should be moved from the hallways in the event of an evacuation, but that is not the priority.
Rescue, Alarm, Contain, Extinguish/Evacuate (R.A.C.E.) would have already been implemented
at this point.
Concepts tested

Question 177
A client is being assessed for flu-like symptoms and a red bite on the leg. The nurse suspects the
client has Lyme disease. Who should the nurse notify?
Question 17 Answer Choices
A Center for Disease Control and Prevention
B Local health department
C Infectious disease specialist
D Hospital risk management

Question Explanation
Correct Answer is B
Rationale: Lyme disease is a trackable disease reportable to the health department. Upon
confirmation, the health department may report it to the CDC. The nurse would not need to
report the information to an infectious disease specialist unless the client has received a
prescription for treatment. Hospital risk management is notified when there is an ethical or legal
issue related to client care.
Concepts tested

Question 178
Which action by the nurse demonstrates understanding of precautions for an
immunocompromised client?
A Takes the meal tray into the client’s room
B Takes the client's vital signs including the temperature every shift
C Makes the client wear a mask while care is provided in the room
D Makes the client brush their teeth before each meal

Question Explanation
Correct Answer is A
Rationale: The nurse taking the tray into the room will limit the number of people entering the
room which reduces the exposure to pathogens. Vital signs, including temperature, should be
taken every 4 hours to detect potential infection. The client does not need to wear a mask while
in their own room but should wear one when leaving the room. Clients should maintain oral
hygiene but brushing before each meal is not necessary.
Concepts tested

Question 179
The nurse is preparing to apply soft physical restraints on a client who is attempting to pull out
the placed indwelling urinary catheter. Which action should the nurse take?

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A Ensure that the strap is tightly secured around the wrist
B Flex the client’s arms slightly before securing the ties
C Create a knot in the middle of the ties
D Secure ties to the bed frame

Question Explanation
Correct Answer is D
Rationale: Restraints are physical devices that can limit the client’s movement and are used to
keep the client safe from injury. When applying soft wrist restraints, the nurse should ensure that
the strap fits snugly around the wrist, allowing two fingers to be inserted under the strap. If the
strap is too tight, it can cause impaired circulation. The nurse should position the client’s arms in
a natural position to the client’s side. Some restraints require the ties to be tied in a knot at the
wrist strap, but the ties should be separate through the length. The nurse will secure the ties to the
bed frame using a quick-release knot.
Concepts tested

Question 180
The nurse is caring for a client who is confused and is directly harming staff and self. The nurse
applies mitten restraints. Which action is the priority for the nurse to take?
A Document use of restraints.
B Obtain prescription for restraints from healthcare provider.
C Educate family on use of restraints.
D Notify the charge nurse that restraints have been initiated.

Question Explanation
Correct Answer is B
Rationale: Restraints, which are safety devices that restrict a client’s movement, should be
implemented as a last resort. Restraints are used when the client’s actions could cause harm to
self or others. Nurses can apply restraints in emergency situations but are required to obtain a
prescription from the healthcare provider immediately after application. Once a prescription is
obtained, then the nurse will document, educate family, and notify staff of restraint use.
Concepts tested

Question 181
A nurse is assessing environmental safety in the home of a client with a toddler. Which
observation by the nurse would require immediate follow up?
A A pile of paper bags in the living room
B A swimming pool in the backyard
C A jewelry box on a high-top counter
D A stairwell cluttered with shoes

Question Explanation
Correct Answer is B
Rationale: Unintentional drowning is one of the leading causes of suffocation in children. A
swimming pool is a high-risk area for toddlers. Identifying environmental risks can prompt the
nurse to educate on water safety. Plastic bags as opposed to paper are a high risk for suffocation.
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Small items, such as jewelry or toys, should be kept out of the toddler’s reach. A high-top
counter is an acceptable area. A cluttered stairwell is a high risk for falls, not suffocation.
Concepts tested

Question 182
The nurse is preparing a client for a prescribed MRI. The client states “If I get anxious during the
procedure, how will I notify staff?” Which statement would be appropriate for the nurse to
make?
A “There will be a microphone in the machine for you speak to the staff.”
B “Just raise your hands to get the attention of the staff.”
C “Press the button to move out of the machine.”
D “A staff member will be in the room with you.”

Question Explanation
Correct Answer is A
Rationale: MRI uses a magnet to get images. The machine is loud. MRI machines have a two-
way microphone to communicate with the staff. The client needs to remain still so the images are
not distorted. Staff members do not remain in the room during the procedure.
Concepts tested

Question 183
A nurse is providing discharge instructions on safety precautions to a client newly diagnosed
with epilepsy. Which client statement indicates the need for further teaching?
A “I will make sure someone is always with me when I drive.”
B “I will pad the hard edges of furniture.”
C “I will wear a medical identification tag at all times.”
D “I will take showers instead of baths.”

Question Explanation
Correct Answer is A
Rationale: Driving laws differ in every state, with some of them restricting or limiting driving for
people who have a history of recent seizure activity. The nurse should encourage the client to
research state driving laws for safety purposes. Padding hard edges of furniture decreases the risk
of injury should a client have a seizure that results in a fall. A medical identification tag is
encouraged. Medical identification tags can alert bystanders of a medical condition in case of an
emergency. Taking a bath increases the risk of a submersion injury should a seizure with loss of
consciousness occur.
Concepts tested

Question 184
A charge nurse is assigning new admissions to the surgical unit. Which client will the charge
nurse assign to the room across from the nurses’ station?
A A postoperative client with history of schizophrenia
B A client transferred from the ICU with severe pain
C A postoperative client with symptoms of delirium
D A client transferred from the ED with a chest tube

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Question Explanation
Correct Answer is C
Rationale: Postoperative delirium can occur as a result of general anesthesia. The client may
experience agitation and hallucinations. Clients with delirium require frequent visual checks to
ensure safety. A client with a history of schizophrenia does not require special accommodations
unless actively experiencing symptoms of the illness. A client with severe pain does not need to
be assigned close to the nurses’ station. The client should be provided instructions on how to call
for assistance. A client with a chest tube does not require frequent visual checks. The nurse
should assess the client and the chest tube as per protocol.
Concepts tested

Question 185
A nurse is providing care to a client with hepatorenal syndrome post-dialysis. Upon assessment,
the client is confused and the nurse notes jaundice and ascites. Which admitting prescription will
the nurse clarify?
A Implement fall precautions
B Obtain consents for paracentesis
C Initiate continuous bedside cardiac monitoring
D Collect type and crossmatch for packed red blood cells

Question Explanation
Correct Answer is B
Rationale: The nurse should clarify the prescription to obtain consents for a paracentesis. Clients
who are post-dialysis are at a high risk for bleeding for the first several hours. A paracentesis is
an invasive procedure that can cause bleeding. Implementing fall precautions is indicated for a
client who is confused. Continuous cardiac monitoring is not an invasive procedure or
contraindicated with dialysis. A type and crossmatch is a laboratory test used to assess
compatibility of blood for a transfusion. Obtaining labs is not contraindicated post dialysis.
Concepts tested

Question 186
The charge nurse is observing nursing personnel provide client care during an external disaster in
the community. Which of the following actions by a nurse would require the charge nurse to
intervene?
A Inserting an oropharyngeal airway in an unconscious client
B Splinting an injured client's extremity in the position they are found.
C Applying pressure after removing penetrating objects from clients
D Providing warming blankets to clients

Question Explanation
Correct Answer is C
Rationale: Guidelines for first aid treatment during a disaster include protecting clients' airways,
splinting injured parts in the position they are found, maintaining normothermia, and retaining
penetrating objects in place. The charge nurse should intervene if staff is observed removing the

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penetrating objects and applying pressure, as these objects should be left in place; removing
them could cause further internal damage and hemorrhage. The other actions are all correct
nursing actions during a disaster.
Concepts tested

Question 187
The nurse has attended a staff training program about recognition of potential bioterrorism in the
community. Which of the following statements by the nurse indicates a need for further training?
A “An unusual geographic clustering of illness may indicate potential bioterrorism.”
B “High incidence of an illness in an expected population may indicate bioterrorism.”
C “An increase in emergency department clients who report similar symptoms may indicate
bioterrorism.”
D “The local health department should be notified of any unusual patterns identified in a facility
that may indicate bioterrorism.”

Question Explanation
Correct Answer is B
Rationale: Health care workers need to have a heightened awareness of patterns that may
indicate potential bioterrorism, such as unusual clustering of illness in a geographic area or an
increase in emergency department visits of clients with similar symptoms. It requires further
teaching if the nurse states that a high incidence of illness in an expected population indicates
bioterrorism. A high incidence of illness in an unusual or unexpected population, such as
chickenpox-like symptoms in adults instead of children, could indicate bioterrorism and such
patterns should be reported to the local health department to determine if a larger pattern is
occurring within the community.
Concepts tested

Question 188
The nurse is assisting a colleague to change the linens on an occupied bed. The client is
dependent after experiencing a large cerebrovascular accident. Which of the following actions
reduces the risk of injury to the client and staff?
A Roll the client toward the nurse using the hip and shoulder as hand positions
B Turn the client away from the nurse using the hip and shoulder as hand positions
C Push the client to the opposite side using force against the hip and shoulder
D Drag the client toward the nurse using the slide sheet and shoulder

Question Explanation
Correct Answer is A
Rationale: When lifting any object, keep it close to the body. Therefore, it is best to roll the client
toward the nurse who is supporting the weight. Pushing and pulling the client can cause injury to
both the nurse and client.
Concepts tested

Question 189
The nurse is providing an in-service to nursing staff on oxygen safety. Which information should
the nurse include in the teaching?

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A Place the cylinder between the client’s legs during transport
B Secure the cylinder in a holder when brought into the MRI suite
C Store unused cylinders upright in a rack
D Store empty cylinders on their side

Question Explanation
Correct Answer is C
Rationale: Compressed gas cylinders must always be in an upright position and supported,
whether full or empty. Acceptable methods of support include wall-mounted or bench-mounted
gas cylinder brackets, chains or belts anchored to walls or benches, and free-standing dollies or
carts designed for gas cylinders and equipped with safety chains or belts. Do not bring oxygen
cylinders into an MRI suite as they are ferromagnetic. If a cylinder falls off the bed, it can
become a projectile.
Concepts tested

Question 190
The nurse is caring for a client who has just had an internal radiation therapy implant placed.
Which of the following actions by the nurse is appropriate to ensure safety?
A Educating visitors to sit on the other side of the room
B Allowing the client’s support person to stay overnight
C Assigning the client to a shared hospital room
D Ensuring that staff members wear a dosimeter badge

Question Explanation
Correct Answer is D
Rationale: For the client undergoing internal radiation therapy, the nurse and all other care staff
should wear a dosimeter badge to monitor the amount or radiation that they are exposed to.
Typically, visitors are asked to be in the room for 30 minutes or less, therefore overnight stays
are not considered safe. Visitors maintain a distance of 6 feet or more from the client. This client
should be assigned to a private room.
Concepts tested

Question 191
The nurse is completing a home health visit for a client who has limited mobility. Which of the
following findings indicates the need for intervention to ensure safety?
A The client’s bedroom is on the second floor of the home
B Grab bars are present in the client’s shower
C The client uses a walker to ambulate in the home
D Exterior windows have a locking mechanism

Question Explanation
Correct Answer is A
Rationale: If the client has limited mobility, a second-floor bedroom is not ideal. Having to go up
and down stairs increases the risk of falls. If the client must have a bedroom on an upstairs floor,
modifications and education are imperative to ensure safety. Grab bars and walkers both are

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devices that can assist the client to perform the activity safely. Locking exterior windows does
not increase the risk of injury.
Concepts tested

Question 192
The nurse is teaching the parents of a school-age client about home safety. Which of the
following statements by the parent indicates the need for further teaching?
A “I will ensure my child wears reflective clothing when walking at night.”
B “I will ensure my loaded firearm is kept in a locked cabinet.”
C “I will ensure my child wears a helmet while using a bicycle.”
D “I will ensure my child is supervised when using electrical appliances and tools.”

Question Explanation
Correct Answer is B
Rationale: It requires additional teaching if the parent states that a loaded firearm is kept in a
locked cabinet. While it is correct to lock firearms, they should be kept unloaded and the
ammunition should be kept in a separate location from the firearm. It indicates a correct
understanding of the teaching if the parent ensures their child wears reflective clothing at night,
wears a helmet while bicycling, and is supervised while using electronic tools.
Concepts tested

Question 193
The home-health nurse is assessing the client’s home for electrical hazards. Which of the
following findings requires intervention?
A Electrical cords are coiled and taped to the ground.
B Electrical appliances are placed away from wet areas.
C Frayed electrical cords are taped with electrical tape.
D Appliances are plugged into grounded outlets.

Question Explanation
Correct Answer is C
Rationale: It requires intervention if the client has repaired frayed electrical cords with electrical
tape. All damaged equipment should be evaluated and repaired by an electrician. It is correct for
the client to coil and tape cords to the ground, to keep appliances away from wet areas, and to
use grounded outlets.
Concepts tested

Question 194
The nurse has attended a staff education conference about incident reporting. Which of the
following statements by the nurse indicates a need for further teaching?
A “An incident report should be submitted when a client chooses to leave a facility against
medical advice.”
B “An incident report should be submitted if a client is given the wrong medication.”
C “An incident report should be submitted when a client develops respiratory arrest after
receiving a prescribed opioid analgesic.”

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D “An incident report should be submitted if the wrong client is transported to the radiology
department for an x-ray.”

Question Explanation
Correct Answer is A
Rationale: An incident report is an agency record of an accident or unusual occurrence in the
healthcare setting, which can be used to help prevent future incidents or accidents. It is the
correct understanding of incident reporting if the nurse states that a medication error, a major
adverse event such as respiratory arrest due to medical treatments, and a near-miss on an
incorrect procedure on a client require incident reports. These are all considered errors or
adverse/preventable events and should be reported to identify strategies to reduce human error
and adverse events in the future. It indicates a need for further teaching if an incident report is
submitted for a client who chooses to leave against medical advice. Clients have the right to
refuse medical treatments at any time. The healthcare provider should be notified and proper
documentation in the medical record regarding refusal of treatment is needed, however, this is
not considered an adverse event that requires incident reporting.
Concepts tested

Question 195
A nurse is providing education to a client on the safe use of oxygen equipment at home. What
will the nurse include in the teaching?
A “Transport the oxygen tank on its side when travelling by car.”
B “Clean the nasal cannula tubing with an alcohol-based product.”
C “Use oxygen tubing that is less than 50 feet in length.”
D. “Keep the oxygen concentrator 6 feet away when you are cooking.”

Question Explanation
Correct Answer is D
Rationale: Oxygen equipment should be kept at least 6 feet away from any source of fire to
decrease the risk of combustion. Oxygen tanks should always be kept upright to decrease the risk
of oxygen escaping and causing combustion. Alcohol is flammable and can cause a fire. Tubing
can be up to 30 meters (98.4 feet) in length to allow the client freedom of movement in the
home.
Concepts tested

Question 196
The charge nurse working in the pediatrics unit responds to the doorbell of the locked unit. A
hospital contractor is at the door to do maintenance but has no identification and is
unaccompanied. Which of the following responses is appropriate?
A Allow the contractor to enter the unit and observe them closely
B Call security to escort the contractor to the security office for identification verification
C Ask someone from maintenance to meet the contractor on the unit
D Direct the contractor to the nurse manager’s office to follow up

Question Explanation
Correct Answer is B

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Rationale: Identification programs are in place as a form of security planning. This includes
employees as well as contractors. In sensitive areas like the pediatrics unit, this is of particular
importance in preventing child abduction. In this scenario, it is appropriate to call security to
escort the individual to the security office. Someone from the maintenance office can verify the
contractor and have an identification tag created. It is important to call security in the event that
the contractor is not authorized to be in that location. Failure to notify security may put other
staff, visitors, and clients at risk.
Concepts tested

Question 197
The nurse reviews the home care instructions with a parent of a 3-year-old client who has
pertussis. Which statement by the parent indicates a need for further teaching?
A "I know that my child will make a loud whooping sound."
B "I understand this whooping cough is viral, and I have to let it run its course."
C "I understand that I need to watch for respiratory distress signs with pertussis."
D "Coughing spells can be triggered by dust or smoke."

Question Explanation
Correct Answer is B
Rationale: Pertussis is caused by the bacteria Bordetella pertussis and treatment requires
antimicrobial therapy. Pertussis is transmitted by direct contact or respiratory droplets from
coughing. The communicable period occurs primarily during the catarrhal stage. Symptoms of
pertussis consist of a respiratory infection followed by increased severity of cough with a loud
whooping on inspiration. The child may experience respiratory distress, and the parents should
be instructed on reducing environmental factors that cause coughing spasms, such as dust,
smoke, and sudden changes in temperature.
Concepts tested

Question 198
The nurse is preparing a sterile field at the bedside a client with confusion. While opening up
supplies, the client reaches over the field and touches several instruments. Which is the
appropriate action for the nurse to take?
A Ask another nurse to hold the hand of the client and continue setting up the field
B Remove the instruments that were touched by the client and continue setting up the sterile field
C. Discard the supplies and prepare a new sterile field with another person holding the client's
hand
D Apply a soft wrist restraint so the client does not touch the field again

Question Explanation
Correct Answer is C
Rationale: Once an item is touched in the field, the whole field is unsterile. The field should be
discarded, and a new field should be set up with someone holding the client’s hands. You would
not continue to set up the field since it is unsterile. Removing the instruments that were touched
does not correct the situation that the field is still unsterile. Applying a wrist restraint may
increase the confusion of the client and needs a healthcare provider's prescription.
Concepts tested

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Question 199
The nurse is working with an unlicensed personal assistant (UAP) to care for a client who has
soft, bilateral wrist restraints placed. Which task is the responsibility of the nurse?
Question 19 Answer Choices
A Assess the client’s skin underneath the restraints
B Provide the client with fluids every two hours
C Assist the client to the bathroom every hour
D Set up the client’s meal tray

Question Explanation
Correct Answer is A
Rationale: Restraints are physical devices that can limit the client’s movement. The nurse is to
protect and promote the client’s rights while in restraints. The client should be provided
opportunities to use the restroom, drink, and eat, which are tasks that can be delegated to the
UAP. The nurse is responsible for the assessment of the client, which includes skin integrity and
circulation.
Concepts tested

Question 200
The nurse is assessing a client who is sitting up in a wheelchair and is wearing a safety vest.
Which finding by the nurse would require immediate intervention?
A Nausea reported by client
B Diminished breath sounds
C Hyperactive bowel sounds
D Headache reported by client

Question Explanation
Correct Answer is B
Rationale: A safety vest is worn when a client is sitting up in a wheelchair or chair and ensures
the client does not slide out of the chair. The vest, which is a type of physical restraint, is
positioned over the client’s chest with the straps on the back of the vest. If the vest is too tight
around the chest, the client is at increase risk of impaired breathing, which could result in
diminished breath sounds. If the vest is too tight around the abdomen, the client could report
nausea and have hypoactive bowel sounds. A headache is not a complication of wearing a safety
vest.
Concepts tested

Question 201
The nurse is stuck in the hand by an exposed needle that was accidentally left in the client's bed.
Which action should the nurse take first?
A Contact employee or occupational health services.
B Look up the policy and procedure on needlestick injury.
C Immediately wash hands vigorously with soap and warm water.
D Notify the nursing supervisor and complete an incident report.

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Question Explanation
Correct Answer is C
Rationale: The immediate action of vigorously washing the hands will help reduce the risk of
potential exposure to bloodborne pathogens. The nurse should then follow the facility’s policy
and procedure for employee needlestick injury.
Concepts tested

Question 202
Several victims from a mass casualty event are brought to the emergency department. Which
client should the nurse see first?
A The client with multiple wounds and an open fracture
B The client with hypotension and a sucking chest wound
C The client with head trauma and agonal respirations
D The client with a nondisplaced fracture of the radius

Question Explanation
Correct Answer is B
Rationale: The nurse should use the disaster triage color system in combination with the
Airway-Breathing-Circulation prioritization approach to decide which client to see first. The
client with head trauma and agonal respirations is most likely suffering from brainstem
trauma/pressure and seems to be near death; therefore, the nurse should see the client with a
sucking chest wound first because that client has a better chance of survival.
Concepts tested

Question 203
A client arrives in the emergency department after a radiological accident at a local factory.
After placing the client in the decontamination room, the nurse shall give priority to which
intervention?
A Ensure physiological stability of the client
B Double bag the client's contaminated clothing.
C Wrap the client in blankets to minimize staff contamination.
D Begin decontamination procedures for the client.

Question Explanation
Correct Answer is A
Rationale: Acute radiation syndrome (ARS) is caused by irradiation of the body by a high dose
of radiation in a very short period of time. The treatment goals for ARS are to prevent further
radioactive exposure and treat life-threatening injuries. The nurse must initially assist in the
stabilization of the client prior to the implementation of any other tasks related to contamination.
Evaluating the client’s airway, breathing, and circulation, i.e., physiological functions, is
the priority. Once the client is deemed stable, the decontamination process can begin.
Decontamination involves removing radioactive particles. Removing clothing and shoes (e.g.,
double bagging clothes) eliminates external contamination.
Concepts tested

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Question 204
The nurse is caring for a client who is prescribed a new medication. Prior to the administration of
the medication, which action by the nurse best demonstrates an awareness of safe and competent
nursing practice?
A Ask the client for their name, date of birth and allergy history, then check the client's
identification band.
B Verify the order for the medication on the admission sheet, then ask the client their name.
C Ask the client for their medical record number, then check the client's identification band.
D Verify the client's name on the admission sheet, then check the client's identification band.

Question Explanation
Correct Answer is A
Rationale: Safe medication administration is an important nursing skill. Using at least two client
identifiers must always be done prior to administering a medication. This involves verbal and
visual checks. Because this is a new medication, an allergy check is also appropriate. The nurse
demonstrates best practice by asking the client for their name, date of birth and allergy history
and then checking the client's identification band. The other actions do not adhere to best practice
recommendations for medication administration.
Concepts tested

Question 205
The nurse is caring for a client with dementia who wanders throughout the long-term care
facility. Which intervention by the nurse would best ensure the safety of the client?
A Apply an electronic alert wristband.
B Explain the risk of walking with no assistance.
C Reorient the client to time, person and place.
D Administer an antianxiety medication.

Question Explanation
Correct Answer is A
Rationale: A "wandering" management system is used to give clients with dementia and other
"at risk" clients the ability to move freely where they live. The sensor in the bracelet sets off an
alarm that is attached to exterior doors if the client attempts to leave the facility. Explaining the
risks of walking without assistance may not help as the client may not understand or remember
the instructions. Reality orientation is inappropriate for someone with dementia. It is
inappropriate and unethical to use medications as chemical restraints to stop the client from
wandering.
Concepts tested

Question 206
The nurse is caring for a client with schizophrenia, who has an order for haloperidol 5 mg PO
every four hours as needed. Which behaviors justify the use of this chemical restraint? Select all
that apply.

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A The client is expressing paranoid delusions.
B The client is verbalizing a plan to harm another client.
C The client is refusing to participate in unit group activities.
D The client is experiencing command hallucinations.

The client is crying after a difficult family meeting.

Question Explanation
Correct Answer is A, B, D
Rationale: Command hallucinations and paranoid delusions can be frightening or dangerous,
potentially causing a client to act aggressively. It is important to intervene before a client act on a
plan to harm another person. An antipsychotic medication, such as haloperidol, will help control
and manage symptoms and behaviors associated with schizophrenia. A chemical restraint should
be used in an extreme or emergent situation. A client has the right to refuse to participate in
activities. Verbal intervention, such as offering to speak with the client 1:1, would be appropriate
if the client is upset and crying.
Concepts tested

Question 207
The parents of a 3-year-old toddler ask the nurse how long their child will have to sit in a child
car seat while in an automobile. Which is the best response by the nurse?
A "The child must be 5-years-old to use a regular seat belt."
B "The child must reach a height of 50 inches (127 cm) to use a regular seat belt."
C "The child can use a regular seat belt when they can sit still."
D "The child should use a car seat for as long as possible."

Question Explanation
Correct Answer is D
Rationale: The American of Academy of Pediatrics (AAP) recommends that all children should
ride in a rear- or front-facing seat for as long as possible or until they reach the highest weight or
height allowed by the car seat manufacturer. Toddlers who have outgrown the weight or height
limit for the rear-facing car seat should use a forward-facing car seat. Many seats can
accommodate children up to 65 pounds (29 kg) or more.
Concepts tested

Question 208
A newly admitted client has a skin ulcer that tested positive for methicillin-
resistant Staphylococcus aureus. Which precautions should the nurse take when caring for this
client? Select all that apply.
A Keep all equipment in the client's room for their sole use.
B Place the client in a private room.
C Wear a mask while providing routine care to the client.
D Perform hand hygiene after contact with the client.
E Keep the door to the room closed at all times.

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F Place personal protective equipment at the door to the room.

Question Explanation
Correct Answer is A, B, D, F
Rationale: Contact precautions are recommended in acute care settings for methicillin
resistant Staphylococcus aureus (MRSA) when there is a risk for transmission or wounds that
cannot be contained by dressings. All equipment, such as stethoscopes, should be for the client's
sole use and kept in the room. The client should be in a single room or share a room with another
client who has MRSA. It is not necessary for the nurse to wear a mask when providing routine
care (e.g., collecting vital signs) to the client. Health care workers must perform hand hygiene
(e.g., wash hands with soap and water) after direct contact with the client and before leaving the
isolation room. Contact precautions require health care workers to wear personal protective
equipment (PPE) such as gloves and a gown, which should be readily available. It is not required
to keep the door closed at all times. MRSA is not spread by droplet or airborne transmission.
Concepts tested

Question 209
The nurse is providing burn prevention and home safety education to parents of small children.
Which safety measures should the nurse include in the teaching plan? Select all that apply.
A Set the water heater temperature to 130° F (54.4° C).
B Check seatbelt buckles before placing a child in a car seat.
C Replace smoke detector batteries once per year.
D Create a fire escape plan and practice it with the family.
E Turn pot handles towards the center of the stove when cooking.

Question Explanation
Correct Answer is B, C, D, E
Rationale: Accidents are usually caused by human behavior and error; thus they can be
prevented. Nurses must work closely with parents to prevent accidents from occurring in the
home. To prevent thermal burns at home, hot water heaters should be set below 120° F (48.8° C).
Parents and caregivers should also test the bath water before placing a child in it. When cooking,
pot handles should be turned towards the center or back of the stove to prevent an item from
being pulled down by a child. A parent or caregiver should check seatbelt buckles before placing
a child in a car seat. Buckles can become hot sitting in the sun. Fire escape plans should be
practiced with children, and they should know what to do in case of a fire. Smoke detector
batteries should be replaced regularly, at least once a year.
Concepts tested

Question 210
The nurse recognizes that client identification in accordance with agency policy must occur
immediately prior to which of the following actions? Select all that apply.
A Discontinuation of an intravenous normal saline infusion
B Placement of the call light activation device within reach of the client
C Collection of a point of care blood glucose test
D Insertion of an indwelling urinary catheter
E Administration of oral acetaminophen
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Question Explanation
Correct Answer is A, C, D, E
Rationale: As part of safe nursing care, the nurse must collect client identification with at least
two approved identifiers according to agency policy immediately prior to medication
administration, implementation of health care provider prescriptions, collection of laboratory
samples, discontinuation of intravenous infusions and many additional situations. It would not be
required to confirm the client's identification immediately prior to placing the call light activation
device within reach.
Concepts tested

Question 211
The nurse notices flames and smoke in the garbage can in a client's room. Which action should
the nurse take first?
A Extinguish the fire.
B Remove the client from the area.
C Close the door to the room.
D Activate the alarm system.

Question Explanation
Correct Answer is B
Rationale: The nurse's first action in an active fire should be to remove the client from imminent
harm. The other actions should occur after the client is taken to safety.
Concepts tested

Question 212
The nurse hears a scream coming from a client's room. When entering the room, the nurse finds
the client lying on the floor beside the bed. Which of the following actions should the nurse
take? Select all that apply.
A Report the incident to the facility's lawyer.
B Place the client in physical restraints to prevent another fall.
C Notify the client's provider about the incident.
D Take the client's vital signs.
E Observe the client for abnormal leg rotation.
F Determine the client's level of consciousness.

Question Explanation
Correct Answer Is C,D, E, F
Rationale: Fall prevention is a national patient safety goal and is monitored closely in all health
care settings. It is important for the nurse to assess and evaluate the client to determine if the
client experienced a loss of consciousness or a change in vital signs that contributed to the fall. It
is important to determine if there are visible injuries and note any areas of pain or abnormal leg
rotation. The nurse will notify the provider and complete an incident report. Risk management
will receive notification through the completion of an incident report; the nurse should not notify

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the legal department by themselves. Physical restraints are not indicated and may, in fact, make
the client more prone for future falls.
Concepts tested

Question 213
The nurse is caring for a client with a chest tube. The client is confused and keeps attempting to
pull out the chest tube. The nurse applies soft restraints on both of the client's wrists. Is the nurse
acting appropriately?
A Yes, the nurse should apply a restraint to protect the client from self-injury, and then must
contact the HCP.
B No, the nurse should first medicate the client with a sedative until the client stops pulling on
the chest tube.
C No, the nurse needs a written order from the HCP before the restraints can be applied.
D No, the nurse should first ask a family member to stay with the client at all times.

Question Explanation
Correct Answer is A
Rationale: Clients have the right to be free from physical or chemical restraints used for the
purpose of discipline or staff convenience. A soft wrist restraint can be applied before a doctor's
order is given, but the nurse must contact the HCP immediately after the restraint is applied to
obtain the order. Sedatives are not appropriate for this client because they can make the client's
confusion worse and cause central nervous system and respiratory depression. Asking a family
member to stay with the client is not an appropriate intervention.
Concepts tested

Question 214
A client's wound has tested positive for methicillin-resistant Staphylococcus aureus (MRSA).
Which transmission-based precautions should the nurse implement for the client?
A Contact precaution and droplet precautions
B Contact precaution and airborne precautions
C Standard precaution and airborne precautions
D Standard precaution and contact precautions

Question Explanation
Correct Answer is D
Rationale: Standard precautions are used for all clients, regardless of their diagnosis or presumed
infection status. Transmission-based precautions provide additional precautions beyond standard
precautions to prevent transmissions of pathogens. Contact precautions are used for infections
such as MRSA that spread by skin-to-skin contact or contact with other surfaces.
Concepts tested

Question 215
The school nurse is providing information for teachers at a school attended by a 10-year-old
child with epilepsy. Which action should a teacher take first in the event the child experiences a
seizure in the classroom?

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A Place something soft and flat under the child's head.
B Notify the child's parent(s) or guardian of the episode.
C Administer a prescribed antiepileptic medication.
D Provide privacy and reassurance to the other children.

Question Explanation
Correct Answer is A
Rationale: During seizure activity, the priority is to protect the child from physical injury.
Placing something soft and flat, like a folded jacket, under the child's head to help prevent head
trauma should be done first. After protecting the head, the next actions should be to move any
furniture away from the child and notify the child's parent(s) or guardian. Reassuring the other
children is important but should be done after caring for the seizing child first. A teacher should
not administer medication, only the nurse is able to do that.
Concepts tested

Question 216
The nurse is preparing to enter a disaster scene to assist with triaging victims. What assessment
priorities should the nurse adhere to? Select all that apply.
A The nurse should consider the age of a victim before allocating any resources.
B The nurse must consult a qualified health care provider prior to making client resource
decisions.
C The nurse requires disaster certification before performing triage during a disaster.
D The nurse should assess clients by considering their airway, breathing, circulation and
neurological function.
E The nurse should allocate resources to those victims with the strongest probability of survival.

Question Explanation
Correct Answer is D, E
Rationale: The goal of disaster triage is to use resources for clients with the strongest probability
of survival. Age is not a consideration when allocating treatment resources and the nurse does
not need to consult a physician prior to making decisions about allocating resources.
Furthermore, a nurse does not need special training to assist in a disaster. However, there are
certifications available for nurses who are interested. Finally, the nurse will make decisions
based on a client's airway, breathing, circulation and neurological function.
Concepts tested

Question 217
The nurse and UAP are preparing to reposition a client in bed. Which of the following actions
indicate that the UAP requires additional training on correct body mechanics?
A The UAP lifts the client, using their upper arm and shoulder strength.
B The UAP stands with their feet shoulder width apart and knees slightly bent.
C The UAP avoids twisting at the hip while repositioning the client.
D The UAP elevates the height of the bed to about waist level.

Question Explanation

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Correct Answer is A
Rationale: It is important to use proper body mechanics when transferring, lifting or
repositioning clients. To apply proper mechanics, the health care worker should stand with their
feet shoulder width apart and their knees slightly bent and avoid twisting when repositioning the
client. Elevate the bed so the working surface is at waist level, which is the health care worker's
center of gravity. The nurse or UAP should bend from the knees to aid in the lift, rather than
using their arms and shoulders to reposition the client.
Concepts tested

Question 218
The nurse is caring for a client diagnosed with gastroenteritis, caused by a Salmonella infection.
Which intervention should the nurse implement to prevent transmission of this infection?
A Wash hands with soap and water after client contact.
B Isolate the client in a single room without a roommate.
C Place the client on contact precautions.
D Wear two pairs of gloves when changing linens.

Question Explanation
Correct Answer is A
Rationale: Salmonella is a bacterium and one of the primary causes of foodborne illnesses such
as gastroenteritis. Bacteria transmission usually occurs through ingestion of the organisms via
contaminated foods and the oral-fecal route. The Centers for Disease Control and Prevention
(CDC) recommends using standard precautions for this infection; therefore, the best way to
prevent spread of the infection is to perform handwashing before and after client contact, using
soap and water.
Concepts tested

Question 219
The nurse incorrectly administers carvedilol to a client with an order for benztropine. What is
the priority nursing intervention after making this medication error?
A Complete an incident report
B Alert the nurse manager
C Notify the health care provider
D Monitor the client's blood pressure

Question Explanation
Correct Answer is D
Rationale: Because the nurse mistakenly administered a beta blocker medication, the priority
intervention is to monitor the client for any adverse physiological response to the given drug.
Carvedilol blocks alpha1 and beta receptors in blood vessels, causing dilation and a decrease in
blood pressure.
Concepts tested

Question 220
The nurse is conducting a community-wide seminar on childhood safety issues. Which child is at
the highest risk for poisoning?
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A A 15-year-old who likes to repair bicycles
B A 10-year-old who occasionally stays at home unattended
C A 20-month-old who has just learned to climb stairs
D A 9-month-old who stays with a babysitter five days a week

Question Explanation
Correct Answer is C
Rationale: Poisoning is one of the most common health care emergencies encountered with
young children. Toddlers, aged 1-3 years (e.g., 20-months-old), are at the highest risk for
poisoning. Toddlers are increasingly active, curious, and anxious to explore. They are too young
to know what is dangerous. Additional risk factors for poisoning include improper storage of
toxins, children spending more time in unfamiliar settings and caregiver distraction.
Concepts tested

Question 221
The nurse is caring for a client who is confused and has repeatedly attempted to pull out their
intravenous lines and feeding tube. The nurse receives an order from the health care provider
(HCP) to apply soft wrist restraints. Which actions by the nurse are appropriate? Select all that
apply.
A Conduct a thorough physical assessment of the client
B Call the HCP every 48 hours for a new restraint order
C Document that alternative interventions were attempted
D Explain the rationale for the use of restraints to the client
E Release the restraints and provide care every four hours
F Tie the wrist restraints using quick-release knots

Question Explanation
Correct Answer is A, C, D, F
Rationale: Restraints should only be used as a last resort. If necessary, the least restrictive device
should be used to restrain a client. Situations that require the use of restraints include when
clients interfere with treatment (e.g., enteral feedings, intravenous infusions, etc.). Every two
hours, restraints must be removed to assess skin integrity, allow for range of motion, and assess
neurovascular status. Even though the client may be confused, the nurse must still explain the
reason for applying restraints. Wrist restraints should be tied to a stationary part of the bed with a
quick-release knot. A new restraint order must be written by the HCP every 24 hours. Prior to
applying restraints, the nurse must conduct a thorough assessment of the client and document the
events leading to the use of the restraint. The nurse should also document which alternatives to
restraints were tried and the client's response to those measures.
Concepts tested

Question 222
A home care nurse is evaluating the home situation for a client with Alzheimer’s disease. Which
statement below, by a family member, should be reinforced by the nurse?
A "We go to a group discussion every week at our community center."
B "At least two full meals a day should be eaten."

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C "We have safety bars installed in the bathroom and have alarms on the exterior doors."
D "To take the medication three times a day is not a problem."

Question Explanation
Correct Answer is C
Rationale: For clients with Alzheimer’s disease, safety is the primary concern. The nurse should
reinforce the use of safety bars in the bathroom and the alarms on the exterior doors. The other
actions are also positive actions for the family in the care of a family member with Alzheimer’s
disease.
Concepts tested

Question 223
An 8-year-old is admitted to the hospital for surgery. The child's parent reports the allergies
listed below. Which of these allergies should alert the staff to implement system safeguards?
A Shellfish
B Mold
C Balloons
D Perfumed soap

Question Explanation
Correct Answer is C
Rationale: A reaction to balloons or rubber toys may indicate a latex allergy; children with a
history of allergies to avocados, bananas, and kiwis may also be at risk for a latex allergy.
Common hospital items that may contain latex include catheters and other tubing, stethoscopes,
blood pressure cuffs, and even wheelchair tires. All personnel who have contact with the child
must be aware of this allergy and use latex-free supplies and equipment. If the child is in a
semiprivate room, latex precautions should be used for both clients.
Concepts tested

Question 224
The nurse is caring for a child with a diagnosis of suspected pertussis (whooping cough). What is
the priority nursing intervention for this child?
A Implement droplet precautions
B Initiate anti-infective therapy
C Monitor respiratory rate and oxygen saturation
D Maintain hydration and encourage fluids

Question Explanation
Correct Answer is A
Rationale: Although all of the responses are appropriate nursing interventions, the priority is to
implement strict droplet precautions in addition to standard precautions. Pertussis is highly
contagious and is spread through close contact. Therapeutic management focuses on providing
respiratory support and eradicating bacterial infection (macrolides, such as erythromycin, are the

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drug of choice). Administer fluids and keep the client hydrated to help thin secretions. It is also
important to monitor the client's heart rate, respiratory status, and oxygen saturation, especially
during coughing paroxysms.
Concepts tested

Question 225
Parents call the emergency department to report that their toddler has swallowed drain cleaner.
The triage nurse instructs them to call for emergency transport to the hospital and suggests that
the parents give the toddler sips of which substance while waiting for an ambulance?
A Water
B Lemonade
C Tea
D Soda

Question Explanation
Correct Answer is A
Rationale: Ingestion of drain cleaner is corrosive to the esophagus and should not be vomited up.
The client should be encouraged to take sips of water or milk if they are able to dilute the
corrosive substance. Lemonade may worsen the corrosive effect. Soda and tea would be
inappropriate to administer.
Concepts tested

Question 226
Sputum culture results for a client admitted with a cough and fever indicate a methicillin-
resistant Staphylococcus aureus (MRSA) infection in the nares. What nursing intervention must
now be taken? Select all that apply.
A Move the client to a private room
B Dedicate the use of personal and noncritical medical equipment to the client
C Place the client in a room with another client colonized with MRSA
D Place a mask on the client if the client needs to leave the room
E Staff will wear N-99 or N-100 particulate respirators when in the client's room

Question Explanation
Correct Answer is A, B, C, D
Rationale: When possible, a private room would be best, but cohorting is often used for
multidrug-resistant organisms, such as MRSA. If the client needs to be transported to another
area, the client should wear a mask, especially if there's a productive cough. Staff should practice
excellent hand hygiene and other standard precautions, but a respirator is not needed for MRSA
in the nares. To minimize the risk of spreading infection, equipment or personal items should be
kept in the client's room and dedicated for his/her use.
Concepts tested

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Question 227
A client who reports unintended weight loss, drug abuse, and night sweats is admitted with a
preliminary diagnosis of HIV/AIDS. Which of these existing clients would be the most
appropriate roommate for this newly admitted client?
A Lupus and vesicles on one side of the middle trunk from the back to the abdomen
B Acute tuberculosis with a productive cough of discolored sputum for more than three months
C Pseudomembranous colitis and C. difficile
D Exacerbation of migrating polyarthritis with severe pain

Question Explanation
Correct Answer is D
Rationale: It is most appropriate to place clients with similar diagnoses in the same room.
Because this option does not exist, the nurse would understand that a client with HIV/AIDS
would be immunocompromised and should not be placed in a room with any client with an
active infection. Of the available options, the client with arthritis would be the best roommate for
the client with HIV/AIDS. Typically, standard precautions would be used for a person diagnosed
with HIV/AIDS (unless the person presents with cough/fever/pulmonary infiltrate, in which case
the person would be placed in a private room and airborne plus contact precautions would be
implemented).
Concepts tested

Question 228
The nurse is attending an in-service about healthcare-acquired infections (HAIs). Which factor is
considered a common cause of HAIs for clients in the acute care hospital setting?
A Inadequate fluid intake over 72 hours
B Decreased mobility for a week or longer
C Presence of an indwelling urinary catheter
D Undergoing a surgical procedure

Question Explanation
Correct Answer is C
Rationale: Catheter-associated urinary tract infections (CAUTIs) are one of the more common
healthcare-acquired infections (HAIs) in the acute care hospital setting. Surgical site infections,
bloodstream infections, and pneumonia are other types of HAIs but are less common than
CAUTIs.
Concepts tested

Question 229
The nurse is caring for an 80-year-old client who requires wrist restraints. Which client
behaviors would support the need to continue to use restraints? Select all that apply.
A The client is directing frequent angry, verbal outbursts at the staff.
B The client is confused and trying to pull out an IV catheter.
C The client is trying to get out of bed without assistance.
D The client is resisting care and attempting to hit the staff.
E The client is pushing the call light button every 10 minutes.

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Question Explanation
Correct Answer is B, D
Rationale: Physical restraints should only be used as a last resort. If restraints are indicated, the
least restrictive device available should be used to restrain the client. The restraint should protect
the individual but also allow for freedom of movement. Circumstances that require the use of
physical restraints include when clients attempt to remove life-support equipment, when clients
interfere with therapy or treatment (e.g., enteral feedings, intravenous infusions, tracheostomy
tubes, etc.), and when clients are combative and a risk to others. Restraints are not indicated for
the convenience of hospital staff. Examples of physical restraints include hand mitts, arm
sleeves, lap belts, and limb restraints.
Concepts tested

Question 230
The hospital has sounded the call for a disaster drill on the evening shift. Which client would
be most appropriate to be discharged to make room for a new admission?

A A client with type 2 diabetes who was admitted for acute cellulitis of the lower leg 48 hours
ago
B A client newly diagnosed with type 1 diabetes who was admitted with antibiotic-induced
diarrhea 24 hours ago
C A client with a history of lupus who was admitted with Stevens-Johnson syndrome that
morning
D A client with a history of being ventilator-dependent who was admitted with pneumonia eight
days ago

Question Explanation
Correct Answer is D
Rationale: The best candidate for discharge is the one who has a chronic condition and has an
established plan of care. The client who has been on the ventilator for some time is most stable
and could continue medication therapy at home or their residence; therefore, this client is the
most appropriate client to be discharged. The other clients are too acutely ill and have a risk for
instability. A client newly diagnosed with diabetes who has an active infection is at risk for
developing diabetic ketoacidosis. This client is also at risk for fluid loss with dehydration and
electrolyte imbalance. A client newly diagnosed with acute cellulitis may require intravenous
(IV) antibiotics. Stevens-Johnson syndrome (SJS) is a hypersensitivity reaction that involves the
skin and mucous membranes. Clients with SJS are treated similarly to burn victims, as they are at
high risk for fluid loss and are susceptible to infections.
Concepts tested

Question 231
The nurse is caring for a group of clients on a medical-surgical unit. The nurse understands that
which situations would require hand hygiene? Select all that apply.
A Prior to entering a client's room
B After making an entry in a client's medical record
C After wiping down a client's bedside table

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D Before and after taking a break and eating lunch
E After changing a client's sterile dressing

Question Explanation
Correct Answer is A, C, D, E
Rationale: Hand hygiene is the most effective way to reduce the transmission of microorganisms
and prevent the spread of infection. Hand hygiene (e.g., cleaning hands using soap and water or
an antiseptic hand rub) is easy and inexpensive. Additionally, hand hygiene reduces the
incidence of healthcare-associated infections (HAIs), as well as the incidence of antimicrobial
resistance. It is necessary for the nurse to wash their hands prior to eating, after removing gloves,
following any client procedure, and even after having contact with intact skin or objects in the
client's room (e.g., the client's bedside table). However, it is not necessary to wash hands after
handling the client's medical record.
Concepts tested

Question 232
The nurse observes a nursing assistant using antiseptic hand sanitizer and rubbing their hands
vigorously after leaving the room of a client diagnosed with Clostridium difficile. Which action
by the nurse is appropriate?
A Instruct the nursing assistant to use bleach wipes to wipe off their hands
B Report the nursing assistant to the infection control practitioner
C Praise the nursing assistant for proper use of antiseptic hand sanitizer
D Instruct the nursing assistant to wash their hands again with soap and water

Question Explanation
Correct Answer is D
Rationale: Anyone who is hospitalized should be encouraged to ask caregivers if they have
washed their hands and should also remind visitors to wash their hands. However, it is the
nurse's responsibility to supervise the nursing assistant and to correct practice errors as
needed. Clostridium difficile is one of the few pathogens that require soap and water for
cleansing the hands. Since antiseptic hand rub is ineffective against the hardy spores produced by
this bacterium, the nurse should require the nursing assistant to wash their hands with soap and
water, especially after providing care for this client.
Concepts tested

Question 233
The nurse is performing a home visit for an older adult client with Alzheimer's disease. Which of
the following observations should be a priority for the nurse to address?
A Throw rugs on the kitchen floor
B Good lighting in the stairwell
C Handrails in the bathtub
D Lamps plugged directly into wall outlets

Question Explanation
Correct Answer is A

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Rationale: Safety, especially falls, is a concern for clients with Alzheimer's disease. The home
should ensure good lighting, especially in dark areas such as stairwells. There should be
handrails on the stairs and in the tub/shower. Showers should have nonskid mats. The client and
caregivers should ensure there are no extension cords in use, as they can be a fire and trip hazard.
Throw rugs are also a trip hazard and should be removed from the kitchen floor. This is the
priority issue the nurse should address.
Concepts tested

Question 234
The nurse is educating a group of individuals about how to prevent hepatitis B and C. Which
statement by the nurse would best describe the prevention of these two diseases?
A "You can receive a yearly vaccination to prevent the diseases."
B "You should use protection when engaging in sexual intercourse."
C "You should talk to your health care provider when traveling internationally."
D "You can eat fresh fruit picked from the tree without the need to wash."

Question Explanation
Correct Answer is B
Rationale: Hepatitis B and C are considered bloodborne illnesses that can be spread by contact
with infectious bodily fluids and blood. Preventative measures should include using safer sex
practices, avoiding risky behaviors, and sharing needles. There is not a yearly vaccine for these
diseases. Individuals in the U.S. receive the hepatitis B vaccination by 6 months of age. There is
no vaccine for hepatitis C. When traveling internationally to locations where sanitation may be a
concern, the individual might be at risk for contracting hepatitis A, not hepatitis B or C.
Concepts tested

Question 235
The school nurse is teaching a group of teenagers about the prevention of sexually transmitted
infections (STIs). Which statement by one of the students indicates an understanding of the
teaching?
A "There are vaccines available that will prevent the majority of STIs."
B "Having multiple sexual partners puts me at a higher risk for an STI."
C "Being on birth control will prevent getting an STI."
D "Wearing a condom will eliminate any risk of contracting an STI."

Question Explanation
Correct Answer is B
Rationale: While educating individuals on sexually transmitted infections (STIs) and prevention,
discussing the risk of exposure should be emphasized. Although the use of condoms has been
shown to reduce the risk of infection for both men and women, they do not completely eliminate
the risk. The nurse should follow up on the other responses, as they indicate a lack of
understanding of how an STI is transmitted or prevented.
Concepts tested

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Question 236
A nurse at a community health clinic is speaking to a group of young adults about preventing
HIV infection. Which high-risk behaviors to avoid should the nurse include? Select all that
apply.
A Donating blood
B Sharing needles
C Smoking e-cigarettes
D Having unprotected sex
E Inhaling illegal drugs

Question Explanation
Correct Answer is B, D
Rationale: Risk factors associated with HIV include sharing injection drug equipment, having
multiple sexual partners, having sexual relations with infected persons, being born to mothers
with HIV infection, and not using some form of protection during sex. The nurse should provide
preventative education regarding using safer sex practices to reduce the risk of transmitting HIV
and avoid sharing any type of needles, razors, toothbrushes, or anything that is potentially
contaminated with blood. The other behaviors are not known to increase the risk of contracting
HIV.
Concepts tested

Question 237
The nurse is caring for multiple clients during their shift. Which method(s) would be
the best approach to correctly identify each client? Select all that apply.
A Check the client identification bracelet
B Compare the client to a labeled photograph
C Ask clients to state their name
D Ask a family member or visitor
E Have clients state their birth date

Question Explanation
Correct Answer is A, B, C, E
Rationale: The best approaches to correctly identify a client would be to check the client’s
identification bracelet, ask clients to state their name and date of birth, and compare the client to
a labeled photograph. Two pieces of identification are required prior to any procedure and/or
medication administration. In long-term care facilities, residents may not wear identification
bands. In this case, a labeled photograph can be used as identification. Asking visitors and family
members would not be the best approach to identify clients.
Concepts tested

Question 238
The public health nurse is teaching parents about injury and accident prevention in children
younger than 4 years old. Which interventions should the nurse include? Select all that apply.
A Store any firearms in a locked container with the ammunition removed
B Make sure the child is up-to-date on all required immunizations

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C Store medications where the child cannot reach them
D Monitor the child for signs of substance use such as alcohol or smoking
E Never leave the child unattended around a pool or body of water
F Always have the child sitting in an approved car safety seat when driving

Question Explanation
Correct Answer is A, C, E, F
Rationale: Injuries are the most common cause of death and disability to children in the United
States. The child's developmental stage partially determines the types of injuries that are most
likely to occur at a specific age and helps provide clues to preventive measures. Drowning and
burns are among the top three leading causes of death for males and females throughout
childhood. In addition, improper use of firearms is a major cause of death among males. Every
year, approximately 95% of medication-related ED visits in children younger than 5 years are
due to ingesting medication while unsupervised. Motor vehicle injuries are the leading cause of
death in children older than 1 year of age. The majority of fatalities involve occupants who are
unrestrained.
Concepts tested

Question 239
The emergency room nurse is caring for a child suspected of poisoning. The child’s parent asks
the nurse what the purpose of the prescribed activated charcoal is. How should the nurse
respond?
A "This substance removes the poison from the body through the urinary system."
B "This substance inactivates the toxins that your child ingested."
C "The activated charcoal binds with the poison to limit absorption from the digestive tract."
D "The activated charcoal induces vomiting to remove the poison."

Question Explanation
Correct Answer is C
Rationale: Activated charcoal may be used for accidental poisoning, as it keeps swallowed
substances from being absorbed from the gastrointestinal tract into the bloodstream. Its action is
to bind to other substances on its surface (adsorption), pushing the poison through the digestive
system faster and decreasing the amount absorbed into the body. It does not inactivate the poison
but rather binds to it in the digestion system to be removed more quickly.
Concepts tested

Question 240
The nurse is providing safety and accident prevention instructions to the parents of 4-year-old
twins. Which statement by the parents indicates a correct understanding of the instructions?
A "Accidents can happen. We will make sure to call 911 right away."
B “We are having a fence installed around the backyard pool."
C "It is normal for little children to be curious and want to explore."
D "The children are old enough to sit in the car without a child safety seat."

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Question Explanation
Correct Answer is B
Rationale: In the United States (US), accidents are the leading cause of death in small children.
Common accidents include choking and suffocation, falls, drowning, and poisoning. Nurses must
teach parents how to promote a safe environment for their children. When there is a pool at the
home, it is recommended, and can be required by law, to have a fence and lockable gate installed
around the pool to prevent unsupervised access and accidental drowning. The other statements
do not indicate a correct understanding of accident prevention for children.
Concepts tested

Question 241
A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis.
Which admission orders should the nurse implement first?
A Initiate droplet precautions
B Administer cefotaxime (Claforan) IV 50 mg/kg/day divided every six hours
C Monitor neurologic status every hour
D Institute seizure precautions

Question Explanation
Correct Answer is A
Rationale: Meningococcal meningitis is a bacterial infection that can be communicated to
others. The initial therapeutic management of acute bacterial meningitis includes droplet
precautions, initiation of antimicrobial therapy, monitoring neurological status along with vital
signs, instituting seizure precautions and, lastly, maintaining optimum hydration. The first action
is to initiate any necessary precautions to protect themselves and others from the potential
infection. Viral meningitis usually does not require protective measures of isolation and these
clients often return home to recover.
Concepts tested

Question 242
The nurse smells smoke and notices a small fire in a non-client storage area. The alarm system
begins to sound. Which action should the nurse take next?
A Wait for the arrival of the fire department.
B Extinguish the fire using an ABC fire extinguisher.
C Back out of the room and close the door.
D Place a thermal blanket over the fire.

Question Explanation
Correct Answer is B
Rationale: A fire in any health care facility presents great potential for harm. In this situation,
there are no clients in imminent danger and the alarm has been activated. The nurse should
attempt to extinguish the fire using an appropriate fire extinguisher. The ABC type is appropriate
for all types of fires. Backing out of the room and closing the door may allow the fire to burn out
of control. Using a blanket is not appropriate at this time. If the fire is manageable, the nurse
should attempt to extinguish it and not wait for the fire department to arrive.
Concepts tested
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Question 243
A client with a diagnosis of methicillin-resistant Staphylococcus aureus (MRSA) has died.
Which transmission-based precautions should be used when performing postmortem care?
A Standard precautions
B Contact precautions
C Airborne precautions
D Droplet precautions

Question Explanation
Correct Answer is B
Rationale: MRSA is transmitted by contact and MRSA bacteria remain alive for up to 3 days
after a client dies. Therefore, contact precautions must still be used, including the use of a gown
and gloves. The body should also be labeled as MRSA contaminated so the funeral home staff
can protect themselves as well.
Concepts tested

Question 244
The nurse asks an unlicensed assistive person (UAP) to help with repositioning of a client in bed.
Which actions by the nursing staff support correct ergonomics and safe client handling? Select
all that apply.
A Use a friction-reducing device/sheet underneath the client.
B Lower the head of the bed into a flat position.
C Instruct the client to hold their breath.
D Coordinate lifting together by counting to three.
E Ask a visiting family member to help.
F Adjust the height of the bed to hip level.

Question Explanation
Correct Answer is A, B, D, F
Rationale: Adhering to ergonomic principles will help prevent injuries to the nursing staff and/or
the client. Raising the bed to hip level, lowering the head of the bed, using a friction-reducing
device and coordinating moving at the same time will help with repositioning the client in a safe
manner and reducing the risk of injury, such as straining the lower back. Asking a visitor to help
and asking the client to hold their breath are not appropriate.
Concepts tested

Question 245
The home health nurse is preparing for a home visit of a new client. Which action
is most important to ensure the safety of the nurse during the visit?
A Carry a cell phone, pager and/or hand-held alarm.
B Observe for evidence of weapons in the home
C Remain alert and leave if cues suggest the home is not safe.
D Review documentation for previous entries about violence

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Question Explanation
Correct Answer is C
Rationale: Nurses need to assess and manage safety risks and have ongoing clinical supervision
and support when making home visits. The most important action a nurse can take to ensure
safety during a home visit is to always remain alert and to leave if there are any cues that the
home is not safe. Proper safety should begin with a thorough assessment of the client's home to
identify potential risks, such as pets (a commonly assessed hazard), drug use and weapons. The
nurse should also develop a plan to eliminate the risks and understand that there is always the
option to end a visit early if the environment does not seem safe. Carrying a phone, using a
buddy system, learning about the client prior to the visit can also help mitigate risks.
Concepts tested

Question 246
The nurse is educating a group of parents about accidental poisoning of children. Which type of
accidental poisoning is common in children under the age of six years?
A Topical contact
B Inhalation
C Eye splashes
D Oral ingestion

Question Explanation
Correct Answer is D
Rationale: The greatest risk for young children is from oral ingestion. While children under age
six may come in contact with other poisons or inhale toxic fumes, these are not as common.
Concepts tested

Question 247
While working a 12-hour night shift, the nurse has a "near miss" and catches an error before
administering a new medication to the client. Which factors could have contributed to the near
miss? Select all that apply.
A The nurse works in the intensive care unit (ICU)
B The nurse was interrupted when preparing the medication
C The nurse is assigned more clients than usual due to staffing issues
D The nurse has worked four 12-hour night shifts in a row
E The nurse has worked on the same unit for five years

Question Explanation
Correct Answer is A, B, C
Rationale: There are a number of reasons for near misses and making medication errors,
including heavy workload and inadequate staffing, distractions, interruptions and inexperience.
Fatigue and sleep loss are also factors, especially for nurses working in units with high acuity
clients such as the ICU.
Concepts tested

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Question 248
The nurse is caring for an 80-year-old client with community acquired pneumonia. Since
admission, the client has been confused, pulling on tubes including his oxygen mask and
peripheral venous access device. The client keeps trying to get out of bed unassisted and has had
several near falls. Which interventions should the nurse include in the client's plan of
care? Select all that apply.
A Request an order for a sedative medication at bedtime
B Place a protective sleeve or elastic bandage over the peripheral venous access device
C Request a PRN order for restraints
D Request electronic or in-person client safety monitoring
E Provide frequent reorientation to the environment
F Discontinue the oxygen since the client has a Do Not Resuscitate order

Question Explanation
Correct Answer is A, B, D, E
Rationale: Older adult clients are at risk for developing delirium when they experience an acute
infection and require hospitalization. The unfamiliar environment will contribute to any anxiety,
fear and disorientation. It is challenging to care for clients with delirium and the nurse shall
implement interventions that preserve the client's dignity and rights while also maintaining the
client's safety and ensuring that the client receives all ordered medical therapies. A calm,
soothing approach will help to establish trust and although not ideal, a mild sedative to facilitate
sleep can be helpful. Many hospitals today utilize electronic or in-person client safety monitors
to prevent falls and injury. The client safety monitor remains with the client at all times and
verbally reorients the client and provides reminders for the client to wait for assistance. Oxygen
therapy should be continued, regardless of resuscitation status, and restraints should never be
ordered as needed or PRN.
Concepts tested

Question 249
A nurse is to administer meperidine (Demerol) 100 mg, atropine sulfate 0.4 mg, and
promethazine (Phenergan) 50 mg IM to a pre-operative client. Which action should the nurse
take first?
A Assist the client to the bathroom
B Instruct the client to remain in the bed
C Raise the side rails on the bed
D Place the call bell within the client's reach

Question Explanation
Correct Answer is A
Rationale: Meperidine is a narcotic analgesic and promethazine is an antihistamine; together
they can potentiate CNS effects such as drowsiness, dizziness, lightheadedness and confusion.
Although all of the options involve client safety, the first thing to do is to assist the client to the
bathroom to void. After administering the preoperative medications, the nurse will instruct the
client to remain in bed, place the call light in the client's hand and raise the side rails.
Concepts tested

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Question 250
The nurse is caring for a client with hepatitis C. Which infection precautions should the nurse
implement?
A Airborne precautions
B Standard precautions
C Droplet precautions
D Transmission-based precautions

Question Explanation
Correct Answer is B
Rationale: Hepatitis C is transmitted via blood. Standard precautions are used for all blood-
borne infections. Droplet precautions, transmission-based precautions and airborne precautions
are not indicated for hepatitis C.
Concepts tested

Question 251
The nurse in an assisted living facility is reviewing the medical record of an older adult client
who has had several falls. Which nursing problem is the priority for this client?
A Inadequate nutritional intake related to anorexia
B Ineffective coping due to loss of independence
C Hopelessness related to death of the spouse
D Alteration in sensory perception due to impaired vision

Question Explanation
Correct Answer is D
Rationale: Safety is crucial in the health maintenance of older adults. When compared to
younger adults, older adults are at higher risk for accidents and falls due to normal sensory
changes, slowed reaction time, decreased thermal and pain sensitivity, changes in gait and
balance, and medication effects. Most accidents such as falls occur in or around the home. Vision
impairment caused by age-related changes will lead to impaired sensory perception that increases
the person's risk for falls. Therefore, alteration in sensory perception due to impaired vision is
the priority nursing problem.
Concepts tested

Question 252
A school nurse is caring for a group of school-age children who have been diagnosed with
ringworm (Tinea corporis). The nurse is preparing educational materials for parents on ways to
prevent the spread of ringworm. What information should the nurse include? Select all that
apply.
A Keep child at home for 5 to 7 days.
B Keep fingernails short and clean.
C Do not walk barefoot in public showers.
D Change socks daily.
E Wash hands after playing with pets.

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F Do not share combs or brushes.

Question Explanation
Correct Answer is B, C, D, E, F
Rationale: Ringworm (Tinea corporis) is a skin and nail fungal infection caused by a parasite
that lives in cells on the outer layer of skin. Ringworm can spread through the environment by
coming in contact with contaminated surfaces (walking barefoot), through person-to-person
contact and by sharing personal items. Ringworm can also spread from an infected pet.
Information on how to prevent transmission should include keeping nails short and clean, not
sharing personal and grooming items such as combs, brushes, hats, scarves and bedding. The
fungus prefers a moist environment. Clothing such as socks and underwear that are in contact
with areas of the body that are moisture prone should be changed daily. Isolating the child at
home is not necessary.
Concepts tested

Question 253
The nurse in the dialysis center suspects that a client receiving hemodialysis is infected with
scabies. Which transmission-based precautions should the nurse implement immediately?
A Contact precautions
B Neutropenic precautions
C Bloodborne precautions
D Airborne precautions

Question Explanation
Correct Answer is A
Rationale: Contact precautions reduce the risk of transmission by direct or indirect contact.
Indirect transmission involves contact with a contaminated object. Scabies is a parasitic skin
infection that is transmitted by direct, physical contact with infected individuals or by sharing
clothing or bedding with an infected individual. The other precautions are not appropriate for
preventing the transmission of scabies. Bloodborne precautions are not transmission-based
precautions. Those precautions fall under standard precautions, which are taken for every client
when the possibility of exposure to blood and/or bodily fluids exists, regardless of the presence
of a communicable infection.
Concepts tested

Question 254
The nurse receives a telephone call from a health care provider who wants to give a telephone
order. Which of the following actions should the nurse take? Select all that apply.
A Request that the order is signed by the provider before implementation
B Begin the order with the abbreviation "P.O." to indicate that it was a "phone order"
C Record the order word-for-word and sign the order
D Ask a second nurse to listen on another extension while the order is being given
E Verify understanding by reading the order back to the provider before hanging up

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Question Explanation
Correct Answer is C, E
Rationale: Reading the order back allows the provider to correct any misunderstanding and is a
Joint Commission read-back requirement. The order should be immediately written and signed
by the nurse. The order should clearly state "telephone order" as abbreviations can be
misunderstood (P.O. could be interpreted as "by mouth"). Having a second person listen in on
the conversation is not required unless the nurse cannot understand the health care provider. The
order may be implemented right away, but it must be countersigned within the time limits set by
the facility.
Concepts tested

Question 255
The nurse is caring for a client who lives in a long-term care (LTC) facility. The client is placed
on contact precautions when drainage from a wound culture is positive for methicillin-
resistant Staphylococcus aureus (MRSA). Which of the interventions should the nurse include in
the client's plan of care? Select all that apply.
A Educate the client on good personal and hand hygiene
B Monitor staff compliance with using required personal protective equipment (PPE)
C Collaborate with the facility infection preventionist on treatment for the wound
D Plan to transfer the client to the hospital
E Move the client to an available private room
F Notify the client's family that no visitors are allowed until the infection is cured

Question Explanation
Correct Answer is A, B, C, E
Rationale: Recommendations are very straightforward for the placement of clients with MRSA
colonization and infection in a hospital—a private room is preferred. Recommendations for
placement in an LTC facility are not as clear cut. Some guidance on the use of contact
precautions in an LTC facility is given in the CDC/HICPAC Guideline for Isolation Precautions:
Preventing Transmission of Infectious Agents in Healthcare Settings, 2007.
Make decisions regarding client placement on a case-by-case basis, balancing infection risks to
other clients in the facility, the presence of risk factors that increase the likelihood of
transmission and the potential adverse psychological impact on the infected or colonized client.
When single-client rooms are available, assign priority for these rooms to clients with known or
suspected multi-drug resistant organism (MDRO) colonization or infection. Give highest priority
to those clients who have conditions that may facilitate transmission, such as uncontained
secretions or excretions and lack of compliance with personal and hand hygiene due to cognitive
deficits.
An LTC infection preventionist should collaborate on the care plan of all clients with wounds in
the facility and monitor any infections they might have.
It is not necessary to transfer the client to a hospital or limiting the client's visitors at this time.
On the contrary, limiting visitors would constitute interference with the client's rights and
dignity.
Concepts tested

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Question 256
The nurse in a long-term care facility is evaluating the plan of care for an older adult client with
advanced dementia. The client has had several falls out of bed. Which initial intervention should
the nurse implement?
A Position all side rails of the bed up and move the bed close to the door
B Put the bed in the lowest position with a thick pad or mat on the floor next to the bed
C Have the client sleep in a recliner at the nurse's station with a tray table across their lap
D Place the client in a bed with an enclosure mesh tent attached to the frame

Question Explanation
Correct Answer is B
Rationale: Falls out of bed are a common occurrence in the long-term care setting. Although it is
nearly impossible to eliminate all falls, the nurse can implement interventions to reduce the risk
for injury related to a fall. The goal is to start with the least invasive and restrictive intervention
to preserve the client's rights, regardless of their level of cognitive function. 'Low' beds and
'landing' mats to soften the fall should the client roll out of bed are commonly used in long-term
care settings and represent an appropriate, initial intervention to implement for this client. The
other interventions are much more restrictive and should be used only after less restrictive
interventions have been attempted.
Concepts tested

Question 257
The nurse on a psychiatric unit is speaking with an unlicensed assistive person (UAP) who was
recently hired. The UAP has been assigned to monitor an older adult client who has been making
inappropriate sexual comments about staff and other clients. Which statement by the UAP
indicates that further clarification from the nurse is needed?
A "I think the client should be placed in the seclusion room."
B "I will assist the client with using the bathroom as needed."
C "The client is requesting medication to help them sleep."
D "I have been reading to the client which seems to help."

Question Explanation
Correct Answer is A
Rationale: None of the behaviors described indicate that the client is a physical threat to
themselves or others that may require the client to be restrained or placed in seclusion.
Furthermore, it is outside of the UAP's scope and responsibilities to suggest that the client should
be placed in seclusion. Therefore, the UAP's statement about placing the client in the seclusion
room should be clarified by the nurse.
Concepts tested

Question 258
The public health nurse is working at a screening clinic for sexually transmitted infections. A
client has tested positive for human immunodeficiency virus (HIV). Which action should the
nurse plan for next?
A The positive test result must be reported to the local health department.

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B The client should be medicated with tenofovir/emtricitabine for pre-exposure prophylaxis.
C The client will be required to notify all past sexual partners.
D The client will need extensive teaching about acquired immunodeficiency syndrome (AIDS).

Question Explanation
Correct Answer is A
Rationale: Many sexually transmitted infections (STI) are reportable at the state and federal
levels, including HIV. A newly diagnosed HIV infection must be reported to the local health
department, therefore the nurse should plan for that next. The client may be asked to provide
information about recent sexual contacts who may have been exposed to the virus, but not
necessarily all past sexual partners. Pre-exposure prophylaxis (PrEP) medications such as
tenofovir/emtricitabine (Truvada) are intended for clients who are at high-risk of contracting
HIV. They are not intended to treat an active HIV infection. AIDS is a complication that may
develop in clients who are HIV positive. A client who is HIV positive does not necessarily have
AIDS.
Concepts tested

Question 259
The nurse receives report on the following four clients. Which client should the nurse
assess first due to a high risk of falling?
A The 81 year-old who fell at home last week who has altered mental status
B The 79 year-old who has rheumatoid arthritis and walks with the aid of a walker
C The 59 year-old who had hip replacement surgery four days ago and is going to physical
therapy
D The 67 year-old who has diabetes and has chronic draining ulcers on the right leg

Question Explanation
Correct Answer is A
Rationale: Although all of the individuals might be at risk for falling, evidence shows that the
greatest risk of falling is a person who is older than age 80, is confused, and has a history of
falling.
Concepts tested

Question 260
The nurse is planning care for a 3-month-old infant who needs a cleft lip and soft palate repair.
During the immediate postoperative phase, the nurse should give priority to which intervention?
A Position the infant on the side or back and assess the skin.
B Provide the infant's family with instructions about care of the sutures.
C Initiate clear liquid feedings by bottle when alert and acting hungry.
D Remove the soft elbow/arm restraints every 2 hours and assess the infant.

Question Explanation
Correct Answer is D
Rationale: The priority intervention after surgery is to protect the new repair and stitches, by
applying soft elbow and arm restraints. These restraints are used to prevent the infant from

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putting their hands in their mouth risking injury to the suture line. The nurse should also be
assessing for circulation, movement, and sensation every two hours. When the infant acts
hungry, they will be given a clear liquid feeding using either a syringe fitted with a special soft
tubing or a special cleft lip feeder. The infant should be repositioned on their side and back to
prevent skin breakdown; however, another choice is higher priority. Before the infant is
dismissed, the nurse will want to provide education to the family regarding the care of the
sutures and need to wear the soft restraints for the first 10 days after the surgery.
Concepts tested

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MANAGEMENT AND CARE
Question 261
A nurse is precepting a graduate nurse on the oncology unit. The nurse notes a copy of a living
will in a client’s chart and asks the graduate nurse to define the meaning of the document. Which
statement by the graduate nurse correctly defines a living will?
Question 1 Answer Choices
A “It is a legal document that expresses our client’s wishes for medical treatment when they can
no longer make those decisions themselves.
B “The document legally appoints another person to make medical decisions for our client
should they be unable to do so.”
C “The information in the document is a guideline for medical treatment but can be overridden
by a provider’s prescription.”
D “Medical decisions outlined in the document are the client’s wishes but do not protect
healthcare providers from liability.”

Question Explanation
Correct Answer is A
Rationale: A living will is a type of advance directive that expresses a client’s wishes regarding
their medical treatment in the event they can no longer make those decisions themselves. A
living will is a legal document. Appointing another person to make medical decisions is a
durable power of attorney. A living will is a legal document and must be honored by healthcare
providers when providing medical treatment. Healthcare providers who follow a client’s living
will are protected from liability by state laws.
Concepts tested

Question 262
A graduate nurse and an experienced nurse are providing care to a client who refuses to be
discharged to a skilled nursing facility. The client’s family does not feel capable of caring for the
client at home. How will the nurse encourage the graduate nurse to practice advocacy?
A By telling the graduate nurse the client’s wishes must be followed
B By instructing the graduate nurse to obtain a social work consult for the client
C By encouraging the graduate nurse to change the client’s decision
D By guiding the graduate nurse to convince the family to take the client home

Question Explanation
Correct Answer is B
Rationale: Using available resources to help clients make a medical decision is part of nurse
advocacy. Discharge conflicts between clients and their family require additional resources, such
as a social worker or case manager. The client’s decision conflicts with the family’s ability to
care for the client at home. Additional resources are necessary. A nurse’s role is not to change a
client’s or family’s decision. A nurse advocate provides all necessary resources to clients and
their family, so they can make a joint medical decision.
Concepts tested
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Question 263
The nurse is caring for a client who is 6 hours post- laparoscopic hysterectomy. Which task
could the nurse delegate to the unlicensed assistive personnel (UAP)?
A Check the abdominal wound for bleeding
B Increase the rate of the IV fluid as prescribed
C Ambulate the client to the bathroom as needed
D Auscultate the breath sounds in all lobes

Question Explanation
Correct Answer is C
Rationale: The Five Rights of Delegation are right task, right circumstance, right person, right
directions and communication, and right supervision and evaluation. Professional nurses are
responsible for delegating nursing activities, but although RNs may delegate elements of care,
they do not delegate the nursing process itself. Nursing care or tasks that should never be
delegated, except to another RN, include initial and ongoing nursing assessment, determination
of the diagnosis and plan of care, evaluation, and client education. Assisting clients to the
bathroom is in the scope of routine care, activities, and procedures that are performed by a UAP.
Concepts tested

Question 264
The nurse is assuming care of assigned clients from the previous nurse. After receiving a report
that all clients are stable, which of the following clients should the nurse plan to see first?
Question 4 Answer Choices
A A client who has a scheduled surgery in one hour
B A client who is ready to be discharged home
C A client who is four days postoperative after an appendectomy
D A client who is admitted for intravenous antibiotic therapy

Question Explanation
Correct Answer is A
Rationale: The client who has a surgery scheduled in one hour needs to be seen before other
clients (assuming all are stable) because any preoperative assessments or medications must be
completed before the client is taken for the procedure. This is the only client that has time-
sensitive needs.
Concepts tested

Question 265
The nurse is evaluating the time management skills of staff members. Which finding indicates an
appropriate use of time while completing a client’s morning hygiene?
A Performing a bed linen change while completing a bed bath
B Postponing feeding assistance until after morning care has been completed
C Making several trips to the supply room to gather supplies
D Having personal conversation with other staff before entering each client room

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Question Explanation
Correct Answer is A
Rationale: Clustering tasks that can be completed simultaneously is a good time management
technique. In this case, completing both a bed bath and a linen change at the same time is an
efficient use of time. Postponing feeding assistance until after morning care is not an efficient
use of time because the client may require additional assistance with hygiene care following
eating.
Concepts tested

Question 266
The nurse is developing the plan of care for a client with sickle cell anemia (SCA) who has a
history of vaso-occlusive events. Which action by the nurse would be the most effective to
include in the plan of care to prevent this occurrence?
A Emphasize the importance of immunizations
B Assist the client with relaxation techniques to relieve stress
C Encourage adequate fluid intake daily
D Advocate for daily administration of folic acid

Question Explanation
Correct Answer is C
Rationale: Adequate hydration is essential to prevent a vaso-occlusive crisis. Fluids should be
increased during infection, with exposure to extreme heat or cold, or during excessive exercise to
prevent sickling of cells leading to blood flow compromise and pain. Relaxation techniques,
breathing exercises, and distraction are helpful for some patients to relieve stress, which may
precipitate a vaso-occlusive event or the pain associated with one. To prevent infection,
immunizations should be administered on schedule. Daily administration of folic acid may
increase serum folate concentrations but has questionable use with sickle cell anemia.
Concepts tested

Question 267
The nurse is preparing to administer prescribed baclofen to a client with multiple sclerosis who is
experiencing bladder spasms. The client states, “I do not want to take that medication; it makes
me sleepy.” Which statement by the nurse would be most appropriate?
A “This medication is needed to stop the spasms.”
B “We can discuss alternative interventions to treat the spasms.”
C “You can discuss your concerns with your healthcare provider.”
D “I can give the medication before bedtime.”

Question Explanation
Correct Answer is B
Rationale: Clients who report unpleasant side effects of medications may be reluctant to continue
taking the medications. Clients have the right to refuse treatments or procedures, and the nurse
should recognize and respect the client’s choice. When a client refuses a treatment, the nurse
should discuss alternative options with the client. Telling the client to discuss the concerns with
the healthcare provider does not address the need to treat the spasms. Explaining what the
medication is for is important but does not address the client’s refusal and dismisses their
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concerns. This medication is prescribed three times a day; a nurse cannot change the dosing
times without discussing it with the healthcare provider.
Concepts tested

Question 268
A nurse is providing care to a client with a language barrier. The client tells the nurse they did
not understand the updated plan of care provided by the healthcare provider during rounds.
Which action does the nurse perform?
A Call the client’s family, and request a family member at the bedside
B Instruct the client to write down any concerns, and inform the nurse supervisor
C Review abnormal laboratory results, and share the information with the client
D Request a medical interpreter, and contact the healthcare provider

Question Explanation
Correct Answer is D
Rationale: The client has the right to understand all aspects of their medical care. It is a nurse’s
duty to provide the client with all necessary resources to ensure understanding of their plan of
care. The nurse contacts the healthcare provider and ensures a medical interpreter is available. A
family member should not translate for the client, particularly if medical terminology is not
known. Escalation of the client’s concerns should be directed to the healthcare provider with the
aid of a medical interpreter. Sharing abnormal laboratory data with the client that has not been
reviewed by the healthcare provider is outside the nurses’ scope of practice.
Concepts tested

Question 269
The nurse is caring for an adult client who has a new diagnosis of diabetes type 2. The client
states, “What would be the best way to keep my blood sugar low and help me lose weight?”
Which member of the interprofessional team should the nurse collaborate with to provide
accurate information?
A Registered dietitian
B Diabetes educator
C Healthcare provider
D Exercise physiologist

Question Explanation
Correct Answer is A
Rationale: A registered dietitian (RD) manages and plans for the dietary needs of patients based
on knowledge about all aspects of nutrition. RDs can adapt specialized diets for the individual
needs of patients, counsel and educate individual patients, and supervise the dietary services of
an entire facility. Diabetes educators have expertise in insulin and oral hypoglycemic treatment
regimens and can provide some information regarding diets. Exercise physiologists can provide
techniques to exercise but do not address the need to control blood glucose levels.
Concepts tested

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Question 270
The nurse has just received a prescription to discharge a client home who has limited mobility.
Which of the following actions would be most appropriate?
A Ask the client if they have family to take care of them
B Delay discharging the client until the client can ambulate independently
C Include the unit social worker in discharge planning
D Tell the client that they need to remove fall hazards from their home

Question Explanation
Correct Answer is C
Rationale: The most appropriate action would be to include a social worker or case manager in
the client’s discharge planning. This person can connect the client with resources that may be
needed for safe discharge. Asking the client about their support system and education about a
safe environment may be necessary but are not the most important action. Clients who cannot
ambulate independently can be discharged but will need support, such as assistive devices,
education, and other resources.
Concepts tested

Question 271
The nurse is performing an admission assessment for a client in labor. Her past obstetrical
history reveals an elective abortion. The client states, “Please don’t tell my husband.” Which
nursing response is best?
A “Your information is not shared without your consent.”
B “You will have to fill out a form to protect your information.”
C “You can tell your healthcare provider which information to protect.”
D “You can leave that information off your records in the future.”

Question Explanation
Correct Answer is A
Rationale: The Health Insurance Portability and Accountability Act (HIPAA) provides for the
maintenance of client confidentiality. There is no medical reason for the client’s obstetrical
history to be revealed at this time. The client has the right to decide when and if her past
obstetrical history needs to be shared with her spouse. A client does not need to sign a form to
protect their information; a form is used when the information is to be disclosed. Documentation
of all past medical history in the electronic health record is appropriate and should be done to
coordinate client care.
Concepts tested

Question 272
The nurse is caring for a client diagnosed with trichomoniasis. The nurse administers a large
dose of antibiotic and notices the following doses scheduled for tomorrow. The nurse documents
the dose administered as which of the following?
A Partial dose
B Preventative dose
C Loading dose

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D Tertiary dose

Question Explanation
Correct Answer is C
Rationale: Trichomoniasis is a protozoal bacteria that causes a common sexually transmitted
infection that can be treated in a variety of ways. Giving the antibiotics in a large single dose is
considered a loading dose and can be followed by subsequent doses. A partial dose would
indicate that a full dose was not administered, and this could indicate the need for an additional
dose to make a full dose. A preventative dose would be given without prior to actual diagnosis of
the bacteria. Tertiary refers to a stage of disease and of medication.
Concepts tested

Question 273
A nurse is prioritizing client care after receiving change-of-shift report. Which of the following
clients should the nurse plan to see first?
A A client who is scheduled for an abdominal X-ray and is awaiting transport
B A client who has a prescription for discharge and needs a dressing change
C A client who received oral pain medication 30 min ago and reports nausea
D A client who has a thoracic aneurysm and reports sudden back pain

Question Explanation
Correct Answer is D
Rationale: When evaluating who to see first, the nurse should assess the client with abnormal
findings that indicate the client is unstable. A client with a thoracic aneurysm reporting back pain
should be seen first, which could indicate that the aneurysm is rupturing. The clients who are
waiting for an X-ray, just received pain medication, and have a prescription for discharge are
stable and not the priority.
Concepts tested

Question 274
A nurse is witnessing a surgical consent for a client. The client tells the surgical resident that
they need time to think about the risks of the procedure. The resident tells the client there is no
time to discuss the consent further. The client hesitantly signs the consent. Which action does the
nurse take next?
A Signs the consent as a witness
B Informs the charge nurse of the situation
C Tells the client the consent is not valid
D Contacts the surgical attending

Question Explanation
Correct Answer is D
Rationale: The nurse should contact the surgical resident’s supervisor or attending. The client’s
concerns and the resident’s behavior should be addressed thoroughly before the procedure
occurs. Signing the consent as a witness disregards the client’s concerns about the risks of the
procedure. Informing the charge nurse of the situation should occur after the nurse addresses the

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concern with the resident’s supervisor. Telling the client that the consent is not valid after it has
been signed does not address the ethical issue.
Concepts tested

Question 275
The nurse is providing an in-service to graduate nurses on the risk of malpractice litigation.
Which is the best strategy to decrease personal risk in the healthcare environment?
A Discuss any errors with the client and family in detail
B Keep incident reports on file
C Carry personal malpractice insurance
D Maintain expertise in practice

Question Explanation
Correct Answer is D
Rationale: Maintaining expertise in practice fosters continued competence in current knowledge
and skills which is the best way to reduce personal risk and malpractice litigation. Incident
reports are filed with a healthcare agency but do not decrease the risk of malpractice litigation.
Discussing errors in detail with the client and family does not reduce the risk of a malpractice
claim. Although a nurse can carry personal malpractice insurance, it does not decrease the risk of
malpractice litigation.
Concepts tested

Question 276
A client who is scheduled for surgery states to the nurse, “I have decided I do not want to have
the surgery.” Which statement by the nurse demonstrates advocacy?
A "That is a difficult decision; I am sure you made the best one.”
B “If I were you, I would discuss it with your family first.”
C “I will inform the healthcare provider of your decision.”
D “You will need to sign forms to decline the surgery.”

Question Explanation
Correct Answer is C
Rationale: The role of the nurse is to advocate for the health, safety, and rights of a client. The
client has the right to refuse treatments, including surgery. If a client has made the decision to
refuse treatment, the nurse will advocate for the client by reporting the client’s decision to the
healthcare provider. The nurse may need to reinforce teaching or explore options with the client,
but the nurse should not impose personal beliefs or belittle the client’s decision.
Concepts tested

Question 277
The nurse is using the fax machine to transmit a client’s laboratory results to another facility.
Which action should the nurse take?
A Dial the number directly into the fax machine
B Enable the fax machine to save a copy
C Clearly label the results with identifying information

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D Call the facility to verify receipt of the fax

Question Explanation
Correct Answer is D
Rationale: When faxing any protected health information, the nurse should use pre-programmed
numbers to prevent misdialing, attach a cover sheet that provides the identifying information,
ensure that the fax machine does not save copies, and ask the sender to verify that the fax was
delivered to the intended person.
Concepts tested

Question 278
The nurse is working in the local health department, and over the last six months, there has been
an increase in chlamydia infections. In order to help reduce the rates of infection, the nurse
suggests which of the following for the next three months?
A Giving handouts to sexually active clients on discharge
B Making condoms accessible to clients on discharge
C Assessing the client’s knowledge of sexually transmitted infections
D Assessing each client’s knowledge of safe sex practices

Question Explanation
Correct Answer is B
Rationale: Everyone who is sexually active is at risk for sexually transmitted infections. For the
nurse to help decrease the instances of infection, providing condoms would be a noninvasive and
private way to assist clients in safer sex practices. This would also allow non-clinical staff to
assist with the intervention. Giving handouts, especially to minors, could induce shame or
embarrassment. Assessing a client’s knowledge could be difficult due to less-than-truthful
responses due to confidentiality concerns. Intervention that does not require the client to engage
their personal information is most helpful.
Concepts tested

Question 279
A nurse is preparing to refer a client with uncontrolled diabetes mellitus type 2 to a self-
management education and support service. What supportive documentation will the nurse
include with the referral?
A The client’s latest hemoglobin A1C level
B A copy of the client’s medical record
C The current capillary serum glucose level
D A record of the last physical assessment

Question Explanation
Correct Answer is A
Rationale: The latest hemoglobin A1C level will help provide information on the client’s
compliance and efficacy of current treatment. A hemoglobin A1C level determines the average
serum glucose level over a period of 3 months. The client’s medical record will provide
information on all medical history and treatment. A diabetes self-management and support

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service focuses on a specific diagnosis. The current capillary serum glucose level and the last
physical assessment do not provide historical proof of uncontrolled diabetes.
Concepts tested

Question 280
The nurse is educating other staff members on the components of informed consent. When
evaluating learning, which of the following responses indicates the need for additional teaching?
A “Informed consent requires disclosure of risks.”
B “The client must be able to understand the information needed to make a decision.”
C “The client should describe the treatment or procedure they are giving consent for in their own
words.
D “The provider should limit the amount of information provided, so the client isn’t
overwhelmed.”

Question Explanation
Correct Answer is D
Rationale: In all health care facilities, informed and voluntary consent is needed for admission,
for each specialized diagnostic or treatment procedures, and for any experimental treatments or
procedures. Informed consent includes 1) disclosure, 2) comprehension, 3) competence, and 4)
voluntariness. If the provider limits the amount of information provided, this must be done in a
way that does not impact the client’s right to self determination (autonomous decision making).
The healthcare provider must always ask What would the average client need to know to be an
informed participant in the decision?
Concepts tested

Question 281
A nurse is discussing advance directives with a client during an admission history. Which client
statement indicates an understanding of a healthcare power of attorney?
A “The person I choose to make medical decisions for me must be someone within my
immediate family.”
B “I can appoint a person I trust to make medical decisions for me when I can no longer do so.”
C “My healthcare proxy will make medical decisions for me anytime I am hospitalized.”
D “Once I choose a person to be my power of attorney, I cannot select someone else.”

Question Explanation
Correct Answer is B
Rationale: A durable power of attorney appoints a healthcare proxy to make decisions for the
client when they can no longer do so themselves. The proxy can be any competent adult the
client chooses. A healthcare proxy will make decisions only when the client is no longer able to
do so themselves. The choice of a healthcare proxy can be revoked or revised at any time by the
client.
Concepts tested

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Question 282
A graduate nurse tells the charge nurse that a terminally ill client has verbalized wanting to end
all medical treatment. The client’s family is concerned with the client’s statement. How does the
charge nurse explain advocacy to the graduate nurse?
A “It is our duty to recognize the needs of both the client and their family.”
B “We need to respect the wishes of our client only.”
C “Always do what is medically necessary to keep the client healthy.”
D “A terminally ill client should not make decisions without the family’s consent.”

Question Explanation
Correct Answer is A
Rationale: The nurse’s role as an advocate is to recognize and understand the needs of the client
and their family. It is important for nurses to find solutions that benefit both the client and their
loved ones. Although nurses advocate for the client’s autonomy, they must also take the family’s
concern into consideration. Nurses should provide competent care but should also respect the
client’s autonomy regarding medical treatment. A terminally ill client who is coherent has the
right to voice their own medical decisions.
Concepts tested

Question 283
The registered nurse is caring for a client who had a cardiac catheterization. Which action is
appropriate to delegate to the licensed practical nurse (LPN/LVN)?
A Performing the initial assessment of the catheter insertion site
B Teaching the client about the post-procedure plan of care
C Administering the scheduled lipid-lowering medication
D Evaluating the effectiveness of the nursing interventions

Question Explanation
Correct Answer is C
Rationale: The Five Rights of Delegation are right task, right circumstance, right person, right
directions and communication, and right supervision and evaluation. Professional nurses are
responsible for delegating nursing activities, but although RNs may delegate elements of care,
they do not delegate the nursing process itself. Nursing care or tasks that should never be
delegated, except to another RN, include initial and ongoing nursing assessment, determination
of the diagnosis and plan of care, evaluation, and client education. Any task that is delegated
should be based on the training and competence of the individual accepting the delegation.
Concepts tested

Question 284
The nurse is preparing to complete a daily assessment and dressing change for a client who is
immobile and has a wound on the coccyx. Which of the following actions by the nurse is
appropriate to manage time effectively?
A Remove the old dressing before gathering supplies
B Complete the dressing change while giving the client a bed bath
C Delegate the dressing change to the unlicensed assistive personnel

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D Postpone the dressing change until after morning care has been completed

Question Explanation
Correct Answer is B
Rationale: The nurse should perform the wound assessment and dressing change while the client
is being bathed. Combining these two actions is an efficient way to get both tasks completed
because the client will need to be positioned and exposed for both procedures. The nurse cannot
delegate an assessment to an unlicensed assistive personnel, and the other responses are not the
most efficient use of the nurse’s time.
Concepts tested

Question 285
The nurse is evaluating the time management skills of staff members. Which action by the staff
member demonstrates effective time management?
A Asking the unit manager to complete some of the assigned tasks
B Delaying non-essential tasks until the next shift
C Documenting all nursing interventions after the shift has concluded
D Reviewing the clients’ prescriptions before beginning to see clients

Question Explanation
Correct Answer is D
Rationale: The nurse should review all of the clients’ prescriptions before beginning to complete
tasks. Doing this ahead of time allows the nurse to plan which interventions can be prioritized.
Delaying tasks until the next shift and documenting after the normally scheduled shift are not
appropriate time management techniques. Asking the unit manager for help is not an indicator of
time management.
Concepts tested

Question 286
The nurse is planning care for a client with pancreatitis who has a prescription for intermittent
nasogastric suction. Which intervention is the priority for the nurse to include in the plan of care?
A Administer the prescribed intravenous (IV) dose of ondansetron
B Encourage supine position to limit gastric losses
C Resume high-fat diet based on client tolerance
D Administer prescribed oral opioid analgesics

Question Explanation
Correct Answer is A
Rationale: The priority intervention of the nurse to include in the plan of care for a client
prescribed nasogastric suction for severe nausea and vomiting is the administration of
ondansetron intravenously as prescribed. The client should be placed in a side-lying position for
comfort and to decrease the risk of aspiration. When diet is resumed, oral intake should be
started slowly with small, frequent, high-carbohydrate meals. A high-fat diet will exacerbate
acute pancreatitis. The client will not be able to receive oral opioid analgesia with nasogastric
suction.

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Concepts tested

Question 287
The nurse is preparing to administer newly prescribed simvastatin to a client who had a
myocardial infarction. The client states, “I am not sure I want to take that medication; I heard it
has side effects.” Which statement by the nurse is appropriate?
A “You need this medication to prevent another myocardial infarction.”
B “I can discuss with you the side effects that can occur with this medication.”
C “I will inform your healthcare provider that you are refusing the medication.”
D “You need to take the first dose to see if you will have any side effects.”

Question Explanation
Correct Answer is B
Rationale: Clients have the right to refuse treatment or procedures. Often the client will refuse
because of concerns related to outcomes, such as side effects with medications. The nurse
should recognize and respect the client’s right to refuse but should also provide additional
information or resources for the client to make the decision. Discussing side effects could
provide the client with more information to make the decision. The nurse may need to inform the
healthcare provider, but this does not address the client’s concerns. Telling the client what would
happen if they do not take the medication dismisses the client’s concerns.
Concepts tested

Question 288
A nurse is assessing a client after morning rounds. The client tells the nurse that the healthcare
provider was rude and did not explain the plan of care. How does the nurse respond to the
client’s concern?
A “You are entitled to receive competent and respectful care.”
B “Healthcare providers are very busy during morning rounds.”
C “What questions do you have regarding your plan of care?”
D “Has your healthcare provider made you feel this way before?”

Question Explanation
Correct Answer is A
Rationale: A client has a right to receive medical care from providers who are competent and
treat the client with respect. The nurse acknowledges the client’s concern. The nurse should not
excuse the behavior of the healthcare provider. The client’s questions regarding the plan of care
should be answered. However, the nurse is not addressing the client’s concern in its entirety. The
nurse’s role is to acknowledge the client’s rights. Asking about past experiences does not address
the current concern.
Concepts tested

Question 289
The nurse is caring for a client admitted with respiratory distress, and endotracheal intubation is
indicated. Which member of the healthcare team should the nurse collaborate with to ensure the
ventilator is set up and operational?

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A Respiratory therapist
B Healthcare provider
C Biomedical services
D Charge nurse

Question Explanation
Correct Answer is A
Rationale: The purpose of mechanical ventilation is to maintain alveolar ventilation and oxygen
delivery. Respiratory therapists are trained in techniques and equipment that improve
oxygenation and pulmonary function, including ventilators. The healthcare team continually
assesses the patient for adequate gas exchange, signs and symptoms of hypoxia, and response to
treatment. Therefore, the nursing diagnosis of impaired gas exchange is, by its complex nature,
multidisciplinary and collaborative. The team members must share goals and information freely.
Concepts tested

Question 300
The nurse is caring for a client who has a thoracentesis and physical therapy scheduled during
the nurse’s shift. Which action by the nurse is most appropriate to effectively manage this
client’s care?
A Request that the client’s physical therapy be performed in the morning
B Cancel the client’s physical therapy prescription for that day
C Ensure that the thoracentesis is performed before physical therapy begins
D Medicate the client with analgesics prior to both activities

Question Explanation
Correct Answer is A
Rationale: The most appropriate action would be to request that the physical therapy be
performed in the morning prior to the thoracentesis. This action still allows both prescriptions to
be completed but in the most effective way. Canceling the physical therapy and planning to
complete the physical therapy after the thoracentesis are not the most effective management of
care strategies. Medicating the client prior to these activities is not an incorrect action but does
not address the schedule conflict.
Concepts tested

Question 301
The nurse overhears an unlicensed assistive personnel (UAP) tell a family member, “The client
that injured your spouse in the motor vehicle accident (MVA) should go to jail, but he just died.”
Which action should the nurse implement first?
A Interrupt the conversation, and discuss the situation with the UAP privately
B Allow the UAP to finish her conversation, and discuss the situation later
C Apologize to the family member for the UAP’s comments
D Tell the UAP that the comment is a violation of confidentiality

Question Explanation
Correct Answer is A

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Rationale: The nurse should stop the conversation immediately and ask the UAP to discuss the
situation privately, so the nurse does not embarrass the UAP. Gossiping about another client is a
violation of his or her privacy and a breach of confidentiality and HIPAA protocol. The nurse
should not allow the conversation to continue. The nurse could apologize for the UAP’s
comments, but this is not the first intervention. The nurse should tell the UAP about the breach
of confidentiality but addressing the situation with her privately and immediately is the priority
intervention.
Concepts tested

Question 302
The nurse is performing an initial skin assessment on a client transferred from a different unit.
The nurse observes redness to the gluteal folds. How should the nurse document the finding?
A Blanching
B Erythema
C Pressure injury
D Atrophy

Question Explanation
Correct Answer is B
Rationale: The initial sign of pressure is redness of the skin, which is called erythema. Blanching
is seen when whiteish coloration of the skin remains longer than normal when pressure is
applied. A pressure injury is evaluated and staged accordingly, and erythema is not classified as
a pressure injury. Atrophy refers to the decrease in the size of an organ, body part, or tissue.
Concepts tested

Question 303
A nurse reviews new prescriptions for several clients on a medical-surgical unit. Which
intervention will the nurse perform first?
A Provide discharge instructions to a client post-abdominal surgery
B Initiate a patient-controlled analgesia pump for a client with uncontrolled pain
C Administer intravenous antibiotics to a newly admitted client
D Perform wound care on a client with a foot ulcer

Question Explanation
Correct Answer is B
Rationale: The nurse should initiate the patient-controlled analgesia pump for a client with
uncontrolled pain. Managing a client’s pain (the fifth vital sign) is a priority intervention for the
nurse. Discharge instructions indicate the client is stable. Providing discharge instructions to a
stable client is not a priority intervention. Administering intravenous antibiotics to a newly
admitted client is an important intervention but is not a priority for the nurse. The client with
uncontrolled pain should be seen first. Wound care is a routine treatment and can be performed
after the nurse completes the rest of the prescribed interventions.
Concepts tested

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Question 304
A charge nurse is preparing the staffing assignment for the oncoming shift. Two nurses have
called in and the client-to-nurse ratio will increase from 1:5 to 1:8. Which action does the charge
nurse take?
A Call the nurse manager to report the situation before the end of the shift
B Ask the staff nurses to volunteer to work a double shift
C Finalize the staffing assignment for the oncoming shift
D Ensure all client care has been completed before the end of shift

Question Explanation
Correct Answer is A
Rationale: The nurse must report the situation to the nurse manager. A significant increase in
nurse-to-client ratios can pose a risk to client safety. Asking the staff nurses to volunteer to work
a double shift is not a safe practice and is not a decision that can be made independently by the
charge nurse. Finalizing the staffing assignment disregards the risk of client safety concerns.
Ensuring all client care has been completed on the unit before the end of the shift is not a
realistic goal. Client care is continuous.
Concepts tested

Question 305
A nurse manager has emphasized the use of bedside reporting to unit nurses. Which client
outcome indicator suggests the performance improvement strategy is effective?
A Customer service reports indicate increased client satisfaction with nursing communication.
B Charge nurse rounds indicate over 80% of unit nurses are performing bedside reporting.
C Timesheets indicate nursing overtime has decreased by 10% on the unit.
D Nurses voice bedside reporting improves their workflow throughout the shift.

Question Explanation
Correct Answer is A
Rationale: The goal of bedside reporting is to improve communication amongst healthcare
providers and ensure that the client is informed about their plan of care. Increased client
satisfaction with nursing communication indicates bedside reporting is successfully meeting
performance improvement goals. The number of nurses performing bedside reporting is a
process indicator, not an outcome indicator. The primary goal of bedside reporting is to improve
communication, not decrease overtime. Nurses voicing improved workflow is not a client-
centered outcome indicator.
Concepts tested

Question 306
The nurse observes a social media post by a staff nurse that discusses the care of a client. Which
of the following actions should the nurse take?
A Request the post be deleted
B Inform the client about the post
C Report the post to a supervisor
D Notify the board of nursing

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Question Explanation
Correct Answer is C
Rationale: Social media are web-based technologies that allow users to create, share, and
participate in virtual communities. These social media networks provide nurses the opportunity
to share ideas, develop professional connections, and access education. There are policies in
place to prevent sharing of client information. Disclosing information or posting defamatory
remarks could lead to serious consequences. The nurse should report the post to a supervisor.
Requesting the post to be deleted does not address the issue.
Concepts tested

Question 307
The nurse manager is reviewing ways that a nurse may risk disciplinary action related to
licensure. Which action would put the nurse’s license at risk?
A Inserting a central catheter under the direct supervision of a healthcare provider
B Participating in lateral violence and bullying on the unit
C Arriving to work with evidence of body odors
D Maintaining a habit of excessive absences and tardiness

Question Explanation
Correct Answer is A
Rationale: The nurse should recognize that inserting a peripheral intravenous central catheter
(PICC) even under the direct supervision of a healthcare provider is outside the nurse’s scope of
practice, which is not allowed as per the state board of nursing and Nurse Practice Act.
Participating in lateral violence/bullying on the unit, arriving to work with evidence of body
odors, and maintaining a habit of excessive absences and tardiness do not pose a risk to
disciplinary action regarding licensure but may result in loss of employment if agency policy is
violated.
Concepts tested

Question 308
The nurse is preparing a questionnaire for the pediatric inpatient unit to evaluate patient
satisfaction. The nurse understands which of the following could impact the results?
Question 18 Answer Choices
A Socioeconomic status
B Marital status of the parent
C Moral evaluations
D Family size

Question Explanation
Correct Answer is C
Rationale: For the nurse to properly evaluate patient satisfaction, moral evolutions should be
reviewed and understood. Moral evaluations are judgments that conform to the standard of what
is right and good. Moral evaluations assess human actions and institutions and avoid giving
special place to a person’s own welfare. Socioeconomic status, family size, and marital status are

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not likely to influence the results but should all be taken into consideration when caring for
clients.
Concepts tested

Question 309
A postoperative client with a hip fracture has been referred to a rehabilitation center for
continuity of care. Which priority documentation will the nurse include with the referral?
A The latest physical therapy progress notes
B The surgical report
C A record of current pain management
D A copy of the last physical assessment

Question Explanation
Correct Answer is A
Rationale: The latest physical therapy progress notes provide information on the client’s mobility
and can help the rehabilitation center formulate a plan of care. The surgical report does not
provide relevant information on the client’s current progress. A record of current pain
management provides information about the client’s treatment; however, it does not provide
relevant information regarding mobility. A copy of the last physical assessment provides
information on the client’s overall health status but is not specific to the diagnosis and client’s
rehabilitation needs.
Concepts tested

Question 310
The nurse is caring for a client who is going to have an invasive procedure. The healthcare
provider has completed the informed consent discussion. Based on knowledge of the nurse’s role
in informed consent, what action by the nurse is most appropriate?
A Answer any additional questions that the client has about the procedure
B Determine if the client has additional questions about the proposed procedure
C Sign the documentation in the role of the witness
D Encourage the family to support the client’s decision

Question Explanation
Correct Answer is B
Rationale: The most important part of the consent process is informing the client. A client's
signature is meaningless if the client is not informed. Nurses are often told that when they obtain
a client signature on a consent form, they are only witnessing the signature and not verifying that
informed consent was obtained. However, nurses have ethical and professional accountabilities
to ensure the client is fully informed and capable of giving consent. It is appropriate for the nurse
to assess if the client has full understanding of the proposed treatment and then advocate to
ensure that the client received the necessary information from the provider.
Concepts tested

Question 311
A performance improvement (PI) nurse is auditing client records and notes a client’s chart is
missing documentation on advance directives. The PI nurse addresses the findings with the
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bedside nurse. Which statement by the bedside nurse indicates further teaching on advance
directives is required?
A “The client denies having an advanced directive, and the information will be charted
shortly.”
B “The client’s spouse is the healthcare power of attorney and is bringing the legal
documentation.”
C “The client is only being admitted for observation, so the information is unnecessary.”
D “The client requested more information and is currently considering their options.”

Question Explanation
Correct Answer is C
Rationale: Information on advance directives should be requested from every client who is
admitted to a healthcare facility regardless of the length of stay. The client’s health status can
change abruptly and healthcare providers should be aware of advance directives. Real-time
charting is encouraged. However, the client has been appropriately assessed for advanced
directives by the bedside nurse. A copy of the legal documentation should be included in the
chart as soon as possible. Clients who do not have an advance directive should be provided with
information that outlines their health care decision rights.
Concepts tested

Question 312
A nurse reviews a discharge home prescription for a client with a traumatic brain injury. The
client is unable to perform activities of daily living independently and lives with elderly parents.
Which action does the nurse perform?
A Coordinates the client’s transportation home after discharge
B Provides discharge instructions to the client’s parents
C Instructs the client’s parents to hire a caregiver upon discharge
D Requests a consult to social work for discharge placement

Question Explanation
Correct Answer is D
Rationale: The nurse’s role as an advocate is to assess the safety of a client’s discharge. A client
who is unable to perform activities of daily living independently is not safe to discharge home
with elderly parents who may be unable to provide safe care. The nurse requests a consult to
social work for possible discharge placement. The client’s transportation home is not the priority
issue at this time. Providing discharge instructions to the client’s parents finalizes the discharge.
The nurse must first assess discharge safety. The nurse should coordinate with the healthcare
team to provide available resources to the client and their family upon discharge.
Concepts tested

Question 313
The nurse is caring for a group of clients with neurological disorders. Which task would be most
appropriate for the nurse to delegate to the unlicensed assistive personnel?
A Teaching Crede’s maneuver to a client needing to void
B Administering tube feeding to a quadriplegic client

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C Assisting with bowel training by placing the client on the bedside commode
D Observing the client for correct self-catheterization

Question Explanation
Correct Answer C
Rationale: The Five Rights of Delegation are right task, right circumstance, right person, right
directions and communication, and right supervision and evaluation. Professional nurses are
responsible for delegating nursing activities, but although RNs may delegate elements of care,
they may not delegate the nursing process itself. Nursing care or tasks that should never be
delegated, except to another RN, include initial and ongoing nursing assessment, determination
of the diagnosis and plan of care, evaluation, and client education. The UAP can assist the client
to the bedside commode. All other tasks should be completed by an individual with licensure.
Concepts tested

Question 314
The nurse is planning out the daily tasks for assigned clients. Which of the following actions by
the nurse should be completed first to manage time effectively?
A Explain the procedures to each client
B Gather all necessary supplies for interventions
C Review the client’s prescriptions in the medical record
D Request that the nursing supervisor assist with tasks

Question Explanation
Correct Answer is C
Rationale: The nurse should first review all of the client’s prescriptions before beginning to
complete tasks. This action allows the nurse to plan what interventions can be clustered together
and/or what tasks need to be prioritized. Gathering supplies and explaining procedures would
occur after the nurse has reviewed the medical record and requesting help from the nursing
supervisor might occur if the nurse realizes that assistance is needed.
Concepts tested

Question 315
The experienced nurse is precepting a graduate nurse who reports having difficulty completing
tasks on time. Which action by the graduate nurse would require follow-up by the experienced
nurse?
A Asks for help with dosage calculation
B Requires two attempts to start a peripheral IV site
C Performs all tasks without delegation to nursing personnel
D Struggles with making staffing assignments
You did not answer this question. Click here to reveal explanation.
Question Explanation
Correct Answer is C

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Question 316
The hospice nurse is planning care for a new client with terminal cancer. Which statement by the
nurse would best assess the client’s needs?
A “How is your family coping with your diagnosis?”
B “Can you describe your spiritual beliefs?”
C “Do you have any questions about your care?”
D “What are your goals that you would like met?”

Question Explanation
Correct Answer is D
Rationale: When a client is new to care, such as with hospice, the nurse should identify the
client’s needs by assessing for goals. The goals a client would like met will guide the nurse in
developing a plan of care that focuses on interventions to meet the goals. Asking the questions
about their care or describing spiritual beliefs are important but does not address the client’s
needs. While asking how the client’s family is coping is important, it does not address the
client’s needs.
Concepts tested

Question 317
A nurse is providing care to a client with diverticulitis who is refusing all medical treatment. The
client tells the nurse “I want to leave the hospital. I know how to manage my condition at home.”
Which action does the nurse perform next?
A Contact the healthcare provider, and explain the risks of leaving against medical advice
B Inform the charge nurse, and tell the client they cannot leave until medically stable
C Tell the client they are not ready to be discharged, and document refusal of treatment in the
medical record
D Discontinue the client’s intravenous access, and escort the client out of the facility

Question Explanation
Correct Answer is A
Rationale: An alert, competent client has the right to refuse treatment and leave the facility
against medical advice. However, the nurse must first inform the healthcare provider and discuss
the risks of leaving without completing medical treatment. The nurse cannot hold the client in the
facility against their wishes. The determination of when a client is ready for discharge is not the
sole decision of the nurse. The client must first be informed of the risks of leaving against
medical advice prior to discontinuing intravenous access and escorting them out of the facility.
Concepts tested

Question 318
A nurse is providing care to a client with a complex abdominal wound. The client tells the nurse,
“My healthcare provider told me I was going to be discharged soon, but I don’t think I can afford
all of my wound supplies.” How does the nurse respond to the client’s concern?
A “Your social worker will be informed of your needs prior to discharge.”
B “A list of wound care supply stores will be given to you at discharge.”
C “Is there anyone in your family who can help you purchase wound supplies?”

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D “How will you be obtaining the medications necessary for your wound care?”

Question Explanation
Correct Answer is A
Rationale: Social workers can assist clients with finding financial resources for their medical
care. The nurse refers the case to the client’s social worker prior to discharge. Providing the
client with a list of wound care supply stores does not address the client’s financial difficulties.
The nurse should refer the client to a social worker prior to suggesting the purchase of wound
care supplies by the family. Asking the client how they will be obtaining their medications does
not address the client’s financial concerns.
Concepts tested

Question 319
The nurse is caring for a client diagnosed with a left hemisphere cerebrovascular accident. The
client has a new prescription for ambulation. Which team member should the nurse collaborate
with to promote an optimal outcome?
A Physical therapist
B Case manager
C Occupational therapist
D Unlicensed assistive personnel

Question Explanation
Correct Answer is A
Rationale: The nurse should collaborate with the physical therapist, who can assess the client and
determine the amount of assistance required to safely ambulate the client. The case manager
coordinates the care of a caseload of patients through facilitating communication between nurses,
other healthcare personnel who provide care, and insurance companies. That is not the
appropriate team member for this particular need. The occupational therapist can assist this client
to complete activities of daily living (ADLs) but not ambulation. The unlicensed assistive
personnel may be needed to assist with ambulation, but this is not the first person the nurse
would collaborate with.
Concepts tested

Question 320
The charge nurse observes staff members arguing about their client assignments. Which action
by the charge nurse is appropriate at this time?
A Let the staff members work it out amongst themselves
B Ask the staff members about their concerns
C Adjust the staff members’ client assignments
D Notify management about the staff members’ incivility

Question Explanation
Correct Answer is B
Rationale: The nurse should ask the staff member about their concerns to gather more
information about the cause of their disagreement before making any changes. Allowing the staff

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members to work it out amongst themselves might be appropriate if they were not already having
an argument. There is not enough information presented to determine if incivility is taking
place.
Concepts tested

Question 321
The nurse overhears nursing students talking on the elevator and describing a client who was
admitted to the unit. One of the nursing students starts to disclose the client’s medical
information. What is the first action by the nurse?
A Stop the conversation in the elevator
B Contact the nursing students’ instructor
C Report the incident to the nurse manager
D Inform the client about the privacy violation

Question Explanation
Correct Answer is A
Rationale: The nursing students are violating HIPAA and confidentiality requirements, and the
nurse should act immediately to stop the conversation. The nurse may contact the nursing
students’ instructor and report the behavior and report the incident to the nurse manager, but
these are not the first actions the nurse should make if overhearing this conversation on an
elevator. The nurse should not tell the client about the breach of confidentiality.
Concepts tested

Question 322
The nurse is reviewing the laboratory data for a client with aplastic anemia and notes a white
blood cell count of 3000 mcL. The nurse should understand that the client is at risk for which
condition?
A Leukocytosis
B Neutropenia
C Phagocytosis
D Erythropenia

Question Explanation
Correct Answer is B
Rationale: Neutropenia is caused by a decrease in the production of neutrophils or increased
destruction of these cells. This can be caused by several medical conditions, such as aplastic
anemia. Leukocytosis is an elevation of white blood cell count. Phagocytosis is the ingestion of
bacteria and ameboid protozoans. Erythropenia is a reduction in the number of red blood cells.
Concepts tested

Question 323
A nurse receives admission prescriptions for a client with suspected sepsis. Which prescribed
intervention will the nurse perform first?
A Initiation of intravenous fluids
B Collection of blood cultures

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C Insertion of an indwelling urinary catheter
D Administration of a prophylactic anticoagulant

Question Explanation
Correct Answer is A
Rationale: The nurse should initiate intravenous fluids as soon as possible. Priority interventions
for a client with suspected sepsis include fluid resuscitation and antibiotic administration.
Obtaining blood cultures is an important intervention for determining the suspected source of
infection. However, fluid resuscitation is the priority intervention. Insertion of an indwelling
catheter and administration of prophylactic anticoagulants are routine interventions for a client
with suspected sepsis. However, fluid resuscitation is the priority.
Concepts tested

Question 324
A nurse is providing care to a 15-year-old client who arrives at the clinic requesting an abortion.
The client states that the parents are unaware of the pregnancy and would like to keep the
treatment confidential. How does the nurse respond to the client’s request?
A “We cannot perform this procedure without your parent’s consent.”
B “I will inform the healthcare provider of your wishes.”
C “Are you aware of all of the risks involved with terminating your pregnancy?”
D “How did you arrive to the decision to terminate your pregnancy?”

Question Explanation
Correct Answer is D
Rationale: The nurse must explore the adolescent client’s ability to make their own decisions.
Asking the client how they arrived at their decision assesses the presence, or lack of, social
support systems. Telling the client that the procedure cannot be performed without the parent’s
consent will cause a loss of rapport with the client and may influence the client to terminate the
pregnancy by other means. The healthcare provider should be informed of the client’s wishes
after the nurse considers the ethical implications of the client’s request. Discussing the risks of
terminating the pregnancy does not address the ethical concern and is not an independent nursing
action.
Concepts tested

Question 325
A nurse is assessing a client with a left lower extremity fracture who has been prescribed
crutches for ambulation. Which observation indicates the client may benefit from a referral to
physical therapy?
A The client asks for assistance before getting out of bed and uses one crutch to stand.
B The client takes frequent breaks during ambulation and uses a four-point gait.
C The client grabs the hand grips and places their body weight on the axillae while ambulating.
D The client flexes their elbows and leans forward while holding the crutches.

Question Explanation
Correct Answer is B

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Rationale: Crutches are prescribed to prevent the client from placing weight on the affected
extremity. A four-point gait indicates the client is placing weight on both lower extremities and
might benefit from a referral to physical therapy for alternative options. Using one crutch to
stand decreases balance. The client should be instructed to hold both crutches while standing.
Weight should not be placed on the axillae while using crutches. The nurse should emphasize
placing the weight on the hand grips. Leaning forward decreases balance. The client should be
instructed to stand up straight while holding the crutches.
Concepts tested

Question 326
The nurse attended an education conference about ethics in nursing practice. Which statement by
the nurse indicates an understanding of nonmaleficence?
A “In my nursing practice, I will follow protocols and policies to prevent harm to my clients.”
B “When providing care, I will act fairly towards my client regardless of culture or race.”
C “When I tell a client I will be back in an hour, I will make every effort to do so.”
D “I will provide my clients with necessary information, so they can make decisions.”

Question Explanation
Correct Answer is A
Rationale: Nonmaleficence is the ethical principle to do no harm. A nurse who demonstrates
nonmaleficence will follow protocols and policies that are in place to prevent harm or injury to
clients. Fidelity is the ethical principle of faithfulness, or keeping promises, such as returning to
the client when stated. The nurse demonstrates autonomy for clients when providing the
necessary information to make decisions. Beneficence refers to taking positive actions to help
others.
Concepts tested

Question 327
The client admitted for an invasive procedure asks the nurse about informed consent. Which
statement best describes the role of the nurse to ensure informed consent?
A “I will give a detailed description of the risks and benefits of the procedure.”
B “I will give an explanation of each step of the procedure.”
C “I will offer alternative options to this procedure.”
D “I will ask questions to determine that you understand what you are signing.”

Question Explanation
Correct Answer is D
Rationale: The nurse's responsibilities related to informed consent include ensuring the consent
form is completed with signatures from the client, serving as a witness to the signature process,
and determining whether the client understands what they are signing by asking pertinent
questions. The healthcare provider is responsible for informing the client about the procedure
and obtaining consent by providing a detailed description of the procedure or treatment, its
potential risks and benefits, and alternative methods available.
Concepts tested

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Question 328
The nurse is working to improve patient satisfaction on the preoperative unit after having poor
scores over the last quarter. A new bedside tool was implemented six months ago, and the results
have been compiled for review. The nurse recognizes the processes as which acronym?
A SBAR
B PDSA
C EBP
D STEPPS

Question Explanation
Correct Answer is B
Rationale: The PDSA model stands for plan, do, study, act. This is a cycle used for testing
change in the work setting by following the steps strategically. The project should be
implemented on a small scale to observe the change effect. SBAR is used for communication.
EBP is the acronym for evidenced-based practice. STEPPS is a framework with five key
principles and is based on a team structure.
Concepts tested

Question 329
The nurse is caring for a client who is refusing a treatment that has limited benefit. The family
asks the nurse to try to convince the patient to begin the treatment. Which action by the nurse is
consistent with ethical practice?
A Decline to convince the client to begin treatment
B Encourage the family to try to convince the client
C Inform the physician that the family would like the client to begin treatment
D Ask the client if they are sure of their decision

Question Explanation
Correct Answer is A
Rationale: The Code of Ethics for Nurses states that the nurse promotes, advocates for, and
protects the rights of the client. This includes the right to make decisions that the nurse or family
may not agree with. The nurse’s primary commitment is to the patient, and they should not
encourage others to persuade the client to change their mind.
Concepts tested

Question 330
The healthcare provider has called and asked the nurse to have the client sign the consent form to
have a surgery scheduled for tomorrow. When approached, the client states, “I haven’t spoken to
my doctor yet.” What action by the nurse is appropriate?
A Obtain the signature, and tell the client that the healthcare provider will be in to speak with
them
B Do not obtain the signature, and inform the healthcare provider that they need to engage in the
informed consent discussion
C Provide the client with the risks, benefits, and alternatives to the surgery, and obtain their
signature on the informed consent document

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D Document this as an informed consent refusal, and notify the healthcare provider

Question Explanation
Correct Answer is B
Rationale: The cornerstone of the informed consent process is the discussion between the client
and the healthcare provider. A client has the right to consent (or not) to any recommended
procedure or treatment. The patient also has the right to enough information to give informed and
meaningful consent. The client should be informed by the healthcare provider performing the
procedure, not the nurse. In this case, the nurse should not obtain a signature and should inform
the provider that they need to meet with the client. The client has not refused the procedure in
this scenario.
Concepts tested

Question 331
A nurse is providing care to a client with a do not resuscitate (DNR) advance directive. The
nurse enters the client’s room and finds the client unresponsive in bed. Which action does the
nurse perform next?
A Initiates chest compressions
B Applies supplemental oxygen to the client
C Checks the client’s pulse
D Contacts the healthcare provider

Question Explanation
Correct Answer is C
Rationale: The nurse checks the client’s pulse to confirm the absence of circulation. Although
the client has a do not resuscitate (DNR) advance directive, the nurse must still confirm the
client’s condition. Initiating chest compressions goes against the client’s advance directive.
Applying supplemental oxygen to the client provides comfort measures. However, the nurse
must first confirm the client is unresponsive. Contacting the healthcare provider is an important
intervention after the nurse confirms the client’s condition.
Concepts tested

Question 332
A nurse is providing care to a client who is on a ventilator following a stroke. The client’s spouse
is denying consent to several prescribed medical interventions. Which action does the nurse
perform next?
A Follow the wishes of the client’s spouse
B Perform the medical interventions as prescribed
C Notify the client’s primary healthcare team
D Document refusal of care in the client’s medical record

Question Explanation
Correct Answer is C
Rationale: The nurse advocate must act in the best interest of the client and notify the primary
healthcare team. The spouse’s lack of consent to medical interventions may harm the client and
the reasons for refusal should be assessed. The nurse must continue to be the client’s advocate
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despite the inability to communicate with the client. Performing the medical interventions will
cause mistrust in the client’s spouse. Documenting the refusal of care is an important
intervention. However, the nurse must first advocate for the client’s medical care
Concepts tested

Question 333
The registered nurse and an experienced licensed practical nurse (LPN/VN) are caring for a
group of clients. Which of the following tasks should the nurse delegate to the LPN/LVN?
A Provide discharge instructions to the spouse of a confused client
B Straight catheterize a client who has not voided in 8 hours
C Develop a plan of care for a client who is recovering from an appendectomy
D Complete the admission assessment for a client with diverticulitis

Question Explanation
Correct Answer is B
Rationale: The Five Rights of Delegation are right task, right circumstance, right person, right
directions and communication, and right supervision and evaluation. Professional nurses are
responsible for delegating nursing activities, but although RNs may delegate elements of care,
they do not delegate the nursing process itself. Nursing care or tasks that should never be
delegated, except to another RN, include initial and ongoing nursing assessment, determination
of the diagnosis and plan of care, evaluation, and client education. Any task that is delegated
should be based on the training and competence of the individual accepting the delegation. The
LPN/LVN scope of practice and training includes performing straight catheterization.
Concepts tested

Question 334
The nurse is planning the daily care for assigned clients. Which of the following tasks can be
delegated to the unlicensed assistive personnel?
A Assessing a client’s surgical wound
B Assisting a client with ambulation
C Removing a peripheral IV
D Documenting medication administration

Question Explanation
Correct Answer is B
Rationale: An unlicensed assistive personnel (UAP) cannot assess a client, remove invasive lines
(such as an indwelling catheter or IV), or document tasks in the medical record that are out of
their scope of practice (medication administration). It is appropriate to ask for a UAP to assist a
client with ambulation.
Concepts tested

Question 335
The nurse is caring for a client with a history of chronic pain who reports inadequate pain relief
from oral analgesics. The client states “I just can’t do the things I used to.” Which action by the
nurse would be most appropriate?

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A Obtain a prescription for a higher dose from the health care provider
B Ask the health care provider to change the analgesic route to IV
C Assess the client’s knowledge of complementary alternative medicine
D Refer the client to a pain specialist

Question Explanation
Correct Answer is C
Rationale: Client independence is best achieved by assessing the client’s knowledge of
complementary alternative medicine. This action supports self-care and client participation. An
increased dose as well as an alternate route of administration (oral to intravenous) may provide
temporary relief but could increase side effects that could limit a client’s independence. Referrals
may be needed but do not support client measures to manage pain and self-care independently.
Concepts tested

Question 336
The nurse is caring for a pediatric client who is being evaluated for cystic fibrosis. When
collecting data to develop a plan of care, the nurse should give priority to which finding?
A Caregiver states stools are bulky and greasy
B Weight of client is below the 50th percentile on the growth chart
C Caregiver reports frequent history of recurrent respiratory infections
D Activity intolerance and fatigue are reported with exercise

Question Explanation
Correct Answer is C
Rationale: The nurse should give priority to respiratory issues (ABCs) in the plan of care of a
client with a possible diagnosis of cystic fibrosis. Due to the genetic dysfunction of the protein
CFTR, the transport of chloride across the cellular membrane is disrupted resulting in thick
tenacious secretions in the lungs and digestive tract. Due to malabsorption, stools may be bulky
and greasy in nature. Malabsorption issues may also result in weight loss and failure to thrive.
Activity intolerance and fatigue reported with exercise are related to respiratory complications of
this disease.
Concepts tested

Question 337
A client with stable angina requests to be discharged from the emergency department. The
healthcare provider explains the risks of not receiving medical treatment and refuses to discharge
the client. Which action does the nurse perform next?
A Encourage the healthcare provider to discharge the client
B Contact the nurse manager to speak with the client
C Ask the client to sign an against medical advice form
D Request an unlicensed assistive personnel to escort the client out of the facility

Question Explanation
Correct Answer is C

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Rationale: Alert, stable, and mentally competent clients have the right to refuse medical care.
The nurse must ensure the client understands the risks of refusing medical care and ask the client
to sign an against medical advice form before exiting the facility. The nurse respects the client’s
wishes but does advocate for an unsafe discharge. Escalation of the situation to a nurse manager
is not indicated if the healthcare provider has explained the risks to a stable, mentally competent
client. A client can be escorted out of the facility if necessary after signing an against medical
advice form.
Concepts tested

Question 338
A nurse is providing care to an older adult client with newly diagnosed cancer. The client’s
family tells the nurse, “We aren’t sure about pursuing treatment; no one in the family has the
resources to care for our loved one at home.” Which action does the nurse perform?
A Contacts the healthcare provider to inform them of the family’s decision
B Refers the case to the ethics committee for review
C Calls the nurse supervisor to report refusal of care
D Requests a consult to case management for care coordination

Question Explanation
Correct Answer is D
Rationale: Case managers can assist the client and their family with resources for treatment and
post-discharge arrangements. The nurse requests a consult with case management to assist the
client’s family with the client’s care. Contacting the healthcare provider regarding the family’s
decision does not advocate for the client. An ethics committee and notifying the nurse supervisor
are not indicated at this time. The nurse must first refer the client’s family to a care coordinator
for assistance.
Concepts tested

Question 339
The nurse is caring for a client with an external fixator on the left leg. The unlicensed assistive
personnel asks how to bathe the client with this device in place. Which response by the nurse is
appropriate?
A “We need to provide meticulous care to all of the pins, so I will help with that part.”
B “Please use normal saline and clean around all insertion points.”
C “We will avoid touching the left leg altogether as it is immobilized.”
D “We will need a bottle of chlorhexidine and some gauze for daily pin site cleansing.”

Question Explanation
Correct Answer is A
Rationale: External fixation involves the surgical insertion of pins through the skin and soft
tissues into and through the bone. A metal external frame is attached to these pins and is
designed to hold the fracture in proper alignment to enable healing to occur. The disadvantage of
an external fixator is an increased risk for pin site loosening and infection, which can lead to
osteomyelitis. Wound care should occur at least daily and include the use of nonshedding gauze.
Normal saline can be used, but wound care should be performed by the registered nurse so the
assessment may occur. Chlorhexidine is too harsh for daily use and should be used weekly.
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Concepts tested

Question 340
Upon walking into a client’s room, the nurse observes a family member yelling at the unlicensed
assistive personnel. Which action by the nurse is most appropriate?
Question 10 Answer Choices
A Ask the family member to discuss their concerns with you
B Call facility security to handle the situation
C Come back to the client’s room at a later time
D Tell the family member that they need to leave

Question Explanation
Correct Answer is A
Rationale: When a client, family member, or staff member is upset, the most appropriate action
by the nurse is to try to deescalate the situation by listening to the person’s concerns. Depending
on what those concerns are, the nurse can choose their actions more appropriately. Calling
security or asking the family member to leave may be necessary if the nurse is unable to
deescalate and address the situation. Coming back at a later time does not address the conflict
and potentially allows the situation to escalate further.
Concepts tested

Question 341
A nurse is working with a graduate nurse. The graduate nurse provided information to a caller
who identified themself as the client’s spouse. After informing the client that their spouse had
been given an update, the client stated, “What? I’m not married.” What is the initial action by the
nurse?
A Ask the client to provide a code for disclosure of health information
B Report the incident to the healthcare provider
C Review policies for handling confidential patient information
D Complete an incident report

Question Explanation
Correct Answer is D
Rationale: The initial action of the nurse is to be accountable for the breach of confidentiality and
complete an incident report as per protocol. Because of the breach of confidentiality, HIPAA
protocol and policies for handling confidential patient information should be reviewed, but it is
not an initial action of the nurse. In addition, an initial action of the nurse would not be to report
the incident to the healthcare provider. For future protection of patient information, it is
important that the client identifies those with who their health information may be shared. Many
patients don’t consent to give their family members updates on their condition. In addition, the
use of a password or code may be incorporated to protect confidential client information.
Concepts tested

Question 342
The nurse is admitting a client from the postoperative care unit following an appendectomy.
Which of the following is the priority for the nurse to assess?
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A Surgical dressing
B Pulses
C Respiratory rate
D Pain

Question Explanation
Correct Answer is C
Rationale: Frequent and skilled assessment of the client’s airway, respiratory function,
cardiovascular function, and the ability to respond to commands. The nurse should immediately
assess the client’s airway upon arrival to the PACU. Assessment of the surgical site, pulses, and
pain should all be completed after the airway is deemed stable.
Concepts tested

Question 343
An unresponsive client arrives at the emergency department after sustaining a fall from a ladder.
Which action will the nurse perform first?
A Auscultate the client’s bilateral breath sounds
B Initiate peripheral intravenous access
C Perform a modified jaw thrust maneuver
D Administer prescribed pain medication

Question Explanation
Correct Answer is C
Rationale: The nurse’s priority is to establish the client’s airway. A client who is unresponsive
after trauma may have cervical spine injuries. The nurse performs a modified jaw thrust
maneuver to safely open the client’s airway. Auscultation of the client’s breath sounds should be
performed after the nurse verifies the client’s airway is secured. Initiating peripheral intravenous
access restores circulation, which should be assessed after airway and breathing. The
administration of pain medication should be performed after the nurse completes the primary
survey.
Concepts tested

Question 344
A day-shift nurse is performing rounds on several clients. Two of the clients tell the nurse that
the night-shift nurse did not come into their room all night. The nurse reviews the clients’
records and observes multiple progress notes by the night-shift nurse. Which action should the
nurse take?
A Show the clients the progress notes written by the night-shift nurse
B Refer the clients' concerns to customer service
C Inform the nurse manager of the clients’ statements
D Ask the rest of the clients if they have any concerns about their care

Question Explanation
Correct Answer is C

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Rationale: The nurse should inform the nurse manager of the clients’ statements. Multiple
concerns regarding lack of nursing care should be referred to a supervisor for follow-up.
Showing the clients the progress notes written by the night-shift nurse is not appropriate. The
nurse may be falsifying documentation and require an investigation by a supervisor. Referring
the client’s concerns to customer service is not indicated unless the unit supervisor is aware of
the situation. The nurse must follow the chain of command. Asking the rest of the clients if they
have concerns about the care received is not the nurse’s responsibility in an ethical dilemma.
Concepts tested

Question 345
A nurse is feeding a client with Parkinson disease. Which nursing observation indicates the client
may benefit from a referral to speech therapy?
A The client tucks their chin while swallowing.
B The client chews the food quickly.
C The client has drooling of food.
D The client requests food to be pureed.

Question Explanation
Correct Answer is C
Rationale: Drooling of food is an indication of possible dysphagia. The client would benefit from
a referral to speech therapy for a safety assessment while feeding. Tucking the chin helps to
move food down the esophagus and is good practice to prevent aspiration. Chewing the food
quickly does not indicate a deficiency. The client requesting food to be pureed is an indication
that they understand the risk of aspiration.
Concepts tested

Question 346
The nurse is preparing a 25-year-old client for surgery and asks the client about an advance
directive. The client states, “Why do you need to know that? I am young and this is supposed to
be a minor surgery.” Which response would be appropriate for the nurse to make?
A “It is required to ask if you have one and provide you with information if you don’t,
regardless of age or reason for hospitalization.”
B “The hospital needs to be sure you have made the proper arrangements ahead of time in case
anything was to happen to you.”
C “Having an advanced directive in place will give the medical personnel the ability to make
decisions for you.”
D “The healthcare provider will need to have you complete the advanced directive before you
have surgery.”

Question Explanation
Correct Answer is A
Rationale: The Patient Self-Determination Act requires all clients are asked if they have an
advance directive in place to communicate the client’s health care wishes. If the client does not
have one, the information will be provided with assistance in how to fill one out. An advance
directive or living will have to do with health care choices and designating someone to speak for

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you when you are not able regarding funeral arrangements. Healthcare providers are not given
rights to express a client’s end-of-life decisions in an advance directive or living will.
Concepts tested

Question 347
A pediatric client is seen by the school nurse who notices several deep, round wounds with well-
defined edges that resemble cigarette burns. The client reveals that a caregiver has been abusive.
What is the nurse's first responsibility in caring for this child?
A Inform the other caretaker of the injuries
B Notify law enforcement
C Notify Child Protective Services
D Document all the areas of injury

Question Explanation
Correct Answer is C
Rationale: Nurses are mandated reporters of abuse and, as such, are required to notify the state's
child protective services department. It is not mandated that the reporter notify the caregivers
that a report has been filed. It is also not necessary to notify the police unless the client is in
immediate danger. Child protective services will involve law enforcement as needed. All areas of
injury should be documented, but the child’s safety is the priority intervention.
Concepts tested

Question 348
The intensive care unit had an increase in falls from last quarter. To help improve patient
outcomes, the nurse recommends including physical therapy during department meetings. Which
type of process has the nurse recommended?
A Patient-centered care
B Care mapping
C Interprofessional collaboration
D Care bundles

Question Explanation
Correct Answer is C
Rationale: Interprofessional collaboration involves multiple healthcare disciplines working with
clients, families, and communities to improve outcomes. Inviting physical therapy to join the
team to invoke change in the unit is an example of this form of collaboration. Patient-centered
care is focused care plans based on the client’s specific outcomes. Care mapping is a form of
evidence-based practice in the form of clinical guidelines. Care bundles are used in the acute care
setting, and many of them are a part of the nurses’ scope of practice and can be implemented
once the bundle is ordered by the healthcare provider.
Concepts tested

Question 349
The nurse is caring for a client at end of life whose advance directive states that they do not want
food or fluids. The nurse notes a new order for a nasogastric tube with enteral feeding. What
action by the nurse is appropriate?
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A Insert the feeding tube
B Report the physician to the nurse manager
C Inform the healthcare provider of the instructions in the advance directive
D Ask a colleague to insert the tube

Question Explanation
Correct Answer is C
Rationale: An advance directive is a legal document that goes into effect if the client is
incapacitated and unable to participate in self-determination. One type of directive is a living will
that spells out the client’s wishes for certain medical treatments, such as resuscitation,
ventilation, and tube feeding, etc. The nurse should collaborate with the provider who wrote the
order as they may be unaware of the instructions in the advance directive. The nurse is not
required to insert the tube and should not ask another colleague to do so. It may be appropriate to
report the physician if an ethical dilemma arises, but at this time, this is not appropriate.
Concepts tested

Question 350
The nurse is educating new nurses on the informed consent process. Which statement by the new
nurse demonstrates an understanding of the nurse’s role in informed consent?
A “I will sign the consent form as a witness to having seen the patient sign the form.”
B “If the client has any questions, I will answer them before having the client sign the form.”
C “If the healthcare provider is unavailable, I can conduct the informed consent discussion.”
D “I do not need to assess the client’s understanding of the procedure before having them sign
the document.”

Question Explanation
Correct Answer is A
Rationale: As a nurse, you sign the consent form as a witness to having seen the patient sign the
form, not as having obtained the consent yourself. Assess whether patients understand what they
are signing and are acting voluntarily and report any concerns to the healthcare provider. Having
patients describe in their own words what they understand they are consenting to is the best way
to make sure that they understand.
Concepts tested

Question 351
A pre-op nurse is reviewing a surgical client’s record and notes a do not resuscitate (DNR)
advance directive. When asked to confirm, the client states, “I want everything done to me if my
heart stops during surgery.” Which action does the nurse take?
A Inform the client changes to the advance directive need to be performed legally
B Instruct the client to the inform the healthcare provider before the surgery begins
C Acknowledge the statement, and transfer the client to the operating room
D Document the client’s statement, and inform the surgical team

Question Explanation
Correct Answer is D

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Rationale: Do not resuscitate (DNR) advance directives can be suspended by the client at any
time during their medical care. The nurse should clearly document the client’s wishes and
communicate the decision with the receiving healthcare team. DNR orders are honored when the
client is unable to communicate their wishes. However, a mentally competent client can change
their decision at any time. The client’s statement should be documented by the staff member it
was disclosed to. The nurse should acknowledge the statement but document the client’s wishes
in the medical record before transferring them to the operating room.
Concepts tested

Question 352
A nurse is discharging a client with newly diagnosed diabetes. The client tells the nurse “I can’t
afford the cost of insulin. I’ll find another way to care for my condition.” How does the nurse
best respond to the client’s statement?
A “There are resources available to assist you with these costs.”
B “It is important that you take your insulin to manage your condition.”
C “Tell me how you plan to manage your condition.”
D “The cost of the medication varies depending on where you buy it.”

Question Explanation
Correct Answer is A
Rationale: The nurse’s role as an advocate is to assist clients who have financial difficulties
caring for their medical conditions. The nurse can refer the client to medication assistance
programs for eligibility on low-cost medications. Emphasizing the importance of medical
treatment and asking the client how they plan to manage their condition does not address the
issue of financial difficulties. Telling the client that the cost of medication varies does not
provide a resource for their financial concern.
Concepts tested

Question 353
The nurse is caring for a group of surgical clients with multiple tasks that need to be completed.
One of the clients is refusing to ambulate. What action is should the nurse take?
A Delegate the ambulation to the unlicensed assistive personnel
B Collaborate with the client to determine the barriers to ambulation
C Request assistance from other staff members to ambulate the client
D Document that the client refused care

Question Explanation
Correct Answer is B
Rationale: The client may be refusing to ambulate because of fear or pain. Collaborating with the
client through assessment and education can aid in overcoming barriers. This client should not be
delegated as this is not a routine situation. Forcing the client out of bed is not appropriate. The
nurse should try all reasonable measure before acquiescing to the fact that the client will not
ambulate
Concepts tested

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Question 354
The nurse is discussing the planned daily care for assigned clients with the unlicensed assistive
personnel. Which of the following statements by the nurse is appropriate?
A “Explain what to expect after the surgery to the client.”
B “Put a nasal cannula on the client if the oxygen saturation is low.”
C “Call the provider if the client has any trouble with eating.”
D “Let me know what the client’s blood pressure is.”

Question Explanation
Correct Answer is D
Rationale: The nurse should instruct the unlicensed assistive personnel (UAP) to report collected
data so that the nurse can determine if assessments or interventions are needed. The UAP should
not be responsible for client education, placing oxygen delivery devices, or notifying the
provider of abnormalities. All of those actions should be completed by the nurse.
Concepts tested

Question 355
The nurse is planning discharge care for a client with a BMI of 32 and uncontrolled hypertension
who had a myocardial infarction. Which resource would be the priority for this client?
A Refer the client to a support group of clients with hypertension
B Refer the client to a cardiac rehabilitation unit
C Refer the client for home health services to reinforce medication adherence
D Refer the client to a personal trainer to increase exercise to 60 minutes/day

Question Explanation
Correct Answer is B
Rationale: Cardiac rehabilitation includes progressive exercise, diet teaching, and classes on
modifying risk factors. This supervised setting would be the priority intervention for this client in
the plan of care. The client should be encouraged to exercise, but it should be in a supervised
setting such as cardiac rehabilitation, not with a personal trainer due to the client’s condition and
pre-existing conditions (i.e., hypertension). This client would also benefit from diet teaching,
which is included in cardiac rehabilitation to reduce weight. Although medication adherence is
important, it is not a priority intervention. Support groups bolter the client’s emotional strength
but are not a priority intervention.
Concepts tested

Question 356
The nurse is discharging a client to an outpatient treatment program after hospitalization for
acute depression. Which statement should the nurse include in the discharge instructions?
A “Attending outpatient therapy will continue to make you feel better.”
B “You need to attend outpatient therapy to prevent readmission.”
C “Your healthcare provider will be able to monitor you closely in outpatient therapy.”
D “Outpatient therapy will allow you to return to your normal life activities.”

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Question Explanation
Correct Answer is D
Rationale: Outpatient therapy allows the client to maintain treatment options (i.e., milieu
therapy) but stay at home and resume normal life activities such as work. With the collaboration
of a case manager and primary care provider, the transition from inpatient mental health service
to outpatient services can be achieved and still provide the client with the services needed after
stabilization. Outpatient therapy will assist the client in managing their condition; it is not a
quick cure and may take time before the client feels the benefits. Inpatient treatment allows a
healthcare provider to closely monitor a client.
Concepts tested

Question 357
A healthcare provider informs the nurse that a client is hesitant about surgery despite an
explanation of the procedure. Upon assessment, the client tells the nurse “I’m not sure I want
surgery. I’m scared I won’t wake up after.” How does the nurse respond to the client?
A “It is normal to feel scared. Tell me why you feel you won’t wake up.”
B “You have nothing to worry about. The surgery will go well.”
C “There are other options besides surgery. Let’s contact your healthcare provider.”
D “You have a right to refuse surgery. I will let your healthcare provider know.”

Question Explanation
Correct Answer is A
Rationale: The nurse uses therapeutic communication to discuss treatment options with the
client. The nurse should reassure the client their concerns are valid and explore the reason for
their concern. Telling the client their surgery will go well is false reassurance. The nurse should
encourage the client to voice their feelings about the current treatment before proposing an
alternative or finalizing a refusal of treatment.
Concepts tested

Question 358
A nurse is providing care to several clients on a medical unit. Which client would best benefit
from an interdisciplinary conference?
A A client with newly diagnosed diabetes who uses a cane to ambulate
B A client with recurring wound infections who is homeless
C A client who requires short term antibiotics and is unemployed
D A client with a lower extremity fracture who has uncontrolled pain

Question Explanation
Correct Answer is B
Rationale: A client with recurring wound infections who is homeless requires resources from
several members of the interdisciplinary team. Case managers and social workers can assist the
client with living arrangements while also providing follow-up care to prevent readmissions. A
competent client can also learn wound care, often taught by physical therapists. A client who
uses a cane to ambulate is still capable of managing a newly diagnosed medical condition. A
client with financial difficulties who requires short-term medication use can be referred to

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pharmacy assistance programs. Uncontrolled pain can be managed in collaboration with the
healthcare provider while the client is hospitalized.
Concepts tested

Question 359
The nurse is caring for a client diagnosed with heart failure who has a prescription for a stat chest
X-ray. The client is 1 hour post femoral cardiac catheterization, and the radiology technician has
asked if the client can be turned to place the X-ray plate. Which response by the nurse would be
appropriate?
A “Yes, the client can turn as long as the head of bed isn’t lowered.”
B “No, the X-ray will have to be rescheduled.”
C “We need to turn the client carefully so that they do not bend the leg.”
D “The client can be turned as long as the head of bed isn’t raised above 45 degrees.”

Question Explanation
Correct Answer is C
Rationale: After a femoral cardiac catheterization, the patient remains on bed rest for up to 6
hours with the affected leg straight and the head of the bed elevated no greater than 30°. For
comfort, the patient may be turned from side to side with the affected extremity straight. When
an X-ray needs to be completed, the client may be turned side to side for correct plate placement,
but the head of the bed must remain <30 degrees elevated. Chest X-rays in clients with heart
failure are important and should not be postponed.
Concepts tested

Question 360
The nurse witnesses a staff member visibly upset after a conversation with a provider. Which
action by the nurse is appropriate at this time?
A Avoid conversation with the staff member until they are no longer upset
B Offer to take the staff member's clients while they take a break
C Tell the staff member that it eventually gets easier to deal with providers
D Ask the staff member what has made them upset

Question Explanation
Correct Answer is D
Rationale: The nurse should ask the staff member if they are alright and gather more information
about what happened. Depending on what has caused the staff member to be upset, the nurse can
choose their response more appropriately. Avoiding the staff member or telling them that they
should take a break does not address the situation. Telling the staff member that it gets easier
implies that whatever upset the staff member is normal.
Concepts tested

Question 361
The nurse is approached by a healthcare provider for an update on a client transferred to another
unit. Which statement would be most appropriate for the nurse to make?
A “The client was fine when I transferred them”.

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B “You will have to check with the nurse that is assigned to that client. ”
C “I can show you the latest lab results if you want. ”
D “I can update you in a more private area. ”

Question Explanation
Correct Answer is B
Rationale: The nurse is ethically and legally obligated to protect clients' privacy and maintain the
confidentiality of their medical information. It is appropriate to direct questions about the client
to the currently assigned nurse who will be able to update the healthcare provider appropriately
and provide lab results if necessary. Since the client was transferred to another unit, the nurse
being questioned for an update neither has the right nor accurate information to provide to the
healthcare provider. Although it is best to make the conversation private, it is a breach of
confidentiality to share information about a client no longer in direct care.
Concepts tested

Question 362
The nurse is preparing to discharge a client from the outpatient surgery center. Which action by
the nurse promotes a safe discharge?
Question 12 Answer Choices
A Change the client’s surgical dressing
B Provide instructions in writing
C Medicate the client for pain before leaving
D Evaluate who will be taking the client home

Question Explanation
Correct Answer is D
Rationale: Clients who have surgery in the outpatient center go home the same day following
surgery. The nurse should evaluate who will be taking the client home and ensure the client will
have someone monitoring them for the first 24 hours. Prior to discharge, the client should receive
written and verbal instructions in the language of their preference on follow-up care. The
instructions for dressing changes should be given by the healthcare provider and followed. The
nurse should avoid giving a client any medication prior to leaving to prevent any adverse effects.
Concepts tested

Question 363
A nurse initiates a rapid response for a client experiencing diaphoresis, heart palpitations, and
chest pain. Which priority action will the nurse perform before the critical care team arrives?
Question 13 Answer Choices
A Initiate an additional intravenous access line
B Request a STAT electrocardiogram
C Ensure the client receives pain medication
D Administer supplemental oxygen to the client

Question Explanation
Correct Answer is D

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Rationale: The nurse should administer supplemental oxygen to the client experiencing signs of a
myocardial infarction. The priority action is to maintain adequate perfusion. Maintaining
intravenous access is important; however, initiating an additional IV line indicates the client
already has a patent access line. An electrocardiogram will likely be requested when the critical
care team arrives. The nurse’s priority is to maintain the client’s perfusion. Pain management is
an important intervention; however, the nurse must first ensure the client has adequate
oxygenation and perfusion to vital organs.
Concepts tested

Question 364
A nurse is providing care to a client in the emergency department who is homeless and is
frequently admitted for emergent dialysis. The nurse understands that the client has the right to
receive access to healthcare under which provision in the nursing code of ethics?
A Provision 2
B Provision 5
C Provision 7
D Provision 8

Question Explanation
Correct Answer is D
Rationale: The scenario is an example of Provision 8 of the nursing code of ethics, which
outlines the nurse’s collaboration with other healthcare providers to protect human rights, see
health as a universal right, and reduce health disparities. Provision 2 discusses the client being
the nurse’s primary commitment within the profession. Provision 5 outlines the nurse’s duty to
maintain professional competence and growth. Provision 7 states that nurses must advance the
profession through professional development and scholarly inquiry.
Concepts tested

Question 365
A nurse is providing care to several post-surgical clients. Which client would benefit the most
from a referral to occupational therapy?
A An accountant who had an internal fixation of the ankle
B A waitress who had a laparoscopic cholecystectomy
C A teacher who had an incision and debridement to an arm wound
D A data entry specialist who had a carpal tunnel release

Question Explanation
Correct Answer is D
Rationale: The primary job function of a data entry specialist is to type on a computer. A client
with a carpal tunnel release would benefit from occupational therapy to regain mobility of the
wrists and hands. The job duties associated with being an accountant do not require frequent
ambulation. Therapy for ambulation is more closely associated with physical therapy. A
laparoscopic cholecystectomy is typically an outpatient procedure with limited restrictions. An
incision and debridement of an arm wound does not restrict the mobility required for a teaching
profession.
Concepts tested
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Question 366
The nurse is caring for a client who had surgery 2 days ago and has a prescription to ambulate
with assistance. The nurse does not assist the client with ambulation resulting in the client falling
and sustaining injury. The nurse could be charged with which of the following?
A Assault
B Battery
C Negligence
D Defamation

Question Explanation
Correct Answer is C
Rationale: Negligence is when care is below the accepted standard that would be provided by a
prudent person. A nurse is negligent when the duty of care is breached, and the client sustains an
injury. Battery is intentional touching of someone without consent. Assault is the verbal threat of
harm. Defamation is the publication of false statements that damage someone’s reputation.
Concepts tested

Question 367
The nurse is working as a triage nurse in an emergency department (ED) and prioritizes
mandatory reporting for which of the following clients?
A A pediatric client with measles
B An adult client injured in a motor vehicle accident (MVA)
C An adolescent client with a non-fatal drug overdose
D An older adult with a recurrent urinary tract infection

Question Explanation
Correct Answer is A
Rationale: The pediatric client with a communicable disease, such as measles, meets the
requirement by law for mandatory reporting. Other guidelines for mandatory reporting include
injuries with weapons, child abuse, and vulnerable adults. All of the other options do not meet
the classifications of mandatory reporting.
Concepts tested

Question 368
The nurse is caring for a client with end-stage renal disease (ESRD) and notices that the client
has a regular diet ordered. Which action would the nurse perform next?
A Advise the client to follow their home diet
B Contact the dietary department to adjust the diet
C Contact the healthcare provider for diet orders
D Advise the non-licensed personal to hold the client’s food tray

Question Explanation
Correct Answer is C

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Rationale: The client with ESRD should be placed on a renal diet that likely includes a fluid
restriction. Fluid volume deficits and fluid volume overload are very common issues that arise in
this client population. The nurse’s first action should be to contact the healthcare provider to get
specific diet orders that may need to correlate with the client’s dialysis orders. The nurse should
educate the client on following the diet they had at home, but the order in the client’s medical
record should be appropriate. The non-licensed personal should not hold the client’s meal tray
without proper cause, and the dietary department should be contacted after the order is received
from the HCP.
Concepts tested

Question 369
The nurse is providing staff training on client advocacy. Which of the following statements by a
staff member indicates an understanding of advocacy?
A "I can advocate for my client by limiting their visitors when they are in severe pain”
B “Conducting a falls assessment is one way I can advocate for my client”
C “Advocating for my client may mean that I make decisions for them in their best interest”
D “Ensuring that my client gets the most aggressive medical treatment is part of my role as an
advocate”

Question Explanation
Correct Answer is A
Rationale: The nurse’s primary commitment is to the patient, so advocating for the client means
promoting, advocating for, and protecting the rights, health, and safety of the patient. Limiting
visitors is an example of advocacy. The nurse recognizes that the client is in pain; therefore,
limiting the visitors allows for the nurse to advocate for additional measures to allow the client to
rest and recover. Conducting a falls assessment is an example of nonmaleficence. Making
decisions for your client because they don’t know what is best is a form of paternalism. The
nurse should promote self-determination (autonomy) and should encourage the client to
participate in determining their own treatment plan.
Concepts tested

Question 370
The nurse is receiving a client into the pre-op holding area from the surgical unit. The client is
scheduled for surgery in two hours. Which question is appropriate for the nurse to ask during the
handoff?
A "Has the client received the prophylactic antibiotic?"
B "Has the informed consent document been signed?"
C “What is the duration of this procedure?”
D “Has the surgical site been marked?”

Question Explanation
Correct Answer is B
Rationale: Protocols for prophylactic antibiotics limit administration to within two hours of
surgical incision. Therefore, the client should not have been given this medication at this time.
The surgical nurse is more knowledgeable about the duration of procedures than the floor nurse,
so this is not an appropriate question. The surgical site will be marked in the perioperative area
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as part of the universal protocol. Informed consent may have been signed prior to arrival in the
preoperative area and is an essential element to the process. This is an appropriate question to
ask.
Concepts tested

Question 371
A nurse is providing care to a client with a traumatic brain injury. The nurse reviews the client’s
living will and notes there is no indication for artificial nutrition and hydration. Which action
does the nurse perform next?
A Checks the client’s record for a healthcare power of attorney
B Contacts the healthcare provider to prescribe artificial nutrition
C Calls the client’s next of kin to inform them of the client’s nutritional needs
D Provides the client with comfort care only

Question Explanation
Correct Answer is A
Rationale: Any medical decisions not indicated on a client’s living will are transferred to a
healthcare power of attorney, if available. The client’s record is to be reviewed by the nurse to
confirm the presence of an additional advance directive. Healthcare providers may prescribe
medical treatment as appropriate. However, the nurse should first check the client’s record for an
advance directive. The next of kin can help guide the client’s care if no healthcare power of
attorney has been designated in an advance directive. Comfort care is only one section of a living
will and is designated for terminal conditions.
Concepts tested

Question 372
The nurse is caring for a client diagnosed with osteosarcoma who has been experiencing severe
pain. The client received oxycodone 5 mg one hour ago and now reports that the pain is 8/10.
Which action by the nurse best demonstrates the role of client advocate?
A Calling the family to come sit with the client
B Notifying the healthcare provider that the treatment is ineffective
C Suggesting guided imagery as an adjunct treatment approach
D Asking the client if they have tried complementary therapies

Question Explanation
Correct Answer is B
Rationale: Most patients with metastatic bone disease experience moderate to severe bone pain.
Oxycodone 5 mg is an immediate release opioid agonist which is administered every 6 hours
PRN. The nurse assesses for decreased pain (patient reports) and a general feeling of well-being.
Untreated pain has physiological and psychosocial consequences. The nurse will best advocate
for more effective pain management by notifying the provider that the opioid medication has
been ineffective. While multimodal approaches may combine pharmacologic and non-
pharmacologic therapies, the first intervention is to notify the provider who will likely increase
the dosage or change the type of opiate being administered. Advocating for the client requires
knowledge of best practices for pain management.
Concepts tested
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Question 373
The nurse is caring for a group of hospitalized clients. Which task is appropriate to delegate to
the unlicensed assistive personnel?
A Assessing the severity of peripheral edema in a client
B Obtaining vital signs on a client who had surgery yesterday
C Measuring the leg circumference of a client with calf pain
D Reporting back on the appearance of a pressure injury

Question Explanation
Correct Answer is B
Rationale: The Five Rights of Delegation are right task, right circumstance, right person, right
directions and communication, and right supervision and evaluation. Professional nurses are
responsible for delegating nursing activities, but although RNs may delegate elements of care,
they may not delegate the nursing process itself. Nursing care or tasks that should never be
delegated except to another RN include initial and ongoing nursing assessment, determination of
the diagnosis and plan of care, evaluation, and client education. Any task that is delegated should
be based on the training and competence of the individual accepting the delegation. The UAP
can obtain vital signs on a stable client. The client with calf pain may be experiencing a DVT, so
this task should not be delegated. UAPs cannot assess or evaluate, so the pressure injury should
be observed by the registered nurse.
Concepts tested

Question 374
The nurse enters the room of a client and finds them unresponsive and pulseless. Which of the
following interventions would be appropriate to delegate to the unlicensed assistive personnel?
A Notifying the provider
B Scanning the medications administered
C Performing chest compressions
D Evaluating the client’s heart rhythm

Question Explanation
Correct Answer is C
Rationale: The unlicensed assistive person (UAP) can perform chest compressions during a
cardiac arrest. Delegating this task to a UAP is ideal so that the registered nurses can perform
other necessary tasks. UAPs cannot administer or document medications in the medical record or
assess the client’s heart rhythm. They also should not be responsible for notifying a provider
about a client status change.
Concepts tested

Question 375
The emergency room nurse is caring for a client with suspected domestic abuse. What will the
nurse do to assist the client first?
A Assess the client’s environment for safety prior to discharge
B Provide the client with a map to local shelters

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C Direct the client to legal services in the community
D Refer the client to a psychological counseling service

Question Explanation
Correct Answer is A
Rationale: Safety is the priority intervention for the client suspected of domestic violence. A
wide range of resources are available to meet the needs of victims of violence. Nurses should be
prepared to help the woman take advantage of these opportunities. Services will vary by
community but might include psychological counseling, legal advice, social services, crisis
services, support groups, hotlines, housing, vocational training, and other community-based
referrals. The client should be given the National Domestic Violence hotline number: (800) 799–
7233.
Concepts tested

Question 376
The nurse is performing discharge teaching to the parent of a pediatric client about supplemental
feedings via a gastrostomy tube (GT). The nurse begins the process by teaching the parent which
actions first?
A Steps to administer feedings
B Maintenance of equipment
C Cleaning insertion site
D Signs of complications

Question Explanation
Correct Answer is A
Rationale: The parents' ability to maintain their child's nutrition is essential to the child's well-
being. It is the priority action in teaching to make sure the parents know the steps to safely
administer feedings. After this skill is acquired and verified by a return demonstration to the
nurse, then proper cleaning of the site, maintenance of the equipment, and signs of complications
can be taught.
Concepts tested

Question 377
A nurse is providing care to a client with a systemic infection who requires long-term
intravenous antibiotics. The client states they are uncertain about an intravenous line and prefer
oral antibiotics. Which action does the nurse perform next?
A Request a prescription for oral antibiotics from the healthcare provider.
B Explain to the patient why intravenous antibiotics are necessary.
C Inform the client that declining an intravenous line is refusal of treatment.
D Obtain a consult to social work for medication assistance.

Question Explanation
Correct Answer is B
Rationale: The nurse must provide information to the client about the treatment options. The
client has the right to request alternative treatment after they have been thoroughly educated on

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the medical necessity of a treatment option. Requesting oral antibiotics from the healthcare
provider does not advocate for the client’s necessary medical care. The client has a right to
refuse treatment. However, the nurse must first clarify any client concerns regarding primary
treatment options. Obtaining a consult to social work for medication assistance is not indicated at
this time. The client has not voiced difficulty with obtaining the medications.
Concepts tested

Question 378
A nurse is providing care to a client post-hemorrhagic stroke. The client has history of
hypertension, diabetes, and bipolar disorder. Which event would prompt the nurse to request an
interdisciplinary conference?
A The nurse receives duplicate prescriptions from healthcare providers of different specialties.
B The client refuses to participate in physical therapy sessions.
C The client’s family voices the inability to care for the client after discharge.
D The nurse notes multiple medications on the client’s electronic medical record.

Question Explanation
Correct Answer is A
Rationale: A client with complex medical conditions may receive treatment from different
healthcare providers and specialties. The nurse requests an interdisciplinary conference to
prevent an overlap of medical treatment. A client who refuses physical therapy sessions would
benefit from education regarding the benefits of mobility. Discharge planning can be referred to
case management or social work. Multiple medications are expected for a client with several co-
morbidities.
Concepts tested

Question 379
The nurse is caring for a group of clients on a medical unit. A new graduate nurse is hanging a
bag of heparin for continuous infusion for one of their assigned clients. How can the nurse be a
resource for the new graduate nurse?
A Offer to double check the hourly rate when the new nurse is programming the pump
B Inform the nurse that the medication cannot be infused on this unit
C Tell the nurse that the bag of medication should be reviewed with another nurse before being
hung
D Visit the client’s room after the medication is hung to ensure the infusion rate is correct

Question Explanation
Correct Answer is A
Rationale: The Joint Commission on Accreditation of Healthcare Organizations (TJC) has issued
a bulletin listing "high-alert" medications that have the highest risk of causing injury when
misused. The list includes intravenous anticoagulants (heparin). TJC recommends strategies such
as a system that confirms the correct drug, dosage, patient, time, and route. Nurses should ask a
colleague to double-check measurements of heparin prior to administration. A more seasoned
nurse should offer to double-check medications prior to administration to protect client safety.
Checking doses after infusions have started does not reduce the risk of injury.
Concepts tested
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Question 380
The nurse overhears two clients in the common area arguing over the television remote. Which
statement by the nurse is most appropriate at this time?
A “If you two cannot get along, we will have to turn off the television.”
B “Who had the television remote first?”
C “We cannot tolerate this behavior. Return to your rooms.”
D “I can see that you all are unhappy. What is going on?”

Question Explanation
Correct Answer is D
Rationale: When a client, family member, or staff member is upset, the nurse should ask them
about their concerns to gather more information about the cause of their disagreement before
taking action. Asking the clients who had the remote first, does not help to solve the
disagreement. Telling the clients that they will need to return to their rooms or that the television
will need to be turned off is not the most appropriate statement.
Concepts tested

Question 381
The nurse received a report on the following assigned clients. Which of the following pediatric
clients should the nurse assess first?
A The child who is reporting pain at the site of an intravenous (IV) catheter
B The child whose parents are reporting has blue-tinged lips
C The child who keeps asking for their parent
D The child with a fever who refuses to eat

Question Explanation
Correct Answer is B
Rationale: The nurse would first assess the child with blue lips and mucous membranes as this
indicates cyanosis/respiratory distress. Reports of pain at the site of an intravenous catheter and a
child who refuses to eat with a fever are not emergencies. Depending on the age of the child,
separation anxiety should be anticipated and is not a medical emergency. The child with a fever
who refuses to eat would be assessed next due to the risk of circulatory dehydration.
Concepts tested

Question 382
The nurse is admitting a client with cellulitis who uses a wheelchair for mobility. The nurse
notes a prescription for IV antibiotics. Which action should the nurse take to promote safe
admission?
A Check the client’s renal function
B Obtain the client’s weight
C Review previous hospitalizations
D Initiate a bed alarm

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Question Explanation
Correct Answer B
Rationale: Clients with disabilities should expect the same clinical assessment with those without
disability. It is the responsibility of the nurse to ensure the client’s weight is accurately
documented on admission as this could affect the medication dosing. The renal function can be
reviewed by the pharmacy and healthcare provider and adjustments can be made prior to dosing.
Previous hospitalizations are important to update in the history but will not have any direct
correlation to the client’s current condition. A bed alarm is initiated if the client is at risk for
falls, and the nurse would need to complete a falls assessment to identify appropriate
interventions.
Concepts tested

Question 383
A nurse is providing care to a newly admitted client with suspected meningitis. Which nursing
care action will the nurse perform first?
A Administer prescribed antibiotics
B Initiate droplet precautions
C Place the client on seizure precautions
D Prep the client for a lumbar puncture

Question Explanation
Correct Answer is B
Rationale: The nurse should initiate droplet precautions before performing all other
interventions. Meningitis is contagious and transmitted via oral secretions. The nurse should
ensure infection control measures before performing nursing care. Administering prescribed
antibiotics is an important intervention for the management of the condition; however, this action
should be performed after isolation precautions are initiated. Meningitis can potentially cause an
increase in intracranial pressure and produce seizure activity; however, placing the client on
seizure precautions should be performed after infection control measures are in place. Prepping
the client for a lumbar puncture assists in the diagnosis of the condition. This intervention is
performed after the client is placed on droplet precautions.
Concepts tested

Question 384
A nurse is precepting a graduate nurse providing care to a client with a sacral pressure ulcer.
During wound care, the graduate nurse takes photos of the client’s wound with a personal cell
phone. Which action should the nurse take next?
A Prompt the graduate nurse to review the code of ethics
B Report the graduate nurse to the nursing supervisor
C Ask the graduate nurse to obtain the client’s consent
D Ensure the graduate nurse does not include identifying information in the photo

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Question Explanation
Correct Answer is A
Rationale: Protection of a client’s right to privacy and confidentiality is part of provision 3 of the
nursing code of ethics. The graduate nurse should be prompted to review this provision to
understand the client’s right to privacy and confidentiality. As a preceptor, the nurse should
guide the graduate nurse to review the code of ethics before reporting the behavior to a nursing
supervisor. Asking the graduate nurse to obtain the client’s consent does not explain to the
graduate nurse why this action is necessary for the protection of client privacy and
confidentiality. Taking a photo without the client’s consent is a breach of privacy and goes
against provision 3 of the nursing code of ethics.
Concepts tested

Question 385
A nurse is providing care to several clients on a medical unit. Which client will most likely
require a referral to a registered dietitian?
A A client with stomach cancer who requires total parenteral nutrition
B A client with a small bowel obstruction who has a nasogastric tube
C A client with diverticulitis who has been NPO for two days
D A client with dysphagia who has a prescription for a puree diet

Question Explanation
Correct Answer A
Rationale: Total parenteral nutrition (TPN) has to be individualized to provide an adequate
amount of nutrients to a client. A registered dietitian can provide input on the best formulation
for a client with prolonged parenteral nutrition. A nasogastric tube is a short-term treatment for a
small bowel obstruction. The treatment for diverticulitis is to keep the client NPO. A referral to a
registered dietitian is not indicated at this time. The need for food to be pureed to prevent
aspiration does not indicate a deficiency in nutrients.
Concepts tested

Question 386
The charge nurse is reviewing the client assignment with a staff nurse who is refusing to care for
a client. Which statement by the nurse would indicate abandonment?
A “The client has a prescribed intervention that is against my religion.”
B "I have not received the training for the care the client requires.”
C “This client was not very nice to me when I provided care before.”
D “The infection the client has can be harmful to me.”

Question Explanation
Correct Answer is C
Rationale: Client abandonment occurs when a nurse refuses to care for a client when a client-
nurse relationship has been established. A nurse can refuse to care for a client if there is a
religious issue, the nurse’s health could be at risk, the nurse does not have adequate training to
care for the client, or the nurse’s judgment is impaired.
Concepts tested

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Question 387
The nurse is caring for a pediatric client admitted to the ED with a dislocated shoulder. When
asked how this occurred, the client states, “I tripped and fell down the stairs.” What action will
the nurse perform next?
A Talk with the client’s parents to get additional details about the injury
B Contact the nursing supervisor, and call the police
C Contact Child Protective Services to report the injuries
D Continue to probe the client about specific details of the injury

Question Explanation
Correct Answer is A
Rationale: A nurse who suspects child abuse should talk with the parents and get additional
details about the injuries and compare their story with that of the child before mandatory
reporting for child abuse occurs. Telling the nursing supervisor to call the police or contacting
Child Protective Services isn't the best action to take at this time. If further investigation
continues to raise questions about abuse, these steps may be appropriate. The nurse does not
need to continue to probe the client about details of the injury.
Concepts tested

Question 388
The nurse is caring for a client with altered mental status due to a urinary tract infection who is
refusing antibiotic therapy. In order to help keep the antibiotic therapy on schedule, the nurse
contacts which of the following?
A Pharmacy
B Power of attorney
C Healthcare provider
D Charge nurse

Question Explanation
Correct Answer is B
Rationale: A living will is a form of advance directive and can often cite a durable power of
attorney, which is a person who is able to make healthcare decisions for the client in the case of
incapacitation. This person often knows the wishes of the client. The HCP and pharmacy should
be called if the power of attorney is not available to give consent to administer the medication.
The charge nurse should be kept abreast of any delay in the care of any client but would not be
the priority in this case.
Concepts tested

Question 389
The nurse is educating new staff on ethical practice. Which of the following statements by the
staff indicates an understanding of professional boundaries?
A “Freely sharing my personal experiences with clients will increase rapport and trust.”
B “I can share my experiences on social media as long as I do not use my client’s names or
personal information.”
C “I should try to avoid caring for clients if there is a pre-existing outside relationship.”

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D “If the situation arose, I could date a former client without question.”

Question Explanation
Correct Answer is C
Rationale: Every nurse-client relationship is viewed on the continuum of professional behavior
from underinvolvement to overinvolvement, with the goal being a therapeutic relationship.
Overinvolvement includes boundary crossings, boundary violations, and professional sexual
misconduct. Oversharing is a form of boundary-crossing. The nurse should avoid situations
where they have a previous personal, professional, or business relationship with the client. Post-
termination relationships are complex because the patient may need additional services. It may
be difficult to determine when the nurse-client relationship is completely terminated. Making a
comment via social media, even if done on a nurse’s own time and in their own home, regarding
an incident or person in the scope of their employment, may be a breach of patient
confidentiality or privacy as well as a boundary violation
Concepts tested

Question 390
The nurse is reviewing the health record of a client scheduled for surgery. Which of the
following is a priority for the nurse to ensure is present in the record?
A Proof of immunizations
B Type and screen
C Advance directive
D Informed consent

Question Explanation
Correct Answer is D
Rationale: A preoperative checklist is often used to outline the nurse’s responsibilities on the day
of surgery; these activities must be completed and documented before the patient is transported
to surgery. The first item on the checklist is often to check that consent forms are signed and
dated, witnessed, and correct. During the preoperative phase the priority is to ensure informed
consent has been obtained for the surgical procedure. While other documents and tests on the
checklist are important, this is the most important data for the nurse to collect currently.
Concepts tested

Question 391
A nurse is performing an admission history on a client. When asked about advance directives,
the client states, “I want my partner to make medical decisions for me when I can no longer do
so.” How does the nurse respond to the client’s statement?
A “Only your next of kin can make medical decisions for you.”
B “It is important you prepare a legal durable power of attorney.”
C “You should express your wishes in a living will.”
D “It is best to choose someone who can objectively make decisions.”

Question Explanation
Correct Answer is B

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Rationale: The nurse should encourage the client to prepare a legal document designating the
partner as their power of attorney. Advance directives communicate a client’s wishes and protect
healthcare providers from liability when providing or withholding medical treatment. A health
care proxy can be any competent adult the client chooses. A living will is a document that
outlines the client’s wishes for medical treatment when they can no longer do so themselves. The
nurse’s role in advance directives is to provide information, not to influence the client’s decision
in selecting a power of attorney.
Concepts tested

Question 392
The nurse is assessing an older adult client who lives with an adult child. The client has bruising
in various stages on the back and upper arms and reports “not knowing how those got there.”
Which of the following actions is appropriate?
A Notify the charge nurse
B Ask for assistance from hospital security personnel
C Call the abuse hotline
D Inform the social worker

Question Explanation
Correct Answer is A
Rationale: Indications of elder abuse are often misinterpreted as normal signs of aging. Careful
observation of the relationship between the older adult and the caregiver may be the first
evidence that the older adult is a victim of abuse. Older adults who have been physically abused
may have injuries that are incompatible with the client or caregiver’s version of how the injury
occurred. Evidence of previously untreated injuries or suspicious cuts and bruises should alert
healthcare providers to the possibility of physical abuse. The bedside nurse should report abuse
via the chain of command, which would include the charge nurse or nurse manager.
Concepts tested

Question 393
The nurse is caring for a group of hospitalized clients. The nurse has several tasks to delegate to
the unlicensed assistive personnel (UAP). Which task should the nurse ask the UAP to perform
first?
A Take a blood specimen to the laboratory
B Transport a client to the radiology department for an X-ray
C Pass out fresh water to the clients
D Obtain a urine sample for a newly admitted client

Question Explanation
Correct Answer is A
Rationale: The work of setting priorities demands careful clinical reasoning. When using the
urgent vs. non-urgent approach to prioritizing client care, the nurse should determine that the
priority action is to take the blood sample to the laboratory. Over time, the specimen will
deteriorate due to coagulation and lysis, making any results inaccurate and potentially delaying
treatment. All other options are important, but bloodwork is the priority.
Concepts tested
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Question 394
The nurse is planning the daily care for assigned clients. Which of the following tasks would be
appropriate to delegate to the licensed practical nurse (LPN)?
A Administer a nasogastric tube feeding
B Initiate blood product administration
C Titrate an intravenous medication
D Perform an admission assessment

Question Explanation
Correct Answer is A
Rationale: LPNs cannot initiate blood product administration but may monitor the client after the
initial administration has begun. LPNs also cannot titrate medications or assess clients. They can
administer tube feedings, so this is an appropriate task to delegate.
Concepts tested

Question 395
The nurse is reviewing the discharge plan for a client who had a laparoscopic cholecystectomy
and was newly diagnosed with obstructive sleep apnea. The nurse should assess the client’s need
for which equipment?
A Continuous positive airway pressure (CPAP) device
B, Sequential compression device (SCD)
C Home oxygen therapy
D Wound care dressing supplies

Question Explanation
Answer correct is A
Rationale: Continuous positive airway pressure (CPAP) is used to prevent airway collapse in
clients with OSA. The use of sequential compression devices (SCDs) are used to improve blood
flow in the legs as a method of deep vein thrombosis (DVT) prevention, not OSA.
Administration of home oxygen therapy at night may help relieve hypoxemia in some patients
but has little effect on the frequency or severity of apnea. Wound care dressing supplies are
appropriate for a client with an open wound or surgical incision. Laparoscopic procedures do not
require wound dressings.
Concepts tested

Question 396
The nurse is performing discharge teaching with an older adult client who was admitted with
urosepsis. Which statement by the client would indicate the need for further teaching?
A “I will continue to take my prescribed antibiotics even if I feel better.”
B “I will drink one glass of apple juice a day.”
C “I will monitor my temperature for signs of a fever.”
D “I will make sure that I void when I feel the urge.”

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Question Explanation
Correct Answer is B
Rationale: In teaching the client recovering from urosepsis, the nurse will provide further
teaching to the client when stating the need to drink apple juice. For recurrent infection of the
urinary tract, it is recommended that at least one glass of cranberry juice be added to the diet
regimen per day. In addition, the use of ascorbic acid (vitamin C), 1000 mg daily, will help
acidify the urine, promoting an environment where bacteria are less likely to grow. Other
teaching recommendations include strict adherence to prescribed antibiotics, voiding every 2-3
hours to prevent overdistension, and reporting signs and symptoms of recurrent infection to the
health care provider.
Concepts tested

Question 397
A nurse is providing care to a client with stage 3 breast cancer. During the shift assessment, the
client tells the nurse, “I have been given several treatment options. What do you think I should
do?” How does the nurse respond to the client?
A “You should choose the treatment that will give you the best outcome.”
B “Tell me how you feel about your treatment options.”
C “Have you discussed the treatment options with your family?”
D “Who will be taking care of you after your treatment?”

Question Explanation
Correct Answer is B
Rationale: The nurse should encourage the client to verbalize their feelings about the treatment
options. The nurse’s role is to clarify concerns, provide information on the treatments, and help
the client make their own decisions. Telling the client to choose the treatment that will give the
best outcome does not allow the client to make their own choice and is unwanted advice. Asking
the client if they have discussed treatment options with family and who will be taking care of
them post-treatment does not focus on the client’s self-determination.
Concepts tested

Question 398
A nurse is providing care to a client with a bloodstream infection. Which situation would prompt
the nurse to request an interdisciplinary conference with a pharmacist?
A The client develops a rash after the first dose of intravenous antibiotics.
B The client refuses to take the prescribed antibiotics.
C The client has history of antibiotic sensitive bacteria.
D The client develops c-diff after multiple prescribed antibiotics.

Question Explanation
Correct Answer is D
Rationale: C-diff is an infection caused by the destruction of normal flora in the large intestine.
Antibiotic use is the primary cause of c-diff. An interdisciplinary conference with a pharmacist
can help guide providers to prescribe the suitable pharmacological treatment. A rash is a sign of
an allergic reaction. The nurse should notify the healthcare provider to report an allergic reaction.
Client refusal of the medication does not require an interdisciplinary conference with a

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pharmacist. The nurse encourages the client to receive treatment and respects the client’s wishes.
A pharmacist collaboration is not indicated for bacteria that can be treated with antibiotics.
Concepts tested

Question 399
The nurse is caring for a client who is recovering from a hip replacement. The client has
verbalized concerns about scheduling physical therapy once they are discharged. Which member
of the healthcare team should the nurse collaborate with to address this concern?
A Physical therapist
B Social worker
C Case manager
D Visiting nurse

Question Explanation
Correct Answer is C
Rationale: The case manager will work with outside healthcare providers to plan for the
transition from inpatient to outpatient rehabilitation services. The social worker’s role is to help
clients find community resources outside of healthcare services. A visiting nurse provides care in
the home but not physical therapy. The nurse would not collaborate with a visiting nurse to
schedule physical therapy. Hospital-based physical therapists do not schedule outpatient services.
Concepts tested

Question 400
The nurse is collecting information to evaluate unit outcomes. Which of the following sources
could the nurse use to gather data about client satisfaction?
A Post-discharge surveys
B Staff interviews
C Hospital infection statistics
D Length of hospitalization

Question Explanation
Correct Answer is A
Rationale: To gather data about client satisfaction, the nurse would need to use sources in which
the clients have answered questions or shared their opinions about the care they received. Post-
discharge surveys are a possible source of this data. Staff interviews and other statistical data
may provide insight about other management outcomes but do not address client satisfaction.
Concepts tested

Question 401
The nurse has received a report from the previous shift. Which of the following is
the priority action for the nurse after receiving the report?
A Suction the airway of a client with thick secretions
B Confirm intravenous (IV) fluids and flow rates
C Replace the empty medication syringe in a patient-controlled analgesia (PCA) pump
D Obtain supplies for a bedside procedure

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Question Explanation
Correct Answer is A
Rationale: Following Maslow’s Hierarchy of Needs, the priority action of the nurse after
receiving the hand-off report is to maintain a patent airway and to suction the airway of a client
with thick secretions followed by confirming intravenous (IV) fluids and flow rates and
replacement of an empty medication syringe. The lowest priority, although important, is
obtaining needed supplies for a bedside procedure.
Concepts tested

Question 402
The nurse is preparing the discharge for a client who is postoperative total right knee
replacement and has a prescription for home health care. To help ensure continuity of care, the
nurse should confirm which information with the client?
A Address and phone number
B Insurance information
C Follow up appointment with HCP
D Ability to change dressing

Question Explanation
Correct Answer is A
Rationale: Coordination of care is the responsibility of the interdisciplinary team. Patient care
coordination should be seamless and accurate and should start at admission. To avoid a lapse in
care and maintain client safety, the nurse should verify the client’s address and phone number
prior to discharge to avoid a lapse in care. The insurance information is not pertinent information
at this point in the process and should be discussed with a different department. The follow-up
with the HCP can be coordinated at home with the home health nurse, client, and family. The
dressing change can be done by the nurse and can be taught to the family by the nurse if needed.
Concepts tested

Question 403
A client arrives at the emergency department after a motor vehicle accident. The client is awake,
responsive, and eupneic. Which action does the nurse perform next?
A Initiate peripheral intravenous access
B Perform a neurological assessment
C Remove all of the client’s clothing
D Administer prescribed analgesics

Question Explanation
Correct Answer is A
Rationale: The nurse should initiate peripheral intravenous access after establishing the client’s
airway and breathing patency. IV access allows for the administration of fluids and restoration of
circulation. A neurological assessment should be performed during the disability portion of the
ABCDE criteria after the nurse ensures effective circulation. Removing all of the client’s
clothing is performed during the exposure portion of the ABCDE criteria. This is the last step of
the primary survey. The administration of prescribed analgesics is an important pain
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management intervention; however, this action is performed after the primary survey has been
completed.
Concepts tested

Question 404
The nurse is admitting a client to the outpatient surgery center. The client states, “I have never
taken my wedding ring off and won’t take it off now.” What is the best response by the nurse?
A “You should have left your valuables at home
B “The unit manager will hold your ring until you return from surgery.”
C “Your ring will be safe in the locked cabinet with security.”
D “Your ring can be taped to your finger prior to surgery.”

Question Explanation
Correct Answer is D
Rationale: The nurse should recognize that there are circumstances when the client may not want
to remove a valuable, such as a wedding ring. Depending on the surgery, some facilities allow a
wedding band to be kept in place if it is secured to the finger with tape. The client is encouraged
to leave all valuables at home or with a family member, although this should be stated to the
client in a non-threatening therapeutic manner. It is not appropriate to lock the ring in the cabinet
or give it to the unit manager to hold while the client is in surgery.
Concepts tested

Question 405
A nurse is providing care an older adult client who has a complex wound to the sacrum. Which
client situation indicates the need for a referral to social work?
A The client will require oral antibiotics for several weeks
B The client lives with their spouse who has advanced dementia
C The client verbalizes uncontrolled pain to the lower back
D The client refuses to look at their wound during dressing changes

Question Explanation
Correct Answer is B
Rationale: A client with a complex wound will require consistent wound care after discharge. A
spouse who has dementia will be unable to provide the client with the treatment needed. The
client would benefit from a referral to social work for community resources or discharge
placement. Oral antibiotics do not require specialized arrangements or a referral to social work.
Uncontrolled pain requires an adjustment to analgesic therapy. The nurse should contact the
healthcare provider for prescription modification. The client’s refusal to look at the wound
during dressing changes does not indicate a need for a social work referral. The nurse should
implement therapeutic communication and encourage the client to voice their concerns.
Concepts tested

Question 406
The nurse is using data collected to monitor the outcomes of a clients on a surgical unit. Which
competency is the nurse demonstrating?
A Patient-centered care

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B Evidenced-based practice
C Quality improvement
D Safety

Question Explanation
Correct Answer is C
Rationale: The Quality and Safety Education for Nurses are competencies needed by nurses to
provide quality, safe, and competent client care. Patient-centered care focuses on the client as a
full partner in their care with the nurse providing compassionate and coordinated care.
Evidenced-based practice integrates the most current research into practice. Quality
improvement uses data to monitor client outcomes, which then can be used to improve delivery
of care.
Concepts tested

Question 407
The nurse is caring for a client currently living in a homeless shelter. During assessment, the
nurse observes ecchymosis and swelling of the client’s eye. When asked about the injury, the
client states, “I get picked on, but I’m pretty tough.” Which nursing response is appropriate?
A “What do you do to defend yourself?”
B “We will do what we can to protect you as required by law.”
C “Nobody will bother you if you stay busy at the shelter.
D “I will recommend that you get a transfer to a safer shelter.”

Question Explanation
Correct Answer is B
Rationale: Based on the assessment data given, the nurse recognizes that the vulnerable client
may have been abused. A more detailed assessment would follow to rule out physiological or
other causes. The nurse is mandated to report abuse in the vulnerable client. The other responses
by the nurse do not provide safety for the client that is required by law.
Concepts tested

Question 408
A client arrives at urgent care after sustaining a fall. During the physical assessment, the nurse
notes decreased passive range of motion to the left hip and the client verbalizes a 3/10 pain with
movement. Which action does the nurse expect to perform next?
A Obtain a prescription for an X-ray, and refer the client to radiology
B Educate the client on mobility, and demonstrate range of motion exercises
C Assess the client’s gait, and document the findings
D Complete the physical assessment, and prepare the client for discharge

Question Explanation
Correct Answer is A
Rationale: The client’s symptoms are indicative of injury to the left hip. The nurse should expect
to obtain a prescription for radiologic studies and refer the client to the appropriate department.
Educating the client on the importance of mobility is important. However, injury to the extremity

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must be ruled out first. The client verbalizes pain with passive range of motion. Assessing the
client’s gait may cause further injury to the extremity. The client cannot be safely discharged
until the abnormal findings are addressed.
Concepts tested

Question 409
The nurse provided staff education on the client’s right to self-determination. Which of the
following actions by a staff nurse demonstrates support of self-determination?
A Provides a client with educational materials written at the 12th grade level
B Encourages a client to ask questions when the healthcare provider is explaining the risks and
benefits of a treatment
C Influences a client to continue to receive a painful treatment
D Advises the client of the nurse’s own personal preference in healthcare providers

Question Explanation
Correct Answer is B
Rationale: Clients have a right to determine what will be done with and to their own person, to
be given accurate, complete, and understandable information in a manner that facilitates an
informed decision, and to be assisted with weighing the benefits, risks, and available options in
their treatment. They have the right to make these decisions without undue influence, duress,
coercion, or prejudice and to be given necessary support throughout the process.
Concepts tested

Question 410
The nurse is caring for a group of surgical clients. Which of the following clients is not able to
give informed consent?
A A client who received 5 mg of oxycodone 30 minutes ago
B The client who is withdrawing from alcohol intoxication
C A client who is a married minor
D The client who reads at the fourth-grade level

Question Explanation
Correct Answer is B
Rationale: Narcotic administration sufficient for pain control does not impair the ability to
provide informed consent. Clients cannot give informed consent when they are very young or
very ill, mentally impaired, demented or unconscious, or sometimes merely frail or confused.
Emancipated (married) minors may give consent. The client with the lower reading level may
require support but may sign their own consent. The client in alcohol withdrawal is potentially
experiencing delirium and should not sign consent.
Concepts tested

Question 411
A nurse is reviewing information about advance directives with a client. The client states they do
not want chest compressions and would like to give a do not resuscitate (DNR) directive. Which
statement does the nurse make next?

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A “Your wishes will be documented and respected.”
B “Do you want other life-sustaining interventions?”
C “You should discuss your wishes with your family before deciding.”
D “Are you sure this is the best decision to make?”

Question Explanation
Correct Answer is B
Rationale: Chest compressions are a primary intervention of cardiopulmonary resuscitation
(CPR). However, the nurse needs to obtain information about the client’s wishes regarding other
life-sustaining measures, such as dialysis, ventilation, and hydration. Telling the client their
wishes will be respected is an important intervention. However, the nurse must first thoroughly
explore the client’s end of life wishes. Involving the family in end-of-life decisions should be the
client’s choice. The nurse’s role in advance directives is to provide information, not question the
client’s decision. Chest compressions are a primary intervention of cardiopulmonary
resuscitation (CPR). However, the nurse needs to obtain information about the client’s wishes
regarding other life-sustaining measures, such as dialysis, ventilation, and hydration. Telling the
client their wishes will be respected is an important intervention. However, the nurse must first
thoroughly explore the client’s end of life wishes. Involving the family in end-of-life decisions
should be the client’s choice. The nurse’s role in advance directives is to provide information,
not question the client’s decision.
Concepts tested

Question 412
The nurse is assessing a hospitalized client who speaks the nondominant language. The client’s
daughter is bilingual and present at the bedside. Which action by the nurse is most appropriate?
A Seek out a certified interpreter
B Utilize a picture board to communicate with the client
C Request that a bilingual nurse complete the assessment
D Ask the client’s family member to interpret

Question Explanation
Correct Answer is A
Rationale: Options for working with clients who do not speak the dominant language include
requesting assistance from a certified interpreter or using a telephone-based interpreter. Using
family members is not appropriate since it is a violation of the client's HIPAA rights. In addition,
clients may not feel comfortable explaining their symptoms with a family member present, and
medical terminology may not be translated correctly. Not asking essential questions may result in
an incomplete assessment. A picture board may be used in an emergency but is inadequate for a
thorough assessment.
Concepts tested

Question 413
The nurse is supervising the care of an older adult client who is receiving assistance with
personnel hygiene from unlicensed assistive personnel (UAP). Which action by the UAP
requires intervention?

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A Testing the temperature of the water in the bath basin
B Exposing only the part of the client being cleansed
C Applying a generous amount of soap directly to the washcloth
D Drying the skin thoroughly including between the toes

Question Explanation
Correct Answer is C
Rationale: Although unlicensed assistive personnel (UAP) are increasingly performing hygiene
measures, the nurse is responsible for ensuring that hygiene measures are performed
satisfactorily. Soap cleans the skin, but at the same time that it removes dirt from the surface, it
affects the lipids that are present on the skin and the skin pH. This contributes to drier skin,
damaging the barrier function of the skin. All other interventions are appropriate.
Concepts tested

Question 414
The nurse is evaluating the completion of a client’s wound dressing that was delegated to a
licensed practical nurse (LPN). Which nursing action is appropriate?
A Obtain report from the LPN.
B Ask the client if the dressing was done.
C Check the medical record.
D Visualize the new dressing.

Question Explanation
Correct Answer is D
Rationale: To evaluate the completion of a dressing change that was delegated, the nurse should
look at the dressing to ensure that it is clean and appropriately placed. Obtaining a report from
the LPN is important for continuity of care, but does not evaluate completion of the dressing.
Checking the medical record is important to ensure documentation has been completed but does
not evaluate the actual task. Asking the client if the dressing was done does not evaluate the
completion of the task.
Concepts tested

Question 415
The nurse is planning care for a client who is postoperative from an intermaxillary fixation for a
mandibula fracture. Which of the following should be the priority of the nurse place at the
client’s bedside?
A Nasogastric tube
B Wire cutters
C Syringes
D depressor

Question Explanation
Correct Answer is B
Rationale: The client who is postoperative intermaxillary fixation will have wires to keep the
jawbone aligned. If a client experiences respiratory distress, the nurse will need to cut the wires

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to access the airway. A nasogastric tube is used to decompress the stomach, syringes are used to
irrigate the mouth, and . depressor retracts the cheeks, but these are not a priority.
Concepts tested

Question 416
The nurse is performing discharge teaching for a client who is postoperative right below the knee
amputation and will receive skilled nursing care at home. Which statement by the client would
indicate a need for further teaching about the home care prescribed?
A “The dressing on my incision will be changed by the nurse.”
B “I can ask the nurse to help me with cleaning my house.”
C “My medication schedule will be reviewed by the nurse.”
D “The nurse can monitor for signs of complications.”

Question Explanation
Correct Answer is B
Rationale: Skilled nursing care focuses on providing the client treatments or interventions that
are performed by a licensed nurse. Nurses who perform skilled care follow care plans developed
based on the client’s diagnosis or condition. Skilled nursing interventions include assessing for
complications, changing dressings, administering and monitoring medications, and assist with
some activities of daily living. A nurse performing skilled care does not provide services such as
cleaning house or preparing meals.
Concepts tested

Question 417
A nurse is providing care to a client post-myocardial infarction who has been prescribed a daily
dose of aspirin. The client tells the nurse “I don’t like taking medications. Do I have to take the
aspirin everyday?” How does the nurse best respond to the client?
A “Taking new medications can be stressful.”
B “You should follow the recommendations of your healthcare provider.”
C “Tell me how you feel about your recent heart attack.”
D “The aspirin can help prevent another cardiac event.”

Question Explanation
Correct Answer is D
Rationale: The nurse’s role is to provide the client with information on their treatment options.
Stating the purpose of the medication will help the client make an informed decision about their
care. Telling the client new medications are stressful does not help address the client’s main
concern. Telling the client they should follow the recommendations of the healthcare provider
does not provide information about the treatment. The client’s feelings about their medical
condition does not address the client’s concern regarding medications.
Concepts tested

Question 418
The nurse is preparing to discharge a client home. A family member reports that the client’s
home has multiple safety hazards. Which member of the multidisciplinary team should be
notified?
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A Social worker
B Case manager
C Visiting nurse
D Healthcare provider

Question Explanation
Correct Answer is A
Rationale: Social workers assist patients and families in dealing with the social, emotional, and
environmental factors that affect their well-being. They make referrals to appropriate community
resources and provide assistance with securing equipment and supplies, as well as with health
care finances. Case managers are closely involved with discharge plans, length-of-stay issues,
and insurance constraints. Visiting nurses provide case management and direct care in the home
setting. The healthcare provider would not have a role in this situation.
Concepts tested

Question 419
The nurse is planning care for a client admitted from a nursing home with a diagnosis of
pneumonia. The client is underweight and is developing a pressure injury on the sacrum. Which
healthcare team member should be consulted to promote healing?
A Dietitian
B Occupational therapist
C Social worker
D Speech therapist

Question Explanation
Correct Answer is A
Rationale: Factors that affect healing include age, circulation to and oxygenation of tissues,
nutritional status, wound etiology, general health status and disease state, immunosuppression,
medication use, and adherence to treatment plan. A registered dietitian (RD) manages and plans
for the dietary needs of clients, based on knowledge about all aspects of nutrition. RDs can adapt
specialized diets for the individual needs of clients and counsel and educate individual clients
related to disease process. Speech therapists assess, diagnose, and treat communication disorders,
such as aphasia and swallowing disorders, such as dysphagia. There is no indication that the
client is experiencing a swallowing disorder.
Concepts tested

Question 420
The nurse manager has initiated a fall risk assessment tool that increases staff and client
interaction to promote increased safety. Which result indicates that the proposed initiative needs
improvement?
A Improved client satisfaction scores
B Decreased volume of unit-based falls
C Adoption of the fall risk assessment tool on a hospital-wide basis
D Staff reporting the time requirement of the new tool

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Question Explanation
Correct Answer is D
Rationale: When implementing a new practice protocol, evaluation of the end users of the
protocol is important for compliance. The staff reported a time requirement of the new tool
should indicate that the proposed initiative needs improvement. If staff feel that the tool takes too
much time, it won’t be used which may negate the goal to decrease falls and increase client
safety. If the volume of client falls decreases, client satisfaction scores increase, and the fall risk
assessment tool is adopted on a hospital-wide basis, then the initiative does not need
improvement.
Concepts tested

Question 421
The nurse has just received change of shift report for four clients in an acute rehabilitation
facility. Based on this report, the nurse should assess which client first?
A The client with arthritis who reports moderate pain
B The client with insomnia who reports daytime fatigue
C The client with a surgical dressing who reports clear drainage
D The client with unilateral leg swelling who reports shortness of breath

Question Explanation
Correct Answer is D
Rationale: The client who reports anxiety and shortness of breath and has unilateral leg swelling
should be seen first. This client is exhibiting signs and symptoms of pulmonary embolism,
which is a life-threatening condition. Increased daytime fatigue may be a symptom of insomnia.
After surgery, an incisional dressing may drain serous or sanguineous fluid. Careful assessment
of the dressing should be monitored. The client with arthritis may report mild to severe pain
based on the type of arthritis they are experiencing. Insomnia, arthritis, and a surgical dressing
site with drainage aren’t medical emergencies. Clients with these disorders don't take priority
over the client with a pulmonary embolism.
Concepts tested

Question 422
The nurse is reviewing the plan of care of a client who has prescription for discharge home.
Which information is the priority for the nurse to report to the interprofessional team?
A The client reports living alone.
B The client ambulates with a walker.
C The client requires the daily wound dressing changes.
D The client attends weekly support group meetings.

Question Explanation
Correct Answer is C
Rationale: The role of the nurse with discharge is to assess for a safe transition for the client.
Healthcare providers, such as nurses, physical therapists, and dieticians, have specific roles that
provide education, interventions, and support to clients. The nurse should report to the
interprofessional team information that requires follow up by members of the team, such as the
requirement of home equipment.
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Concepts tested

Question 423
A nurse is reviewing care plans for several clients in the geriatric unit. Which intervention on a
client’s care plan will the nurse revise?
A Keep a client with diverticulitis on NPO status.
B Continue fall risk precautions for a client with dementia.
C Maintain bedrest for a client who is malnourished.
D Implement aspiration precautions for a client with a stroke.

Question Explanation
Correct Answer is C
Rationale: The nurse should revise the intervention of bedrest for a client who is malnourished.
The client is at risk for skin integrity issues and requires frequent position changes or
ambulation. An NPO status for a client with diverticulitis is expected and does not need to be
revised. A client with dementia is at risk for falls due to disorientation and decreased
coordination. This intervention does not need revision. A client with a stroke can have
dysphagia, increasing the risk of aspiration. Aspiration precautions maintain client safety.
Concepts tested

Question 424
The nurse manger is providing education to staff members on the importance of safeguarding
client valuables during admission. Which statement by a staff member indicates the need for
further teaching?
A “Clients are discouraged to leave valuables at home.”
B “All valuables should be documented during the admission process.”
C “Use of a hospital safe may be used to store client valuables until discharge.”
D “Valuables should be properly labeled with client’s name.”

Question Explanation
Correct Answer is A
Rationale: Clients are encouraged to leave valuables at home. The admission process is used to
record an inventory of personal belongings and valuables to ensure their return to the patient on
discharge or transfer to another facility. Valuables, if kept with the client, should be placed in an
appropriate place, such as a hospital safe. Valuables kept in hospital safe should be properly
labeled with the client’s name and description of the valuable.
Concepts tested

Question 425
A nurse receives a chest physiotherapy prescription for a client who is unable to clear their
respiratory secretions. After performing manual percussion, the nurse does not observe adequate
airway clearance in the client. Which action does the nurse perform next?
A Document the treatment as being unsuccessful.
B Continue performing the procedure until the client clears their secretions.
C Educate the client on coughing and deep breathing.

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D Request a referral to respiratory therapy.

Question Explanation
Correct Answer is D
Rationale: Chest physiotherapy is a skill that can be performed using percussion or vibration.
Respiratory therapists are skilled in providing treatments to aid in airway clearance. A referral to
respiratory therapy is indicated. Documentation of the procedure is important; however, the
nurse must seek further resources to help the client clear their airway. Chest physiotherapy
applies increased pressure to the chest wall. Extending the length of the procedure may cause
injury. Educating the client on coughing and deep breathing promotes lung expansion and may
help mobilize secretions; however, this intervention does not meet the goal of chest
physiotherapy.
Concepts tested

Question 426
The nurse is providing a transfer report for a client. Which of the following is the priority for the
nurse to include in the report?
A When the next dose of prescribed medications is scheduled
B What allergies the client has
C Whether the client will be discharged to a skilled nursing facility
D The last set of vital signs

Question Explanation
Correct Answer is B
Rationale: When completing the transfer report, the nurse should provide information about the
client that is relevant to the client’s safety. The nurse should report the name, age, admitting
diagnosis, and allergies. While the next dose of prescribed medication, the last set of vital signs,
and discharge plans are important, it is information that can be retrieved from the medical record
and is not imperative to client safety.
Concepts tested

Question 427
The nursing instructor observes a student nurse perform a urinary catheterization in the clinical
setting. The student asks if there would be any legal implications if complications from the
procedure occurred. What is the initial response by the nursing instructor to address this issue?
A “You are within legal scope of practice by following facility procedure.”
B “Documentation of the procedure is supported by facility policy.”
C “All caregivers can be summoned if there is legal concern.”
D “The client consented to the urinary catheterization so there is no liability for complications.”

Question Explanation
Correct Answer is A
Rationale: The nursing student needs to recognize that by following facility policy and procedure
guidelines under the direction of a nursing instructor that care is provided within legal scope of
practice. This is the initial response by the nursing instructor. Completion of the procedure

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should include documentation in the medical or electronic record. Although all caregivers can be
summoned if there is a legal concern, the best response is to directly address the student’s
concern regarding complications and working within scope of practice. The legal responsibilities
are included in the client's agreement to the urinary catheterization.
Concepts tested

Question 428
A nurse is performing a focused health history on a client scheduled for an urgent appendectomy.
The client verbalizes being homeless and denies a social support system. Which action will the
nurse perform?
A Refer the client to case management for a financial assistance application.
B Collaborate with social work to locate a temporary shelter for the client upon discharge.
C Encourage the client to call a family member before the procedure.
D Perform a full health history to identify the client’s social needs.

Question Explanation
Correct Answer is B
Rationale: The nurse should expect to collaborate with the unit social worker to locate temporary
shelter for the client. The client may require medical care postoperatively and the nurse should
ensure adequate shelter for the client before discharge. There are various reasons the client may
be homeless aside from financial struggles. The nurse’s priority is to ensure the client has shelter
before discharge. The client has denied having a social support system. Encouraging the client to
call a family member does not provide sensitive care. The client is scheduled for an urgent
appendectomy. Performing a full health history is not appropriate at this time.
Concepts tested

Question 429
The nurse is caring for a client who is scheduled for surgery. The client is competent and
neurologically intact. The nurse should inform the surgeon who will be providing informed
consent?
A The client
B The person granted power of attorney for healthcare
C The legal next of kin
D The client’s emergency contact

Question Explanation
Correct Answer is A
Rationale: Informed consent reflects a process of effective communication that results in the
patient’s voluntary agreement to undergo a particular procedure or treatment (such as surgery). A
healthcare power of attorney states who should speak for the client if they are unable to make
decisions for themselves. This client is competent to make their own decisions and should be
involved in the informed consent process. A person's next of kin is their closest living blood
relative whereas the emergency contact is someone the client specifies.
Concepts tested

Question 430
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The nurse is performing an assessment of one of their assigned clients. When would be the most
appropriate time to document the assessment findings in the electronic medical record?
A Immediately after completing the assessment
B After completing assessments on all assigned clients
C At the conclusion of the nurse’s shift
D While the assessment is in progress

Question Explanation
Correct Answer is A
Rationale: The nurse should document assessment findings as soon as possible after completing
the assessment to ensure accuracy. Delaying documentation until after other assessments have
been performed or at the end of the shift increases the risk of inaccurate documentation. The
nurse should avoid documentation in the middle of the assessment as this can cause the client to
feed disconnected from the nurse.
Concepts tested

Question 431
A nurse is performing an assessment on a client post cardiopulmonary resuscitation for
myocardial infarction. The client tells the nurse, “If this were to happen again, I would not want
those chest compressions.” How does the nurse respond?
A “Have you considered making a living will?”
B “Why would you refuse resuscitation efforts?”
C “You should not worry about this happening again.”
D “It is important to focus on getting better right now.”

Question Explanation
Correct Answer is A
Rationale: A living will is a type of advance directive that provides instructions for medical care
when the client can no longer make decisions themselves. Refusal of chest compressions with
cardiopulmonary resuscitation (CPR) can be included in a living will. “Why” questions do not
provide therapeutic communication. Telling the client that a medical condition will not happen
again is false reassurance. Telling the client to focus on getting better disregards the client’s
statement.
Concepts tested

Question 432
The nurse is participating in collaborating with the interdisciplinary team for an assigned client.
The nurse has identified that the client will need access to community resources after discharge.
Which member of the team would be best equipped to address this need?
A Social worker
B Healthcare provider
C Charge nurse
D Nurse manager

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Question Explanation
Correct Answer is A
Rationale: Based on the need, the appropriate team member to collaborate with would be the
social worker. Making referrals to appropriate community resources is one of the roles of the
social worker. All other members of the team play a role in addressing inpatient needs.
Concepts tested

Question 433
The nurse is caring for a client with renal disease who has not started dialysis. When delegating
tasks to the unlicensed assistive personnel, which statement is appropriate?
A “Provide oral care to the client every 2-3 hours.”
B “Monitor the client for signs of fluid overload.”
C “Tell the client that they cannot drink as much cola.”
D “Inform the other UAPs that we will need to weight this client daily.”

Question Explanation
Correct Answer is A
Rationale: The Five Rights of Delegation are right task, right circumstance, right person, right
directions and communication, and right supervision and evaluation. Nursing care or tasks that
should never be delegated except to another RN include initial and ongoing nursing assessment,
determination of the diagnosis and plan of care, evaluation, and client education. Any task that is
delegated should be based on the training and competence of the individual accepting the
delegation. Providing oral care for the client every 2–3 hours is within the scope of practice of a
nursing assistant. The other actions should be completed by the registered nurse.
Concepts tested

Question 434
The nurse needs to evaluate that an unlicensed assistive personnel (UAP) has completed
delegated tasks. Which question by the nurse is most appropriate?
Question 4 Answer Choices
A “Did you obtain the client’s blood glucose before breakfast?”
B “Why haven’t you finished taking vital signs yet?”
C “Which clients are being discharged today?”
D “Was the client’s blood pressure better this time?”

Question Explanation
Correct Answer is A
Rationale: The nurse should evaluate delegated tasks by ensuring that they have been completed
at the appropriate time. In this case, asking if the UAP obtained a blood glucose before the client
ate breakfast is appropriate. The UAP is not responsible for knowing which clients will be
discharged or assessing if a client’s status has improved or worsened. If the UAP is struggling to
complete a task like vital signs, the nurse should step in and ask if the UAP needs help, but
asking why they haven’t finished is not an appropriate way to evaluate the task.
Concepts tested

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Question 435
The nurse is teaching the parent of a child who just had a tracheostomy inserted for subglottic
stenosis. Which of the following statements would the nurse include regarding supplies needed
for this procedure at home?
A “You will need sterile gloves for this procedure.”
B “Old tracheostomy ties can be used as long as the site is cleansed.”
C “An extra tracheostomy should be available in case of dislodgement.”
D “Oxygen therapy is necessary during cleansing of the site.”

Question Explanation
Correct Answer is C
Rationale: The nurse should teach the parent to gather the following supplies needed for
tracheostomy care in the home: prescribed cleaning solution, precut gauze, clean tracheostomy
ties, gloves (not sterile), and cotton-tipped applicators. An extra tracheostomy is essential in case
of accidental dislodgement. Parents should be taught not to use the old tracheostomy ties, but to
use new ones after the site is cleansed. It is not necessary to use oxygen therapy for routine
tracheostomy care in the home.
Concepts tested

Question 436
The nurse is providing discharge instructions to a female client was diagnosed with factor v
Leiden about newly prescribed warfarin. The client asks, “Should I continue taking oral
contraceptive?” Which statement should the nurse make?
A “You will resume the oral contraceptive once you reach therapeutic levels with the
warfarin.”
B “You can take an oral contraceptive if it is estrogen.”
C “You will need to discuss alternative birth control methods with your healthcare provider.”
D “You can restart the oral contraceptive after you finish your warfarin prescription.”

Question Explanation
Correct Answer is C
Rationale: Factor v Leiden is an inherited condition where there is a mutation in a gene
resulting in a hypercoagulable state. Clients diagnosed with factor v Leiden are at an increased
risk of developing clots and will require life-long treatment with anticoagulants, such as
warfarin. Estrogen based oral contraceptives increase the risk of developing clots and are
contraindicated in clients with hypercoagulable disorders. The client should be instructed to
discuss alternative birth control methods with their healthcare provider. Warfarin is dosed based
on therapeutic levels, but does not indicate an oral contraceptive can be resumed.
Concepts tested

Question 437
A nurse is witnessing a healthcare provider tell a client with a gangrenous foot ulcer that the best
course of treatment is a foot amputation. The client states, “I think I need to talk to my family
before making such a big decision.” Which statement does the nurse make?
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A “It’s important you make this decision independently.”
B “Let’s call your family so we can discuss your treatment.”
C “Your condition may worsen without a prompt decision.”
D “Tell me why it’s important that you speak to your family.”

Question Explanation
Rationale: The nurse should respect the client’s request to make a shared medical decision with
their family. The nurse facilitates the interaction by contacting the client’s family. The client
does not have to make a medical decision independently if they are not prepared to do so. The
nurse and healthcare provider should allow the client time to decide their treatment. The nurse
should not question the client’s request to make a shared medical decision. The client has a right
to discuss their treatment with family.
Concepts tested

Question 438
The clinic nurse is reviewing the laboratory results for a client who is postoperative gastric
bypass surgery. The nurse notes the client’s WBC of 7,000 per microliter, serum glucose of 102
d/L, vitamin D level of 30 ng/mL, ferritin level of 200 mcg/L, and a serum albumin of 25 g/L.
The nurse should request a referral to which member of the healthcare team for this client?
A Registered dietitian
B Infectious disease practitioner
C Endocrinologist
D Social worker

Question Explanation
Correct Answer is A
Rationale: A registered dietitian (RD) manages and plans for the dietary needs of patients, based
on knowledge about all aspects of nutrition. RDs can adapt specialized diets for the individual
needs of patients, counsel, and educate individual patients. This client is demonstrating protein
malnourishment based on the serum albumin level. Therefore, the dietitian should be informed.
All other lab work is normal. The social worker may be needed later on, but it not initially
needed in the development of the plan of care.
Concepts tested

Question 439
The nurse is caring for a group of clients. Which situation would the nurse report to the social
worker?
A A client is worried about how they will pay their bills after a motor vehicle crash.
B A client needs a repeat MRI on the same day as the scheduled discharge.
C Transportation needs to be scheduled for a client going to acute rehabilitation.
D The healthcare provider has prescribed early ambulation for a client after hip replacement
surgery.

Question Explanation
Correct Answer is A

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Rationale: Sometimes a client needs specialized counseling from other healthcare professionals.
Social workers assist clients and families in dealing with the social, emotional, and
environmental factors that affect their well-being. They make referrals to appropriate community
resources and aid with securing equipment and supplies, as well as with healthcare finances.
Making sure a client has a test prior to discharge is the responsibility of the nurse. Transportation
is usually scheduled by the case manager. Assistance with early ambulation can be obtained from
physical therapists.
Concepts tested

Question 440
The nurse manager has implemented a team care process that pairs each new graduate nurse with
an experienced unlicensed assistive personnel (UAP) to address increased client acuity levels.
Which is the best action to evaluate the outcome of the quality improvement initiative?
A Assign the charge nurse to monitor the graduate nurse.
B Monitor the unit-based patient satisfaction scores.
C Require daily reports from the graduate nurse on the UAP performance.
D Provide an in-service on the benefits of team nursing.

Question Explanation
Correct Answer is B
Rationale: To determine if the management initiative (i.e., pairing new graduate nurse and
experienced unlicensed assistive personnel) results in the desired outcome of improved care, the
best action is to monitor the unit-based patient satisfaction scores. The charge nurse would not
have time to complete his or her own work in addition to their role as a charge nurse. Requiring
daily reports from the graduate nurse on the UAP performance would not be an effective use of
time and may not be an objective evaluation of the UAP’s performance. Providing an in-service
on the benefits of team nursing would provide needed education for the change in the proposed
model of nursing but would not be the best action to evaluate an improvement in care.
Concepts tested

Question 441
The nurse is handing off care for a client on a postpartum unit at the end of the shift. Which of
the following statements would be the most important to include in the report?
A “The client is not taking any time off from work after delivery. ”
B “The client’s perineal pain is best relieved in a side-lying position. ”
C “The client did not want to meet with the lactation consultant. ”
D “The client had several visitors throughout the day.

Question Explanation
Correct Answer is B
Rationale: When handing off care during shift report, the nurse should provide relevant and
concise information about the client’s diagnosis, change in status, pain relief strategies,
intake/output and level of activity. Indicating that the client had visitors all day and that the
client will not be taking time off from work are not the most important statements/information to
include in the report. Although knowledge that the client did not want to meet with the lactation

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consultant may be important in care of this client, it is not as important as pain relief strategies
for ongoing care planning.
Concepts tested

Question 442
The nurse is caring for a client who is being transferred to the operating room (OR) for hip
surgery. The client reports to the nurse that they did not mark the operative hip with the surgeon.
Which action should the nurse take first?
A Proceed with transferring the client to the OR.
B Perform a “time out” so the site can be marked before the client is in the OR.
C Call the surgeon to mark the site with the client before transfer to the OR.
D Have the client mark the site before the transfer to the OR

Question Explanation
Correct Answer is C
Rationale: According to The Joint Commission, the surgical site should be marked by both the
client and the surgeon before anesthesia is administered and surgery begins when the surgery
involves a specific side.
Concepts tested

Question 443
A nurse is providing care to a client post ischemic stroke. Which client activity prompts the
nurse to revise the care plan?
A The client tolerates ambulating 20 feet with a physical therapist.
B The client drops hygiene products while performing self-care.
C The client performs 2 range of motion exercises while in bed.
D The client clears their throat after each bite of a mechanical soft diet.

Question Explanation
Correct Answer is D
Rationale: A client with a stroke is at risk for dysphagia and aspiration. Constant throat clearing
during mealtimes indicates the client’s diet is not appropriate or safe. Ambulation with physical
therapy is a safe intervention that promotes mobility and protects skin integrity. The distance
ambulated is expected to gradually increase. Dropping objects may be an expected response to
weak extremities following a stroke. Self-care should continue to be encouraged. Range of
motion exercises help the client prevent skin integrity issues and promotes muscle strength. The
nurse should continue to encourage the client’s repetitions.
Concepts tested

Question 444
While a client is attending a physical therapy session, the nurse observes an unlicensed assistive
personnel (UAP) trying on a client’s jewelry. What is the most appropriate action by the nurse?
A Report the incident to the client and family.
B Reinforce facility policy on safeguarding client valuables with the UAP.
C Notify the nursing supervisor.

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D Remind client and family not to leave valuables unattended.

Question Explanation
Correct Answer is B
Rationale: Nurses are responsible for safeguarding and respecting clients' personal possessions
and valuables; they must also not, under any circumstances, borrow or steal their personal
possessions and valuables. The UAP should first be updated on facility policy rather than report
the incident to the family. Although policies and procedures relating to the safeguarding of
clients' personal possessions and valuables may vary a little from one healthcare facility to
another, these policies and procedures typically include discouraging clients to retain personal
possessions and valuables while hospitalized, and then securing maintained and retained personal
possessions and valuables in a locked and secure safe.
Concepts tested

Question 445
A nurse is providing care to an older adult client with hypertension who is on a low sodium diet.
The client states the food tastes bland and refuses to eat the meals provided. Which action does
the nurse perform?
A Educate the client on the importance of a low sodium diet.
B Allow the client to select their food preferences.
C Obtain a registered dietitian consult.
D Encourage the client’s family to bring food from home.

Question Explanation
Correct Answer is C
Rationale: The client’s refusal to eat the prescribed diet will lead to inadequate nutrient intake.
The nurse should obtain a consult to a dietitian for further assessment and suggested alternatives.
Educating the client on their diet is important; however, this does not address the reason for the
client’s refusal to eat. Allowing the client to select their food preferences does not fulfill the
ordered prescription. Encouraging family to bring the client food from home is not appropriate.
The nurse is unable to verify the prepared food is low in sodium.
Concepts tested

Question 446
The nurse is performing chart audits for hospital-acquired conditions. Which condition that
occurred during the hospital admission is a reportable event?
A A client left the hospital against medical advice.
B A client refused treatment.
C A client received the wrong type of blood transfusion.
D A client was discharged to the care of a family member.

Question Explanation
Correct Answer is C
Rationale: The National Quality Forum Serious Reportable Events in Healthcare identify
specific events that happen to clients that may result in death, injury, or near miss. These events

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include surgery on the wrong part of the body, receiving the wrong type of blood transfusion,
and development of a pressure ulcer. A client has the right to leave the hospital against medical
advice and refuse treatment. A client can be discharged to the care of a family member.
Concepts tested

Question 447
The nurse is caring for a client that has been transferred from critical care following abdominal
surgery. Which nursing interventions would be safely delegated to a licensed practical nurse
(LPN) to assist the nurse?
A Perform wound care after the initial assessment.
B Administer prescribed unit of blood.
C Assess bowel sounds and advance diet as prescribed.
D Teach the client how to splint the incision to decrease pain.

Question Explanation
Correct Answer is A
Rationale: A complete and thorough assessment is needed by the registered nurse as the client
was just transferred from the critical care unit. The nurse may delegate to the LPN
responsibilities of wound care after the initial assessment. The nurse would administer prescribed
unit of blood as this is out of scope of practice for the LPN. The nurse would also complete any
initial postoperative assessment such as bowel sounds and teaching because the nurse holds the
responsibility for this task within legal scope of practice.
Concepts tested

Question 448
A nurse is providing care to a client with cancer. The client tells the nurse, “I often feel alone.
It’s not easy to talk to my family about my illness.” How does the nurse respond?
A “Would you like to talk more about your condition?”
B “Why do you think your family doesn’t want to talk about your illness?”
C “There are several support groups in the community to help you cope.”
D “It is not uncommon to feel alone given your diagnosis.”

Question Explanation
Correct Answer is C
Rationale: The nurse recognizes the client’s statement as an opportunity to provide information
on community resources. Support groups can provide the client with an opportunity to share
emotions and experiences with other people who have a similar diagnosis. The client’s statement
indicates an ongoing lack of social support systems. Asking the client to talk more about their
condition does not address the long-term need. Questioning the client about the family’s lack of
support does not promote a client-centered, therapeutic relationship. Telling the client it is not
uncommon to feel alone does not offer support.
Concepts tested

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Question 449
The nurse is caring for an adult client who experienced a closed head injury and is sedated and
ventilated. The client does not have an advanced directive. Which action by the healthcare team
is appropriate?
A Obtain consent from the emergency contact
B Ask the individual at the bedside to sign the consent form
C Determine the client’s legal next of kin
D Continue to provide interventions based on presumed consent

Question Explanation
Correct Answer is C
Rationale: Informed consent is still required in an emergency circumstance if the client is cogent
and conscious. In emergency situations were a decision-maker is unavailable and delay will harm
the client, then informed consent is presumed for the client. The client is presumed to have
consented to any and all relevant, emergency care such as intubation. However, once a client is
stabilized, further treatments require consent from a legally acceptable decision-maker, including
next of kin. The emergency contact may no participate in consent unless they are also legally
designated to do so via advance directive or as next of kin.
Concepts tested

Question 450
The nurse is administering ordered medications when the client refuses to take one of the pills.
How should the nurse document this in the medical record?
A “Client was combative and would not take medications.”
B “Education was provided but the client declined the medication.”
C “Medication administration was not possible at this time.”
D “Incident report completed after client would not take the medication.”

Question Explanation
Correct Answer is B
Rationale: The client has the right to refuse treatment (including scheduled medications) but the
nurse needs to document that the client refused/declined the medication and that education was
provided. In some cases the client needs a better understanding of the purpose of a medication to
be comfortable taking it. There is not enough information in the question to determine if the
client was combative, and there is no need to complete an incident report. Documenting that
medication administration is not possible implies that the client was physically unable to take
medications, therefore this is not the most appropriate statement.
Concepts tested

Question 451
A nurse is providing care to a client with a gangrenous foot ulcer. The client states, “My
healthcare provider told me the best course of treatment is to amputate the foot. I will not allow
that.” How does the nurse respond to the client’s statement?
A “A gangrenous foot is dangerous. You should listen to the advice from your healthcare
provider.”

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B “Try to rethink your decision. Refusing the treatment will worsen your condition.”
C “This is not a choice you should make on your own. You should discuss this with your
family.”
D “It must be a difficult decision to make. Tell me more about what the treatment means to
you.”

Question Explanation
Correct Answer is D
Rationale: The nurse’s role is to act as an advocate in the client’s decision making. The nurse
should explore the client’s reasoning for refusing the course of treatment. Causing fear does not
promote sensitive care. The nurse’s role is to guide the client’s decision, not influence their
choice. Discussing the decision with family should be the client’s choice. The nurse’s role is to
promote self-determination.
Concepts tested

Question 452
The nurse is caring for a client who has a history of cerebrovascular accident. The client is awake
and alert but struggles to feed themself due to fine motor dysfunction. Which of the following
members of the healthcare team would best meet the client’s need?
A Physical therapist
B Occupational therapist
C Healthcare provider
D Case manager

Question Explanation
Correct Answer is B
Rationale: The occupational therapist (OT) can evaluate the functional level of the client and
teach activities to promote self-care in activities of daily living, such as feeding oneself. The OT
can also provide assistance with securing any needed assistive equipment. The physical therapist
plays a role in assisting the client to develop strength and gross motor function. The healthcare
provider and case manager are not best suited for this client’s need in the inpatient setting.
Concepts tested

Question 453
The nurse is caring for a client who has prescribed albuterol via nebulizer and is feeling short of
breath. The nurse calls the assigned respiratory therapist to administer the treatment, but the
therapist is unable to come immediately due to an emergency. Which action is appropriate?
A Notify the healthcare provider.
B Stay with the client until the therapist arrives.
C Administer the prescribed albuterol via nebulizer.
D Instruct the client to use their personal albuterol metered dose inhaler.

Question Explanation
Correct Answer is C

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Rationale: Assignment and delegation abilities should not impact quality patient care. The
client's needs are preeminent, so the nurse should administer the nebulizer treatment
immediately. Administering nebulized medications is within the nurse’s scope of practice. There
is no need to involve the provider at this time. Staying with the client is important, but it isn't a
substitute for administering the needed bronchodilator. The order is for a nebulizer treatment not
a metered-dose inhaler, so the nurse can't change the route without a new order from the
healthcare provider.
Concepts tested

Question 454
The nurse has delegated a client’s indwelling catheter care to the unlicensed assistive personnel
(UAP). Which question by the nurse is appropriate to evaluate that the tasks were completed
appropriately?
A “Did the client understand the education you provided?”
B “Do I need to replace the indwelling catheter?”
C “Did you assess the skin condition of the perineal area?”
D “How many milliliters of urine were emptied from the drainage bag?”

Question Explanation
Correct Answer is D
Rationale: The nurse should gather feedback from the UAP about the task that includes, but is
not limited to: when the task was completed, how much urine was emptied from the drainage
bag, and if the UAP had any difficulty with the task. The UAP is not responsible for assessments,
teaching, or clinical judgements about the client condition; therefore, these questions are not
appropriate to evaluate completion of the task.
Concepts tested

Question 455
The nurse is planning care for a client with respiratory failure who is receiving mechanical
ventilation. The nurse should prioritize which equipment for the bedside?
A Pulse oximeter
B Suction canister
C Sterile suction catheters
D Manual resuscitation bag

Question Explanation
Correct Answer is D
Rationale: The client with pneumonia exhibiting respiratory compromise who is placed on
intermittent mechanical ventilation depends on oxygen for tissue perfusion. The piece of
equipment the nurse must prioritize is a manual resuscitation bag at the bedside in case of
ventilator malfunction. Having a pulse oximeter at the bedside would be helpful to monitor
oxygen saturation levels, but not a priority. The use of a functioning suction canister and sterile
suction catheters may be necessary to clear the airway of secretions while the client is
mechanically ventilated, but not a priority.
Concepts tested

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Question 456
The nurse is administering several oral medications to a client with Parkinson’s disease. Which
observation would require the nurse to update the client’s plan of care?
A The client begins to cough after taking a medication.
B The client takes one medication at a time.
C The client uses a straw to drink when taking a medication.
D The client has difficulty putting the medication in their mouth.

Question Explanation
Correct Answer is A
Rationale: Parkinson’s disease is a progressive disorder that affects muscle movement. Clients
with Parkinson’s disease will have tremors, making it difficult to hold objectives or control
movements. The nurse would need to update the plan of care if the client demonstrates
complications. A client with Parkinson’s disease who begins coughing after taking medication
might be experiencing dysphagia and would require interventions to prevent aspiration.
Concepts tested

Question 457
A graduate nurse tells the precepting nurse that a client post total knee replacement has requested
for physical therapy sessions to be performed earlier in the day. How will the precepting nurse
tell the graduate nurse to address the client’s request?
A “The client should be educated that physical therapy is best performed in the afternoon.”
B “The physical therapists already have a set schedule for all their clients and cannot be
changed.”
C “Collaborate with physical therapy to modify the schedule to meet the client’s wishes.”
D “Inform the client it is important to continue the physical therapy as prescribed.”

Question Explanation
Correct Answer is A y C
Rationale: The client has the right to modify their plan of care if the outcome will continue to be
safe and achieve the same goal. The nurse collaborates with the healthcare team to adjust
activities that best meet the needs of the client. Unless there is a specific prescription for physical
therapy timeframes, the nurse should respect the client’s wishes to perform therapy at an earlier
time. The nurse should not assume that physical therapy will be unable to accommodate the
client’s request. Telling the client it is important to continue physical therapy is not indicated
because the client is not refusing to participate in their care.
Concepts tested

Question 458
The nurse is caring for a client receiving treatment for methicillin resistant staphylococcus
aureus (MRSA). Which of the following findings should be reported to the pharmacist?
A Vancomycin trough level 22 mg/L
B Creatinine Clearance 80 ml/min
C White Blood Cell Count 10,000
D Serum osmolality 290 mOsm/kg

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Question Explanation
Correct Answer is A
Rationale: The pharmacist plays a role in determining the appropriate amount of drug
administered, especially in cases where the drug may cause toxicity. Measurement of both peak
and trough levels helps maintain therapeutic serum levels without excessive toxicity. A trough
above 20 mg/L indicates that a dosage adjustment may be needed to reduce the risk of kidney
injury. The remaining lab values are within expected ranges and do not need to be reported.
Concepts tested

Question 459
The nurse is admitting an older adult client with diabetes who has a suspected blood stream
infection. The client lives alone, and an unstageable sacral wound was identified during the
assessment. Which of the following referrals is the priority?
A Wound care nurse
B Social worker
C Physical therapist
D Diabetes educator

Question Explanation
Correct Answer is A
Rationale: Wound care nurses are registered nurses who hold a baccalaureate degree or higher
and have completed additional education focused on wounds, ostomies, and/or continence care.
This nurse can assist by assessing the wound and helping the healthcare team devise appropriate
interventions. The social worker helps clients with social, emotional, and environmental factors
that affect their well-being. This client is still quite ill so this is not the priority. Physical therapy
and diabetes education are not the priority because the client is likely acutely ill and cannot
participate in rehabilitation or education.
Concepts tested

Question 460
The nurse is providing an in-service on client confidentiality. Which statement requires further
education on disclosure of client information?
A “If a child is being abused, this must be reported to authorities.”
B “When a client tests positive for HIV, their partners will need to be notified.”
C “If a client tests positive for smallpox, public health officials are notified.”
D “A client’s mental health information can only be shared with permission.”

Question Explanation
Correct Answer is B
Rationale: Confidential information may be lawfully disclosed about a client when the welfare
of others is at stake. Confidentiality of HIV testing is required and may not be disclosed to the
client’s partners, that is the responsibility of the client to provide that information. This statement
requires further education by the nurse. In cases of child abuse, this information must be legally
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disclosed to the proper authorities. Public health officials are notified with client information for
any reportable condition (e.g., smallpox or COVID) to protect the welfare of the general public.
A client’s mental health information can only by shared with permission.
Concepts tested

Question 461
The nurse is coordinating care for a client with a left-sided hemiparesis who is being transferred
from inpatient rehabilitation to a long-term care facility. Which document would best provide
continuity of care?
A Recent medication administration record
B Transfer summary with in-patient history and plan of care
C Referral form for an occupational therapist
D Original medical record from the rehabilitation facility

Question Explanation
Correct Answer is B
Rationale: A transfer summary would be the best document to provide continuity of care as it
summarizes significant findings, the procedures performed and treatment rendered, the patient’s
condition on discharge or transfer, and any specific pertinent instructions. The original chart will
not accompany the client, but copies or sections of the chart may be sent based upon agency
protocols. A referral form for an occupational therapist may be needed, but is not the best way to
provide continuity in care. Pertinent medications from the medication administration record
(MAR) may be reviewed in the hand-off report with the nurse at the long-term care facility.
Concepts tested

Question 462
The nurse is reviewing the laboratory data for a client with a history of hypertension who is
taking prescribed hydrochlorothiazide. Which result would indicate to the nurse that the client
would require a different treatment option?
A serum potassium 5.5 mEq/L
B BUN 16 mg/dL
C creatinine 1.2 mg/dL
D serum osmolarity 280 mosm/kg

Question Explanation
Correct Answer is A
Rationale: HTN results in vasoconstriction and fluid volume overload, which can lead to kidney
insufficiency. The client with kidney insufficiency will have an elevated serum potassium level,
greater than 5.0 mEq/L. Normal BUN is 6-24 mg/dL, creatinine is less than 1.5 mg/dL, and
serum osmolarity is 275-295 mosm/kg.
Concepts tested

Question 463
A nurse receives report on a couple of clients who require total care. After performing shift
assessments, which client would benefit from a care plan revision?

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A A client who states they urinated on the bedsheets
B A client who is able to tolerate a high-Fowler’s position
C A client who is able to brush their own teeth
D A client who uses the call bell to request pain medication

Question Explanation
Correct Answer is C
Rationale: A client who is able to perform self-care activities is no longer considered total care.
The nurse should discuss the client’s abilities with the healthcare team to promote independence.
A client who is incontinent cannot provide for their own hygiene needs. A client who is able to
tolerate a high-Fowler’s position does not indicate they can reposition themselves. A total care
client still has the ability to feel pain. Requesting pain medication does not indicate
independence with self-care activities.
Concepts tested

Question 464
The nurse is caring for a client that requires peritoneal dialysis. The nurse has not performed this
skill before. What is the best action by the nurse to ensure safe care?
A Contact the unit educator for guidance during the procedure.
B Initiate the dwell portion of the peritoneal dialysis procedure.
C Request a different client assignment and need for further education.
D Defer the procedure to a more experienced nurse on the oncoming shift.

Question Explanation
Correct Answer is C
Rationale: The nurse recognizes the lack of knowledge, skill, and competency to perform
peritoneal dialysis and needs further education. Gaining the appropriate knowledge, skill, and
competency to complete this skill will require further education and practice, not just a bedside
session. The other options are incorrect because they are neither appropriate nor safe and do not
address the nurse’s need for further education.
Concepts tested

Question 465
A nurse is preparing to discharge a client with a diabetic foot ulcer. The client tells the nurse,
“It’s so hard for me to keep track of all my medications and treatments.” How does the
nurse best respond?
A “I will obtain a consult to social work to help you explore your options.”
B “It is important for you to organize all your medications and treatments.”
C “I understand it is difficult to manage such a complex disease.”
D “Let’s call your family to see who can assist you at home.”

Question Explanation
Correct Answer is A
Rationale: A client with a diabetic foot ulcer indicates their disease is not being managed
adequately. The client’s concern can best be addressed by a social worker who can arrange

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community resources. Telling the client it is important to organize medications and treatments
does not address the client’s concern. Empathizing with the client is an important aspect of
therapeutic communication; however, it does not address the issue. The nurse cannot assume the
client’s family will be capable in assisting the client with their diagnosis.
Concepts tested

Question 466
The nurse is developing the plan of care with a client who is postoperative right hip replacement.
The client has identified several goals. Which goal should the nurse identify as short-term?
A The client will have pain control at an acceptable level.
B The client will be able to bear weight on the right leg.
C The client will walk independently to the bathroom.
D The client will understand incision care before discharge.

Question Explanation
Correct Answer is A
Rationale: Client goals are identified as long-or short-term outcomes, focusing on when the
client will achieve the goal. A short-term goal focus on client outcomes that focus on the
immediate needs of the client, such as pain control. Long-term goals require a longer time to
achieve the client outcomes, such as discharge instructions or return of function.
Concepts tested

Question 467
A nurse uses the Nurse Practice Act to guide professional standards. What actions are within the
legal scope of practice for the registered nurse?
A Formulating a medical diagnosis and treatment plan
B Prescribing alternative therapy for chronic pain
C Delegating wound care to a licensed practical nurse
D Consulting a dermatologist for skin care

Question Explanation
Correct Answer is C
Rationale: The registered nurses’ scope of practice includes delegating wound care to a licensed
practical nurse. Registered nurses need a healthcare provider’s order to consult a dermatologist,
prescribe alternative therapy for chronic pain, or formulate a medical diagnosis and treatment
plan.
Concepts tested

Question 468
A nurse is assessing an older adult client with diabetes mellitus type 2. The client’s latest
hemoglobin A1C level is 8.5%. The client tells the nurse, “It’s hard to eat healthy because I
cannot drive to the grocery store.” Which nursing action best addresses the client’s situation?
A Educates the client on the importance of healthy eating to control their illness.
B Refers the client to a diabetes educator for information on disease management.
C Calls the client’s family to arrange for transportation to the grocery store.

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D Collaborates with case management for meal delivery services.

Question Explanation
Correct Answer is D
Rationale: The client’s latest hemoglobin A1C level indicates poor management of the disease
primarily due to an unhealthy diet as indicated by the client. The nurse identifies this as an
opportunity to collaborate with case management for possible meal delivery services. Educating
the client on healthy eating is important. However, this action does not address the issue of
transportation. Referring the client to a diabetes educator does not address the problem of
inaccessible groceries. Addressing the situation with the client’s family does not guarantee
reliable transportation.
Concepts tested

Question 469
The nurse is caring for a 16-year-old client in the emergency department who requires informed
consent for surgery. The 18-year-old spouse is at the bedside. Who will the healthcare team
approach to obtain informed consent?
A The adult spouse
B The client
C One of the client’s parents
D The client’s legal guardian

Question Explanation
Correct Answer is B
Rationale: A married minor may be treated without parental or legal guardian consent. Other
exemptions include, but are not limited to, pregnant minors, minors over a specific age being
treated for sexually transmitted diseases, emancipated and mature minors such as those in the
military and living apart from parents.
Concepts tested

Question 470
The nurse is gathering supplies to insert an intravenous (IV) line when they notice that the supply
kit contains a new type of antiseptic for skin prep. Which action by the nurse is most
appropriate?
A Performing the IV start as usual
B Asking a fellow nurse if they have used the new product
C Reading the antiseptic manufacturer’s instructions
D Tell the supervisor that the staff will need training

Question Explanation
Correct Answer is C
Rationale: Any time that a nurse needs to use new product or supply, it is important that they
familiarize themselves with the manufacturer’s instructions on proper use. The nurse should not
perform the skill as usual because there may be a need to change current practice when a

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different product is used. Asking another nurse if they have used the product does not provide
the nurse with proper instructions on how to use the new supply. While training may be
necessary, telling the supervisor does not immediately address the need to perform the IV start.
Concepts tested

Question 471
A nurse is providing care to a client receiving chemotherapy for stage 4 colon cancer. The client
tells the nurse, “I am tired of being in the hospital. I just want to stop treatment and go home.”
How does the nurse respond to the client’s statement?
A “I will inform the healthcare team so we can discuss your options.”
B “I know your medical condition is tough but you have to be strong.”
C “How did you arrive to this difficult decision?”
D “Why do you want to give up on treatment?”

Question Explanation
Correct Answer is A
Rationale: The nurse’s role in advocacy is to provide alternative options for treatment in
collaboration with the healthcare team. The nurse will advocate for the client’s right to make
their own decisions. Acknowledging the client’s condition is difficult provides empathy but does
not address the client’s statement. Questioning how and why the client made their decision does
not promote autonomy.
Concepts tested

Question 472
The nurse is planning care for a client with heart failure. Which of the following tasks is
appropriate to delegate to experienced unlicensed assistive personnel (UAP)?
A Monitor the client for shortness of breath after ambulation.
B Instruct the client to alternate activity with rest.
C Obtain the blood pressure and pulse rate after ambulation.
D Determine whether the client is ready to increase the activity level.

Question Explanation
Correct Answer is C
Rationale: The Five Rights of Delegation are right task, right circumstance, right person, right
directions and communication, and right supervision and evaluation. UAPs are not licensed;
therefore, they cannot teach or assess a client. Therefore, any instruction or assessment must be
done by the registered nurse. UAPs can collect data but only the nurse can interpret this data.
Concepts tested

Question 473
The registered nurse is working with a licensed practical nurse (LPN/VN) in a team nursing
model. Which elements of the nursing process can be delegated to the licensed practical nurse?
A Assessment of the client
B Development of the plan of care
C Provision of nursing interventions

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D Evaluation if goals are met

Question Explanation
Correct Answer is C
Rationale: The Five Rights of Delegation are right task, right circumstance, right person, right
directions and communication, and right supervision and evaluation. Professional nurses are
responsible for delegating nursing activities, but although RNs may delegate elements of care,
they do not delegate the nursing process itself. Nursing care or tasks that should never be
delegated, except to another RN, include initial and ongoing nursing assessment, determination
of the diagnosis and plan of care, evaluation, and client education. Any task that is delegated
should be based on the training and competence of the individual accepting the delegation.
Concepts tested

Question 474
The nurse needs to evaluate that tasks delegated by the licensed practical nurse (LPN) were
completed effectively. Which action by the nurse is most appropriate?
A Verify the provider’s prescriptions for each task.
B Ask the LPN for feedback about the tasks.
C Observe the completion of all delegated tasks.
D Complete a comprehensive assessment.

Question Explanation
Correct Answer is B
Rationale: To ensure that a task has been completed appropriately, the nurse should ask the LPN
for feedback about those tasks. This allows the nurse to gain insight about the task(s) to evaluate
that they were completed. Observing all tasks that have been delegated is not an effective way to
evaluate completion because the nurse would be spending the same amount of time observing
that it would take for them to complete the task themselves. Verifying the provider’s prescription
does not evaluate tasks, and completing a comprehensive assessment is important but does not
necessarily provide data about the delegated tasks.
Concepts tested

Question 475
The nurse is preparing an admission assessment for a client diagnosed with roseola. Which
action should the nurse take initially?
A Initiate oxygen therapy.
B Request a private room with negative airflow pressure.
C Notify staff of need for personal respiratory protection mask.
D Assess need for suction equipment.

Question Explanation
Correct Answer is B
Rationale: Roseola (measles) is transmitted via airborne droplets. The initial action the nurse
should make on assessment for supplies for a client with known airborne infection is to provide a
private negative airflow pressure room to decrease incidence of transmission. It is important to

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notify the staff of need for personal respiratory protection mask (e.g., N95 respirator), but not the
initial action. The initiation of oxygen therapy and suction setup may be needed for this client
with a respiratory compromise, but safety and isolation is the initial action by the nurse to
prevent transmission of infection.
Concepts tested

Question 476
The nurse is reviewing the plan of care for a client with dehydration and has a serum calcium
level of 7.2mg/dL. Which intervention is the priority for the nurse to implement?
A Monitor ECG for changes in P-waves.
B Obtain prescription to measure vitamin D level.
C Assess for Chvostek sign.
D Initiate seizure precautions.

Question Explanation
Correct Answer is D
Rationale: The normal total serum calcium level is 8.6 to 10.2 mg/dL. Seizures may occur
because hypocalcemia increases irritability of the central nervous system as well as the
peripheral nervous system. A prolonged QT interval is seen on the ECG due to prolongation of
the ST segment not a shortened P wave. Chvostek sign is contraction of the facial muscle that
occurs with a light tap on the facial nerve. This is seen in hypocalcemia but does not present
immediate danger to the client. Vitamin D levels should be evaluated but should be ordered by
the HCP.
Concepts tested

Question 477
A nurse is performing an admission history on a client. When asked about medical history, the
client tells the nurse, “I should not have to discuss my past illnesses with anyone.” How does the
nurse best respond to the client’s statement?
A “It is important to know your medical history so we can make better decisions about your
care.”
B “Why don’t you want to share information about your medical history?”
C “Would you feel more comfortable sharing your medical history at a later time?”
D “We cannot treat you if we don’t know your past medical history.”

Question Explanation
Correct Answer is A
Rationale: The client has a responsibility to share information about their past medical care with
healthcare providers. A comprehensive history facilitates a patient care partnership. The nurse
encourages the client to share information by providing education on the purpose of a health
history. “Why” questions do not promote therapeutic communication and may cause the client to
lose rapport with the nurse. Offering to collect the medical history at a later time does not
address the client’s hesitancy to provide information. The client can still receive treatment even
if their medical history is unknown.
Concepts tested

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Question 478
The nurse is assessing a group of clients. Which client problem should be reported to the
respiratory therapist?
A Sanguineous drainage on the nasal packing of a client who is 1 day post hypophysectomy
B Dry mucus membranes and sore throat of a client on continuous positive airway pressure
(CPAP)
C Shortness of breath in the client diagnosed with heart failure
D Complaint of chest pain from a client who experienced a motor vehicle collision (MVC)

Question Explanation
Correct Answer is B
Rationale: Respiratory therapists are trained in techniques and equipment that improve
oxygenation and pulmonary function, including CPAP. The client with the hypophysectomy is
expected to have some drainage, but this may require intervention from the surgeon. The client
with heart failure may require diuresis and may later require a respiratory thereapist, but not at
this time. The client with chest pain from an MVC likely requires radiologic testing and pain
management.
Concepts tested

Question 479
The nurse is caring for a client in respiratory distress who has been receiving 100% oxygen via
nonrebreather mask and now appears fatigued. The client’s most recent arterial blood gas is pH
7.29 pCO2 55, pO2 59, HCO3 18. The nurse will plan to do which of the following
interventions first?
A Obtain a serum lactate level.
B Reassure the client.
C Prepare for imminent intubation.
D Request a prescription for IV sodium bicarbonate.

Question Explanation
Correct Answer is C
Rationale: Acute respiratory failure is defined as a decrease in arterial oxygen tension (PaO2) to
less than 60 mm Hg (hypoxemia) and an increase in arterial carbon dioxide tension (PaCO2) to
greater than 50 mm Hg (hypercapnia), with an arterial pH of less than 7.35. Endotracheal
intubation and mechanical ventilation may be required to maintain adequate ventilation and
oxygenation while the underlying cause is corrected. This is the priority in order to prevent
deterioration to respiratory arrest and possibly death. All other interventions may be appropriate,
but not the priority.
Concepts tested

Question 480
The client asks the nurse, “What is wrong with that person who is always screaming out?” What
is an appropriate action by the nurse to address the client’s concern?
A Ask if the client knows the other client before providing information.
B Tell the client about the condition in layperson’s terms.

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C Explain that information about other clients is considered private.
D Inform the client that the staff is handling the situation.

Question Explanation
Correct Answer is C
Rationale: The nurse should teach the client about HIPAA and confidentiality rules that govern
any information concerning clients in a healthcare setting. Client information is private. The
nurse should not tell the client about the condition or determine if the client knows the other
client as this would be a breach in confidentiality and violation of privacy. It is a priority to
address the client on confidentiality rules. Informing the client that the staff is handling the
situation is dismissive and does not address the confidentiality issue.
Concepts tested

Question 481
The nurse in the labor and delivery unit is giving a report to the nurse in the postpartum unit.
Which is the most effective way for the nurse to ensure essential information about the client is
reported?
A Give written report to the nurse.
B Audiotape the report for future reference and documentation.
C Document transfer information in the client's electronic health record.
D Use a printed checklist with information individualized for the client.

Question Explanation
Correct Answer is D
Rationale: Using a checklist assures that all key information is reported; the checklist can then
serve as a record to which nurses can refer later. Giving a written report leaves no room for the
receiving nurse to ask questions, and using an audiotape or an electronic health record requires
nurses to spend unnecessary time retrieving information.
Concepts tested

Question 482
The nurse has received morning change of shift report about four assigned clients. Which of
client should the nurse assess first?
A A 23-year-old client with a migraine headache and reports severe nausea
B A 45-year-old client scheduled for heart catherization in 30 minutes and needs preoperative
teaching
C A 63-year-old with multiple myeloma who has an oral temperature of 101.8 F (38.8 C) and
reports flank pain
D A 59-year-old with heart failure who requires assistance to the bathroom.

Question Explanation
Correct Answer is C
Rationale: When evaluating who to see first, the nurse should assess the client with any reported
abnormal findings or change in condition. A client with multiple myeloma who has an elevated
temperature should be seen first, as this could indicate an infection. The client with migraine

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reporting nausea and the client with heart failure report assistance to the bathroom are expected
findings. The client who is preop for a heart catherization and requires teaching is stable and not
the priority.
Concepts tested

Question 483
A nurse is reviewing the care plan of a client post total hip replacement 72 hours ago. The
current goal is for the client to ambulate 50 feet with the use of a walker by post operative day 3.
During the physical therapy session, the client is able to ambulate only 35 feet. Which revision
will the nurse make to the client’s care plan?
A Choosing an alternate nursing diagnosis
B Adjusting the time criteria
C Changing the assistive device for ambulation
D Decreasing the distance goal

Question Explanation
Correct Answer is B
Rationale: The nurse should adjust the time criteria for the current outcome statement. The client
is able to ambulate, but it may be too soon to accomplish the goal set by the initial care plan. The
nursing diagnosis does not need to be modified. Mobility is a priority for a client with a total hip
replacement. Changing the assistive device for ambulation is not required. The client is able to
ambulate with the current assistive device. A distance of 50 feet is a realistic goal. The client has
achieved a significant distance for the current time criteria.
Concepts tested

Question 484
The nurse is admitting a client from a long-term care facility who is confused and unable to
answer any questions. The client does not have any caregivers present. Which resource should
the nurse utilize to obtain the most accurate information about the client?
A The verbal report from the transport team
B The client’s recent laboratory reports
C The transfer form from the long-term care facility
D The prescriptions from the healthcare provider

Question Explanation
Correct Answer is C
Rationale: The long-term care facility will send a transfer form with the client on admission with
a detailed history, medication list, and other pertinent information about the client. The verbal
report from the transport team will only provide a brief report and not the most accurate
information needed for the client. The client’s recent laboratory reports will only provide a
glimpse of the client’s condition and is not the most accurate. The prescriptions from the
healthcare provider will include a diagnosis, but no information on the client’s condition or
medical history.
Concepts tested

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Question 485
A nurse is performing client rounds with a healthcare provider on the unit. The healthcare
provider assesses a client who had a stroke and has difficulty performing fine motor movements
with the hands. Which priority action does the nurse take?
A Document the assessment findings in a progress note.
B Verify the client’s prescriptions with the healthcare provider.
C Suggest a referral to occupational therapy.
D Encourage the client to ask questions regarding their plan of care.

Question Explanation
Correct Answer is C
Rationale: The client would benefit from a referral to occupational therapy. Occupational
therapists help clients regain motor skills after an illness or procedure. Documentation of the
observations is important; however, the nurse must ensure the client is referred to the appropriate
resource first. Verification of the client’s prescriptions with the healthcare provider and
encouraging the client to ask questions about their plan of care is standard for every client.
Concepts tested

Question 486
The nurse is documenting on the plan of care of a client who had a right total knee replacement.
The nurse is utilizing a clinical pathway for the client’s care. Which should the nurse identify as
the purpose of a clinical pathway?
A Provide client information for the healthcare team.
B Identify critical information about the client’s condition.
C Standardize expected client outcomes based on clinical guidelines.
D Provide a diagram to organize data to identify client problems.

Question Explanation
Correct Answer is C
Rationale: There are different formats to develop and document the client's plan of care. A
concept map care plan uses a diagram to represent client problems and interventions and is
organized by client data. Change of shift reports focuses on the critical client information being
communicated between nurses for continuity of care. Computerized care plans are accessible by
anyone on the healthcare team to access client information. Clinical pathways are standardized,
interdisciplinary care based on evidenced-based clinical guidelines for a specific condition or
illness.
Concepts tested

Question 487
The nurse and unlicensed assistive personnel (UAP) are caring for clients in the labor and
delivery unit. Based on scope of practice, which action would be delegated to the unlicensed
assistive personnel (UAP)?
A Teaching a client how to breastfeed her infant
B Removing a fetal monitor and assisting the client to the bathroom.
C Checking for deep vein thrombosis while ambulating the client

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D Palpating the fundus and perform gentle fundal massage

Question Explanation
Correct Answer is B
Rationale: Removing a fetal monitor from a client and assisting her to the bathroom is within the
legal scope of practice of an unlicensed assistive personnel (UAP). Performing a fundal check,
palpating the fundus, and performing fundal massage is a responsibility of a registered nurse.
Checking extremities for the presence deep vein thrombosis is an assessment skill performed by
the registered nurse. Education is also part of the professional nursing role. Although a UAP can
assist a mother with breastfeeding, the formal client education must be completed and validated
by the nurse.
Concepts tested

Question 488
The nurse is reviewing the discharge plans for assigned clients. Which client should the nurse
request a prescription for skilled nursing home care?
A The client who has cancer and is weak from chemotherapy.
B The client with an infection and requires IV antibiotics.
C The client who had knee surgery and is walking with crutches.
D The client with dementia and needs assistance with meals.

Question Explanation
Correct Answer is B
Rationale: When reviewing discharge plans, the nurse should assess for the need of skilled home
care to ensure a safe transition home. Skilled nursing home care is prescribed for clients who
required specific, skilled professional care, such as requiring of enteral tube feeding, wound care,
medication management, and blood therapies. The client with crutches and client who is weak do
not require skilled nursing care at home. The client with dementia who needs assistance with
meals does not require skilled nursing care.
Concepts tested
Question 489
The nurse is planning education for a client who is Spanish speaking and hard of hearing. The
client’s adult child is bilingual. What teaching method is essential for this client?
A Arrange for an interpreter to translate the lesson.
B Provide written materials in Spanish.
C Use hand gestures to communicate the meaning.
D Educate the client’s family member

Question Explanation
Correct Answer is B
Rationale: Clients must be given oral and written educational material written at the client’s
reading level. In this case, written materials are even more important due to the hearing
impairment. At times, written material is beneficial for clients and, at other times, the assistance
and services of a professional translator may be indicated. An adult client should be educated

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directly and not only a family member. Use of a family member not trained in interpretation
may lead to misunderstandings and confusion.
Concepts tested

Question 490
The nurse is preparing to administer a client’s intravenous medications concurrently. Which
action by the nurse is appropriate at this time?
A Mix the two medications in the same syringe
B Add one of the medications to the maintenance fluid bag
C Administer a liter bolus of normal saline between each medication
D Check the facility’s medication compatibility reference

Question Explanation
Correct Answer D
Rationale: Before giving medications concurrently, the nurse should access the facility’s
medication compatibility resource to check for any medication incompatibilities between
medications/fluids. The nurse should not mix multiple medications in one syringe or add a
medication to the maintenance fluids unless the prescription includes these instructions.
Administering a liter of normal saline between each medication is not necessary and may cause
complications related to excess fluid volume.
Concepts tested

Question 491
A nurse is providing education on insulin administration to a client with newly diagnosed
diabetes. The client tells the nurse, “I don’t want to take insulin for my diabetes. Please stop
teaching me about injections.” Which action does the nurse take next?
A Tell the client that refusing treatment will worsen their condition.
B Contact the healthcare team for alternative treatment options.
C Continue to instruct the client how to administer insulin.
D Document the client’s refusal of treatment on the medical record.

Question Explanation
Correct Answer is B
Rationale: The client has the right to refuse treatment options. The nurse’s role in advocacy is to
provide alternative treatment options to a client in collaboration with the healthcare team.
Emphasizing the client’s refusal does not provide alternative options or promote advocacy.
Continuing to instruct the client on insulin administration does not address the client’s statement.
Documenting the client’s refusal of treatment is an important intervention. However, the client
should be offered alternative treatment options first.
Concepts tested

Question 492
The nurse is preparing to transport a client who is scheduled for a surgical procedure. The nurse
observes that the informed consent for surgery has not been completed. Which action by the
nurse is appropriate?

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A Cancel the client’s scheduled surgical procedure
B Tell the operating room that they will need to get consent
C Inform the surgeon that the client’s consent form has not been signed
D Have the client sign before speaking with the surgeon

Question 493
Correct Answer is C
The nurse is caring for a client who has been admitted for a chronic respiratory condition
exacerbation. Which of the following findings should be reported to the provider immediately?
A Oxygen saturation of 92% on room air
B Blood pressure of 128/90 mmHg
C Respiratory rate of 28 breaths per minute
D Heart rate of 95 beats per minute

Question Explanation
Correct Answer is C
Rationale: The normal respiratory rate is 10-20 breaths per minute (bpm); therefore, a rate of 28
bpm needs to be reported to the provider as an abnormality. While the ideal oxygen saturation is
95% or higher, clients who have chronic respiratory conditions often have slightly lower oxygen
saturation levels as a normal finding. The client’s blood pressure and heart rate are not findings
that need to be reported to a provider.
Concepts tested

Question 494
The nurse is caring for a client who states that they would like to leave against medical advice.
Which statement by the nurse is appropriate?
A “You have the right to leave but you will need to sign a form stating that you know the
risks.”
B “You cannot leave until you have completed your treatment plan.”
C “If you don’t want to help yourself the hospital cannot help you.”
D “If you leave before you have a discharge order I will have to notify law enforcement.”

Question Explanation
Correct Answer is A
Rationale: Clients have the right to refuse treatment and leave a facility if they choose. It is
important that the nurse explains to the client the risks of leaving against medical advice but if
the client still wants to leave after this education, they will sign a form that states they understand
the education presented. Unless the client cannot make decisions for themselves, medical staff
cannot force a client to stay. The other statements are not appropriate for the nurse to make.
Concepts tested

Question 495
The nurse manager is presenting quality improvement initiatives to staff nurses on how
effectively use supplies on the unit. Which of the following statements indicates further teaching
is needed on cost effective measures?

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A “As long as we don’t overstock supplies, we can cut costs.”
B “Inventory of items we don’t use should be monitored.”
C “Supplies discharged with clients should be unlimited.”
D “We should return unused supplies at the end of the shift.”

Question Explanation
Correct Answer is C
Rationale: Effective nurse managers should be alert to the type and quantities of supplies used in
their unit for cost effective care. Supplies discharged with clients should be limited, not
unlimited, as well as limits to the practice of overstocking bedside supplies to reduce costs.
Monitoring inventory of stock and obsolete or slow-moving stock also represents potential cost
savings. Another way to cut supply cost and increase cost effective care is to remind staff to
return unused supplies at the end of the shift.
Concepts tested

Question 496
The nurse is developing the plan of care for a client with a history of coronary artery disease who
was admitted with stable angina. Which intervention should the nurse implement?
A Limit the number of visitors.
B Initiate strict bedrest.
C Instruct client to eat small frequent meals.
D Encourage client to maintain cooler temperature in the room.

Question Explanation
Correct Answer is C
Rationale: Clients with coronary artery disease have a decrease perfusion to the heart muscle,
which can cause angina or chest pain. Stable angina occurs when the client experiences chest
pain with activity but goes away with rest. The client should be instructed to eat small frequent
meals to prevent increase blood flow to the digestive tract, which can increase angina. The client
is permitted to ambulate, but only short distances and rest before chest pain begins. The client
does not need to limit the number of visitors. Cooler temperatures can increase vasoconstriction,
which can cause angina.
Concepts tested

Question 497
A nurse is admitting a client to the medical unit. During the initial assessment, the client tells the
nurse, “I don’t want anyone knowing the reason I am in the hospital.” How does the nurse
respond to the client?
A “We will respect your decision to not disclose your medical information.”
B “Visitors can be restricted while you are in the hospital.”
C “It may be necessary to give information to your employer.”
D “You will need to specify which medical information needs to remain confidential.”

Question Explanation
Correct Answer is A

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Rationale: Clients have a right to know their medical information will remain confidential.
Clients must be provided with a notice of the facility’s privacy practices upon admission. The
client is not refusing visitors so a restriction is not indicated. Providing medical information to
the client’s employer is a breach of privacy. The client does not need to specify which medical
information is to remain confidential. The client has a right to protect their information.
Concepts tested

Question 498
The nurse is caring for a client who is post-operative right knee arthroplasty and has a
prescription for physical therapy and occupational therapy. Which of the following actions by the
nurse is appropriate?
A Ask the case manager to remind the therapists.
B Notify the therapists during the next multidisciplinary meeting.
C Seek out the therapists at the beginning of the shift to schedule therapy.
D Rely on the entry into the electronic health record as the mode of communication with the
therapists.

Question Explanation
Correct Answer is C
Rationale: Priority setting in nursing is based on meeting a client’s unmet needs in a timely way.
It is inappropriate to delegate the scheduling of inpatient therapy to the case manager. The nurse
should not wait for the next meeting to inform the therapists as this will potentially delay care.
While the electronic health record is designed as a form of communication, it is important to
maintain interpersonal communication to promote teamwork.
Concepts tested

Question 499
The nurse is caring for an older adult client who has a history of falls related to impulsiveness
and impaired gait. Which of the following strategies will best address this safety concern?
A Provide the client with the call bell.
B Place the client in a room near the nurse’s station.
C Apply soft wrist restraints.
D Inform the team that the client’s bed alarm should always be turned on.

Question Explanation
Correct Answer is D
Rationale: The nurse must be vigilant for potential threats to the patient’s safety, because
impulsiveness may impair judgment. Close monitoring, frequent reorientation, hourly rounding,
and implementing interventions to prevent falls (e.g., bed alarms) are essential. Just being closer
to the nurse’s station may not be enough. Informing all staff members of the client’s risk and
need for the bed alarm will aid in preventing a fall or injury. Soft wrist retraints are used to
prevent injury from removal of a medical device and do not prevent falls. The client is impulsive
so they may not use the call bell or if the call bell isn’t answered quickly enough, the client may
attempt to get out of bed alone.
Concepts tested

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Question 500
The nurse is discussing the importance of client confidentiality during a staff in-service. Which
action by the staff would require the need for further teaching?
A The nurses complete end-of-shift reports at the bedside.
B Health information is written on the client’s whiteboard.
C Computers are logged off when not in use.
D Staff requests to see identification before providing access to records.

Question Explanation
Correct Answer is B
Rationale: The nurse should not put up the client's health information on a whiteboard to be seen
by other healthcare workers. This would require further teaching of client confidentiality by the
nurse. End-of-shift reports to the nurse coming on duty presented in the client's room or other
secure area are a good way to protect client confidentiality instead of sharing information to
those that do not need to know that information. Staff should log off from computerized
workstations and monitor use of electronic health information to only those in direct care of the
client.
Concepts tested

Question 501
The nurse manager is providing education to staff nurses on the importance of documents to
communicate client information. Which of the following statements would require further
teaching by the staff nurse?
A “The healthcare team reviews progress notes to make clinical decisions.”
B “Utilization of a graphic record shows trends in client status.”
C “An admission assessment is a good source for a record of routine care.”
D “Discharge documents include a summary of care pri.”

Question Explanation
Correct Answer is C
Rationale: A flow sheet, not an admission assessment, is a documentation tool used to efficiently
record routine aspects of nursing care (e. g. , wound care, hygiene, nutrition). An admission
assessment provides results of client history and physical assessment which becomes a baseline
for later comparisons as the client’s condition changes. The graphic record is a form used to
record specific patient variables where trends in client status may be monitored, such as pulse,
respiratory rate, or fluid intake and output. The multidisciplinary healthcare team reviews
progress notes to make clinical decisions. Discharge or transfer documents summarizes the care
the client has received and the patient’s condition on discharge.
Concepts tested

Question 502
The nurse has received report on a group of assigned clients. Which client should the nurse
assess first?
A The client with liver disease with a calcium level of 10.0 mg/dL
B The client with a fever with a sodium level of 136 mEq/mL

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C The client who has a burn with a magnesium level of 2.0 mEq/L
D The client who reports muscle weakness with a potassium level of 6.1 mEq/L

Question Explanation
Correct Answer is D
Rationale: The nurse should see first the client with abnormal lab results exhibiting
manifestations. A potassium level of 6.1 mEq/L is elevated and should be seen first. The client
with a calcium of 10.0 mg/dL, the client with a sodium level of 136 mEq/mL, and magnesium
level of 2.0 mEq/L are within the normal range.
Concepts tested

Question 503
A nurse is evaluating the plan of care of a client on a patient-controlled analgesia (PCA) pump
for intractable pain. The PCA delivery record indicates the client is attempting to deliver more
doses than the prescribed delivery limits. How will the nurse document the care plan evaluation?
A Outcome not met – Client requires further education on the purpose of a PCA pump.
B Outcome not met – Client continues to require maximum doses of pain medication.
C Outcome met – Client demonstrates ability to use a PCA pump.
D Outcome met – Client is receiving an adequate amount of pain medication.

Question Explanation
Correct Answer is B
Rationale: The goal for a client with intractable pain is pain relief and adequate pain
management. A client who attempts to deliver more doses than the prescribed limits on the
patient-controlled analgesia (PCA) pump indicates their pain is not well-managed. The PCA
usage record does not indicate a client’s lack of understanding of the purpose of a PCA. The
ability to use a PCA pump does not indicate the outcome has been met. A client who attempts to
deliver more doses than the prescribed limit indicates their pain is not being adequately
managed.
Concepts tested

Question 504
The nurse is preparing to administer for the first time a prescribed medication to a client. What is
the initial action the nurse should take prior to administering this medication for the first time?
A Ask an experienced nurse who is familiar with the medication regarding adverse effects of the
medication.
B Contact the healthcare provider.
C Refer to a drug handbook for safe dosage considerations.
D Check with the client regarding the accuracy of the medication.

Question Explanation
Correct Answer is C
Rationale: A nurse must be knowledgeable about a medication before administering it to a
client. The initial action of the nurse would be to consult a nursing drug handbook which would
include information about the drug's expected action, usual dosage, adverse effects, and nursing

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considerations. An experienced nurse who is familiar with the medication may be consulted after
the nurse looks up the medication in the drug handbook. It is not reliable to refer to the client
regarding the medication. While many clients are very knowledgeable, nurses should not assume
this. The healthcare provider would be contacted if the nurse had questions regarding the dosing,
action, or adverse effects of the medication as prescribed.
Concepts tested

Question 505
The preoperative nurse is witnessing a client sign consents for surgery. The client states, “I am
not sure if I should have the surgery.” Which statement would be appropriate for the nurse to
make?
A “Tell me more about what makes you think you do not want the surgery.”
B “You should talk to your family about your concerns.”
C “I will let your healthcare provider know your feelings.”
D “This is a hard decision for you to make.”

Question Explanation
Correct Answer is A
Rationale: The nurse’s role with informed consent is to the witness the client’s signature of the
consent. If the client expresses concerns, the nurse should gather more information about the
client’s feelings. The nurse should alleviate the client’s anxiety by allowing the client to discuss
their feelings and concerns. The nurse should notify the healthcare provider if the client refuses
the surgery or has specific questions about the surgery.
Concepts tested

Question 506
The nurse is reviewing the interventions in the plan of care for a client admitted with pneumonia.
Which action implemented by the nurse would be documented as an indirect care intervention?
A Auscultating breath sounds
B Chest physiotherapy
C Measuring client’s intake
D Closing the door to the client’s room

Question Explanation
Correct Answer is D
Rationale: Nursing interventions are treatments based on clinical judgment and knowledge by
the nurse and can either be direct or indirect. A direct care intervention refers to actions by the
nurse that are performed with interaction with the client. Indirect care interventions are
performed away from the client but the outcomes will benefit the client, such as managing the
client environment.
Concepts tested

Question 507
The nurse is caring for a client with congestive heart failure who has anxiety about discharging
home. To decrease readmission rates, the nurse recognizes that the client might benefit from
which of the following services?
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A Frequent home health visits
B Implementation of telehealth visits
C More written literature on discharge
D Follow up physical therapy evaluation

Question Explanation
Correct Answer is B
Rationale: Using health information technology to improve quality, efficiency, and delivery of
healthcare services is widely recommended. To assist with managing chronic conditions, the
client should be offered telehealth visits. This would aide in decreasing anxiety and reduce the
likelihood of the client returning to the emergency department for non-emergency issues. This
will also facilitate the development of more personalized care plans. The frequency of the home
health visits can be adjusted but may prove difficult due to client and nurse availability.
Literature on discharge should still be given but will not likely decrease anxiety about the
client’s condition. Physical therapy evaluation should be considered prior to discharge.
Concepts tested

Question 508
A nurse is discussing the plan of care with a family of a client with advanced dementia. The
family tells the nurse they cannot provide adequate supervision for the client at home. How does
the nurse respond?
A “There are long-term care facilities that can provide constant supervision."
B “The client only requires supervision during nighttime.”
C “What is the reason the supervision cannot be provided?”
D “Is there anyone else that can provide supervision?”

Question Explanation
Correct Answer is A
Rationale: A client with advanced dementia requires constant supervision to ensure safety. The
nurse should provide the family with options for community health care services. Clients with
advanced dementia require supervision at all times. The nurse’s duty is to provide community
resources for the family and the client. The nurse does not need to question the family’s inability
to provide supervision. Asking if there is anyone else that can provide supervision does not
guarantee the client will be safe at home at all times.
Concepts tested

Question 509
The nurse is educating a client receiving a prescription for an oral chemotherapeutic using the
assistance of a certified translator. The client’s primary spoken language is Portuguese. What
methods will the nurse include in the teaching plan?
A Observe the client complete a return demonstration
B Provide the client with written instructions in Portuguese
C Have the client complete a post-test on the content taught
D Request that a visiting nurse provide additional teaching

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Question Explanation
Correct Answer is B
Rationale: The client should be provided with written materials in the primary language. Written
materials supplement the instruction provided by the nurse and translator. Return demonstration
is appropriate for a client being taught a technical skill and not self-administration of a “pill”. A
post-test would not be appropriate unless available in the client’s spoken language and at the
client’s reading level. It is not cost effective for a visiting nurse to see this client for additional
education on this matter unless they are visiting for other conditions.
Concepts tested

Question 510
The nurse is caring for a client who has an order for continuous bladder irrigation. The nurse
does not perform this procedure frequently and is unsure which supplies are needed. Which
action by the nurse is appropriate?
A Read the facility’s bladder irrigation procedure
B Ask another nurse to initiate the irrigation
C Delay the irrigation until the next shift
D Manually flush the catheter with normal saline

Question Explanation
Correct Answer is A
Rationale: If the nurse is unsure of any part of the procedure, the best action is to pull the facility
policy to ensure that the appropriate supplies used and steps are done correctly. While asking
another nurse to initiate the irrigation may accomplish the task, the nurse still needs education on
the procedure. Delaying this procedure may result in complications for the client, and manually
flushing the catheter does not satisfy this prescription.
Concepts tested

Question 511
A nurse is providing education on prescribed medications to a client diagnosed with anxiety. The
client tells the nurse, “I will be managing my condition with alternative medicine.” How does the
nurse respond to the client’s statement?
A “Alternative medicine is not proven to be effective.”
B “Anxiety is best controlled with prescribed medication.”
C “You should discuss this with your family before making a decision.”
D “Tell me what you know about alternative medicine.”

Question Explanation
Correct Answer is D
Rationale: The nurse’s role as an advocate is to guide the client in making their own medical
decisions. The nurse must ensure the client fully understands their options. Discrediting a
treatment option does not promote a therapeutic relationship between the nurse and the client.

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Providing medical advice is not within the nurse’s scope of practice. A family discussion is the
client’s choice. The nurse should promote client autonomy.
Concepts tested

Question 512
The nurse is caring for a client with acute kidney injury. Which of the following actions can the
nurse delegate to the unlicensed assistive personnel (UAP)?
A Check for the presence of edema.
B Listen for bowel sounds.
C Obtain vital signs.
D Monitor fluid balance.

Question Explanation
Correct Answer is C
Rationale: The Five Rights of Delegation are right task, right circumstance, right person, right
directions and communication, and right supervision and evaluation. UAPs are not licensed and
therefore cannot assess a client. Therefore, any instruction or assessment must be done by the
registered nurse. UAPs can collect data but only the nurse can interpret this data.
Concepts tested

Question 513
The nurse has just successfully inserted a client’s indwelling urinary catheter. Which of the
following statements by the nurse is appropriate when discussing this update with the unlicensed
assistive personnel?
A “Assess the client’s skin around the catheter each day.”
B “Document each time you perform perineal care.”
D “Flush the catheter if the urine output decreases.”
D “Discontinue the catheter when the client feels the need to void.”

Question Explanation
Correct Answer is B
Rationale: The unlicensed assistive personnel (UAP) can perform perineal care and should
document each time that they perform this task. UAPs cannot assess the client or perform tasks
such as flushing or discontinuing indwelling urinary catheters. They should be instructed to
report things like urine output and client concerns to the nurse.
Concepts tested

Question 514
The nurse is assessing a new staff member’s competency before delegating tasks to them. Which
action by the nurse is most appropriate?
A Request that the staff member to share their educational background.
B Ask the staff member if they are able to complete the task independently.
C Observe the staff member complete a task for the first time.
D Assess the staff member’s level of experience.

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Question Explanation
Correct Answer is C
Rationale: To ensure that a new staff member is competent with a skill, the nurse should observe
that staff member perform that task for the first time. Gathering data about the staff member’s
education and experience or confidence in completing the task might be helpful, but does not
directly evaluate competence.
Concepts tested

Question 515
The nurse is reviewing discharge instructions with a client who has a new prescription for a
brand-name medication. The client states, “I don’t think my insurance will cover that; I won’t be
able to take it.” Which statement would be appropriate for this nurse to make?
A “The pharmacy can check with your insurance company if the medication is covered.”
B “Your healthcare provider prescribed this specific medication for a reason.”
C “You may need to pay for the medication to see if it is effective.”
D “I can ask your healthcare provider if a generic medication is available.”

Question Explanation
Correct Answer is D
Rationale: The nurse recommending that the client ask the provider if the client can take the
generic brand of the medication instead of the brand-name medication would be a cost-effective
way of assisting this client to afford the medication. Nurses do not prescribe medications. Simply
stating the client should contact a family member is not assisting the client with this problem.
The health care provider ordered this drug because of symptom exacerbation. Telling the client
to wait to see if the medication will be effective does not address the issue if the client cannot
pay for it.
Concepts tested

Question 516
The nurse is assessing a client with a history of diabetes type II. Which finding would require
the nurse to update the client’s plan of care?
A The client requests to rotate fingers for blood glucose monitoring.
B The client reports numbness in feet when walking.
C The client asks for assistance with meal planning.
D The client requires a snack before physical therapy.

Question Explanation
Correct Answer is B
Rationale: Clients with diabetes are at risk for developing neuropathy, nerve damage that occurs
from elevated blood glucose levels. Clients who have developed diabetic neuropathy will report
numbness or tingling in the feet. The nurse will need to update the plan of care to prevent injury
or further complications. A client who requests to rotate fingers is normal. A client may ask for
assistance with meal planning. A snack before physical therapy is appropriate for a client with
diabetes to prevent a hypoglycemic event with activity.
Concepts tested

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Question 517
A nurse manager delivers an in-service to unit staff on reviewing the plan of care with clients.
Which statement made by a nurse indicates an understanding of client rights?
A “The client can request a modification to their plan of care.”
B “The plan of care should be reviewed with the client only when there are changes.”
C “Consent for individual procedures is not necessary if a client agrees with the plan of care.”
D “The treatment outlined in the plan of care is chosen by the client.”

Question Explanation
Correct Answer is A
Rationale: A nurse has a duty to review the plan of care with clients. Clients have the right to
accept, refuse, or request a revision to their plan of care. The nurse communicates the client’s
request with the healthcare team. The plan of care should be reviewed with the client on an
ongoing basis to ensure understanding of the medical treatment. Individual procedures,
particularly if they are invasive, require additional written consent. The treatment plan is
determined by the healthcare provider and discussed with the client.
Concepts tested

Question 518
The nurse is caring for a client who has been nothing by mouth (NPO) for a test and is now
prescribed a diet. Which action by the nurse is appropriate?
A Call the dietary department to ensure that the client gets a correct tray.
B Notify the dietitian that the diet has been changed.
C Enter the order into the electronic health record for the healthcare provider.
D Wait until the next mealtime to begin feeding the client.

Question Explanation
Correct Answer is A
Rationale: Continuity is a process by which healthcare providers give appropriate, uninterrupted
care. Continuity depends on excellent communication to prevent omissions in care. The nurse’s
priority is to ensure that the client gets appropriate care based on their physiological needs.
Concepts tested

Question 519
The nurse is planning care for a client who is experiencing shortness of breath upon exertion.
Which intervention should the nurse include in the plan of care?
A Increase intravenous fluid intake.
B Encourage rest periods during activity.
C Avoid ambulation as much as possible.
D Maintain a clear liquid diet.

Question Explanation
Correct Answer is B
Rationale: The client who is experiencing shortness of breath with exertion should rest often
during activities. The nurse should plan for these rest periods and ensure that the client has the

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ability to pace themselves and a place to sit while performing activities. Ambulation should still
occur if the client can tolerate it. Increasing IV fluids and maintaining a clear liquid diet do not
address the client’s shortness of breath.
Concepts tested

Question 520
The client with acute coronary syndrome (ACS) is transferred from the emergency department
(ED) to a telemetry unit three days ago. Which action by the nurse would breach client
confidentiality?
A The emergency department (ED) nurse gave a verbal report to the nurse on the telemetry unit
before transferring the client to that unit.
B The telemetry nurse notified the on-call provider about a change in the client’s condition.
C The emergency department (ED) nurse reviewed the client’s latest laboratory results.
D The telemetry nurse updates the client’s spouse on their condition with the client’s
permission.

Question Explanation
Correct Answer is C
Rationale: The ED nurse is no longer directly involved with the client’s care and has no legal
right to information about the client's present condition or latest laboratory results. Anyone
directly involved in their care, such as the telemetry nurse and the on-call provider, has the right
to information about the client's condition. Because this client asked the nurse to update their
spouse, doing so doesn’t breach confidentiality. The ED nurse can give a verbal report to the
telemetry nurse prior to transfer to that unit, as this is not a breach of confidentiality.
Concepts tested

Question 521
The nurse is conducting an admission interview for an older adult client with altered mental
status. . The nurse notes the client is poor historian. . Which action is the most appropriate for the
nurse take to obtain the client’s past medical history?
A Wait until the client can provide the information.
B Review information from previous admission in the medical record.
C Document that the client is unable to provide information.
D Check to see if there is contact information for family on the chart.

Question Explanation
Correct Answer is B
Rationale: The health history and assessment is conducted to determine the client’s states
wellness or illness. There are a variety of ways to collect data for an assessment and the nurse
should ensure that the data is obtained from a reliable source. The client has altered mental status
so the information obtained from the client could be inaccurate. The information should not be
left blank until all resources are used to obtain the information. Obtaining the information from

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the neighbor could violate the client’s privacy and should be avoided. Using the EMR, the nurse
could look at the client’s previous history.
Concepts tested

Question 522
The nurse is planning care for a group of assigned clients. Which clients are at the highest risk
for impaired skin integrity?
A The client with cognitive impairment who has an indwelling urinary catheter
B The client who had a colonoscopy with a prescription for bedrest
C The client who had a knee replacement who requires assistance out of bed
D The client with bronchitis who is receiving prescribed oxygen via nasal cannula

Question Explanation
Correct Answer is A
Rationale: Clients who are at highest risk for impaired skin integrity have underlining health
issues that impair wound healing, have mobility issues, and take prescribed medication that can
suppress wound healing. The client with cognitive impairment may not be able to reposition or
verbalize the need to change positions. An indwelling urinary catheter increases moisture, which
can cause skin impairment.
Concepts tested

Question 523
A nurse is providing care to a client who is unconscious following a motor vehicle accident with
significant internal bleeding. After the healthcare provider discusses life-sustaining measures, the
client’s spouse refuses a blood transfusion due to religious reasons. Which action does the nurse
take next?
A Refer the case to the ethics committee.
B Respect the wishes of the client’s spouse.
C Request for the healthcare provider to discuss alternative treatment
D Document the spouse’s refusal of treatment for the client.

Question Explanation
Correct Answer is C
Rationale: The nurse should request for the healthcare provider to discuss alternative treatment
options with the client’s spouse. The nurse must still advocate for the client while respecting the
wishes of decision-makers. Referring the case to the ethics committee is not indicated until after
all options have been discussed with the client’s spouse. Respecting the wishes of the client’s
spouse without discussing alternative life-sustaining options does not advocate for the client.
Documenting the spouse’s refusal of treatment for the client should occur until all alternative
treatment options are discussed.
Concepts tested

Question 524
The healthcare provider requested an interpreter for a client who is deaf to obtain consent for
surgery. The nurse knows that this request is based on which legal consideration?

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A Compliance with the American Disabilities Act (ADA) of 1990
B Mandate from the National League for Nurses (NLN)
C Approval from the Board of Nursing
D Advice from the hospital’s legal counsel

Question Explanation
Correct Answer is A
Rationale: In addition to following facility policies and procedures, nurses must follow and
comply with any federal and state laws relating to interpreters and serving as an interpreter. The
American Disabilities Act (ADA) of 1990 prohibits and forbids any discrimination against any
people with disabilities including those who are deaf. A sign language interpreter could be used
in a healthcare organization to comply with this law. The National League of Nurses (NLN) is a
national organization for faculty nurses and leaders in nurse education and not the basis for legal
consideration. A board of nursing does not need to give approval for an interpreter for a client
that is deaf. Advice from a hospital’s legal counsel does not pertain to the legal consideration for
use of an interpreter.
Concepts tested

Question 525
The nurse is working with unlicensed assistive personnel (UAP) to care for a client with chronic
obstructive pulmonary disease (COPD) who is receiving oxygen therapy and is stable. Which
action would be appropriate for the nurse to delegate to the UAP?
A Report SpO2 levels.
B Titrate oxygen flow rate.
C Educate client about oxygen use.
D Evaluate if client has dyspnea.

Question Explanation
Correct Answer is A
Rationale: Members of the healthcare team who are caring for clients receiving oxygen therapy
have specific scopes of practice. The nurse is responsible for assessing the need for titration of
oxygen flow rate, educating the client about oxygen use, and evaluating if the client has dyspnea.
The nurse can delegate reporting the SpO2 levels to the UAP.
Concepts tested

Question 526
The nurse is identifying interventions for a plan of care developed for a client who had a stroke.
The client has a nursing diagnosis of risk for falls. Which intervention would be appropriate to
document for this client?
A Administration of prescribed pain medication
B Application of soft wrist restraints
C Initiation of a bed alarm
D Referral for physical therapy

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Question Explanation
Correct Answer is C
Rationale: The focus of interventions is based on the type of nursing diagnosis. For actual
nursing diagnoses, such as acute pain, the nurse would implement interventions that address the
problem and promote well-being. A risk nursing diagnosis, such as the risk for falls, the nurse
would implement interventions to prevent the problem. Collaborative nursing diagnosis requires
interventions that manage changes in status with nurse-prescribed and healthcare prescribed
interventions, such as the use of restraints or referral for interdisciplinary care.
Concepts tested

Question 527
The nurse is preparing to call the healthcare provider regarding a change in the client’s condition.
The nurse understands to ensure effective communication, which information should be
given first?
A Recommendation
B Current situation
C Clinical background
D Client preferences

Question Explanation
Correct Answer is B
Rationale: When calling the healthcare provider, the nurse should always be sure to organize
information in a manner to facilitate good communication. The SBAR form of communication is
recommended and widely used. The first thing communicated using this method is the current
situation or what is happening with the client. The recommendation of the nurse is the last
portion of the communication. The clinical background of the client should be given after the
current situation. In this case, the client’s preferences may not be a priority but can be added to
the assessment portion of the communication.
Concepts tested

Question 528
A nurse is providing care to a client with a traumatic brain injury. The client will require
individualized financial assistance and long-term medical needs. The nurse will refer the client
and their caregiver to which specialty resource?
A Life care planner
B Support group
C Rehabilitation center
D Counseling service

Question Explanation
Correct Answer is A
Rationale: Life planners help clients coordinate their long-term needs within the community.
Life care planners develop an individualized plan for each client based on their needs and assist
with finding necessary resources. Support groups help clients and caregivers cope with a
diagnosis, but do not offer specialized care. Rehabilitation centers offer long-term physical

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therapy but do not assist with financial concerns. A counseling service provides mental and
emotional assistance. However, this service does not provide for physical and financial needs.
Concepts tested

Question 529
The nurse is caring for a client who will be undergoing an elective surgery in 1 week. The client
speaks English as a second language. What action is the priority?
A Obtain an informed consent form in the client’s spoken language
B Schedule a chest radiograph
C Complete an electrocardiogram
D Have the interpreter ask the client if they have an advance directive

Question Explanation
Correct Answer is A
Rationale: Clients who do not speak English should be presented with a consent document
written in a language understandable to them and have an interpreter to aid in the consent
process.
Concepts tested

Question 530
The nurse is caring for a client who has been diagnosed with an advanced stage of cancer. The
client asks the nurse “Do I have to go through treatment.” Which response by the nurse is
appropriate?
A “You should consider treatment to spend more time with your family.”
B “You have the right to choose how you want to proceed.”
C “I need to fulfill the provider’s orders regardless.”
D “This cancer can cause serious pain.”

Question Explanation
Correct Answer is B
Rationale: Clients have the right to refuse treatments and procedures for any reason; therefore
telling the client that they have choices is an appropriate response. All other responses do not
respect this right. Forcing or coercing the client into a plan of care that they do not agree with is
a legal issue.
Concepts tested

Question 531
A nurse receives a discharge prescription for a client with right hemiplegia. The client tells the
nurse, “I do not want to go home and burden my family.” Which action does the nurse take next?
A Contacts the healthcare provider to cancel the discharge.
B Calls the client’s family to notify them of the client’s statement.
C Obtains a referral for a social work consult.
D Continues to prepare the client’s discharge.

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Question Explanation
Correct Answer is C
Rationale: The nurse’s role as an advocate is to respect the client’s wishes and offer all
alternative treatment options. A social work consult will help assess other discharge options for
the client. Canceling the discharge is not an appropriate intervention if the client is stable.
Disclosing the statement to the family violates the client’s privacy and may cause the nurse to
lose rapport with the client. Continuing to prepare the discharge does not address the client’s
concern.
Concepts tested

Question 532
The nurse is caring for a client who is preparing to have a cholecystectomy and has a history of
type II diabetes. Which action is appropriate to delegate to an unlicensed assistive personnel
(UAP)?
A Perform a fingerstick blood glucose test and report the findings to the registered nurse.
B Discuss the reason for the use of insulin therapy during the immediate postoperative period
with the client.
C Administer the prescribed lispro insulin before transporting the client to surgery.
D Plan strategies to minimize the risk for abnormal blood sugar results during the postoperative
period.

Question Explanation
Correct Answer is A
Rationale: The Five Rights of Delegation are right task, right circumstance, right person, right
directions and communication, and right supervision and evaluation. UAPs are not licensed;
therefore, they cannot engage in the nursing process nor practice inside the nursing scope of
practice. Therefore, any assessment, planning, instruction, or medication administration must be
done by the registered nurse. UAPs can collect data but only the nurse can interpret this data.
Concepts tested

Question 533
The nurse is caring for a client who is 28 hours post-operative following a total knee
replacement. Which of the following assessment findings should the nurse report to the client
immediately?
A The client has unilateral calf redness.
B The client reports increased knee pain with activity.
C The client has anorexia.
D The client’s IV was pulled out during ambulation.

Question Explanation
Correct Answer is A
Rationale: Unilateral calf pain, redness, and swelling indicate a possible venous
thromboembolism and should be reported to the provider immediately. Knee pain post knee
replacement is a normal finding and should be managed with prescribed analgesics. While
anorexia and accidental IV discontinuation are abnormal findings, they are not cause of
significant concern.
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Concepts tested

Question 534
The nurse is preparing to assign tasks to various staff members. Which task would be appropriate
to delegate to an experienced unlicensed assistive personnel (UAP)?
A Assisting a client with ambulation
B Inserting a straight urinary catheter
C Assessing a client’s oxygenation status
D Documenting an admission assessment

Question Explanation
Correct Answer is A
Rationale: The UAP can assist a client with ambulation regardless of their level of experience.
UAPs cannot perform or document assessments and they cannot complete invasive procedures,
such as catheter insertions.
Concepts tested

Question 535
The case management nurse is reviewing the medical record for an older adult client who was
admitted with dehydration. The nurse notes the client has had several admissions over the past
months for the same diagnosis. Which action should the case management nurse take to advocate
cost effective care for this client?
A Suggest the client contact a family member to verify need for future admissions.
B Emphasize the importance of case management to coordinate outpatient follow-up care.
C Request that the health care provider discuss nursing home placement with the client.
D Listen compassionately to the client's concerns about recent hospitalizations.

Question Explanation
Correct Answer is B
Rationale: The nurse should ensure case management is actively involved in the client's care.
Case management is essential to coordinating care for clients with chronic conditions such as
social work, physical therapy, home health care, and other needs that may prevent further
hospitalizations that can incur costs. The client’s family member is not responsible to verify a
need for future admission. This intervention would neither advocate for the client or be cost-
effective. This client may be able to return to previous living arrangements with appropriate
support, so a nursing home placement is inappropriate for this client. The nurse should always
listen to a client's concerns with compassion, but this does not address cost-effective measures.
Concepts tested

Question 536
The home health nurse is conducting a home visit with a client who has terminal heart failure
and their partner who is the primary caregiver. Which statement by the partner would require the
nurse to evaluate the plan of care?
A “I take a walk around the block twice a day.”
B “I forgot when the last time I visited with friends.”

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C “I often order dinner to be delivered.”
D “I find time to take a shower in the evenings.”

Question Explanation
Correct Answer is B
Rationale: Clients who have chronic or terminal conditions often require family to become
caregivers. When conducting a home visit, the nurse should also assess the coping skills of the
client’s primary caregiver to evaluate for caregiver burnout. A caregiver who has limited contact
with people outside the house, does not take time to maintain their personal hygiene, does not
take breaks from chores or find time to engage in activities are at risk for burnout.
Concepts tested

Question 537
A nurse is precepting a graduate nurse who is providing care to a client with a language barrier.
The healthcare provider prepares to discuss the plan of care with the client. Which action by the
graduate nurse indicates an understanding of the client’s rights?
A Ensures the client’s family is available to translate
B Requests a medical interpreter for the client
C Instructs the client to ask questions if clarification is needed
D Provides a written summary of the plan of care in the client’s language

Question Explanation
Correct Answer is B
Rationale: Clients have the right to understand all aspects of their medical care. A client with a
language barrier requires an interpreter to assist with translating information being delivered by
the healthcare team. A family member should not be used to translate medical information. The
client requires an interpreter with knowledge of medical terminology. All clients have the right
to ask clarifying questions. However, this does not address the language barrier. Providing a
written summary does not allow the client to be actively engaged in a conversation with the
healthcare provider about their plan of care.
Concepts tested

Question 538
The charge nurse is planning to make the staffing assignments for the next shift. Which action by
the charge nurse will ensure continuity of care for a client with complex needs?
A Choose the nurse with the most experience to this client.
B Reassign the nurse that cared for the client yesterday.
C Assign the nurse who has been off for several days.
D Collaborate with the staff to determine who would like to care for the client.

Question Explanation
Correct Answer is B
Rationale: Continuity of care is a process by which healthcare providers give appropriate,
uninterrupted care. Continuity depends on excellent communication as clients move from one
caregiver or health care site to another. Have consistent nursing care by the same individuals

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promotes continuity. Choosing the nurse with the most experience may ensure things are done
correctly but does not promote continuity.
Concepts tested

Question 539
The nurse is caring for a client who has a surgical wound infection. Which of the following
strategies should be included in the client’s plan of care?
A Utilize alcohol-based hand rubs before interacting with client.
B Restrict visitors to the client.
C Monitor the client for signs of sepsis.
D Place the client on airborne transmission precautions.

Question Explanation
Correct Answer is C
Rationale: The nurse should plan to monitor the client for signs of improvement or deterioration
related to the infection. Early identification of sepsis improves client outcomes. Handwashing
with soap and water is recommended for this client. The client may have visitors, but those
visitors should be educated on infection control practices. There is no indication for airborne
transmission precautions for this client.
Concepts tested

Question 540
The nurse receives a telephone call in an assisted living facility from a caller asking if a client
was admitted to the facility. The caller identifies himself as a friend. Which nursing response is
appropriate?
A “There is no one here by that name.”
B “I will transfer your call to the client’s room.”
C “The client is being transferred here from another facility.”
D “We do not provide that information without permission from the family.”

Question Explanation
Correct Answer is D
Rationale: The nurse needs to tell the caller that it is not proper to identify the client's location
for confidentiality and privacy. The nurse should not transfer the telephone call, which would
confirm the client's location, and the nurse should not identify if the client is not at the skilled
nursing home so that confidentiality and privacy are maintained.
Concepts tested

Question 541
The nurse is performing a vision screening on a client using the Snellen chart. Which is the
correct way to document the findings?
A OD and OS
B OR and OL
C AS and AU
D ON and OT

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Question Explanation
Correct Answer is A
Rationale: Common abbreviations related to eye health include OD oculus dexter, right eye and
OS oculus sinister left eye. To document both eyes, the abbreviation OU is used.
Concepts tested

Question 542
The nurse is developing the plan of care for a group of assigned clients. Which client should the
nurse identify as having the highest risk of developing aspiration pneumonia?
A The client who is a resident of a long-term care facility
B The client who is prescribed immunosuppressive therapy
C The client who has a history of smoking cigarettes
D The client who has a head injury

Question Explanation
Correct Answer is D
Rationale: Aspiration pneumonia occurs when abnormal material, such as food, liquid, or
bacteria, from the mouth or stomach enter the trachea and lungs. Clients who are at risk for
aspiration pneumonia have a decreased level of consciousness, difficulty with swallowing, or
have a nasogastric tube placed. A client with a decrease in level of consciousness, from a head
injury, seizures, or anesthesia, can cause a depression of the client’s cough and gag and reflex.
Clients who are prescribed immunosuppressive therapy, smoke cigarettes, or are residents in
long-term care facility are at risk for community-acquired pneumonia.
Concepts tested

Question 543
A nurse is providing care to a client who has a pending discharge prescription from the previous
day. The client is uninsured and requires total care. The client’s family has refused to learn care
and tells the nurse the hospital is responsible for the client’s treatment. Which action does the
nurse take?
A Provide the discharge instructions to the client’s family.
B Request the discharge prescription be discontinued by the healthcare provider.
C Arrange home transportation for the client upon discharge.
D Report the situation to the interdisciplinary team.

Question Explanation
Correct Answer is D
Rationale: The nurse should report the situation to the interdisciplinary team. The family’s
refusal to learn care can impact the client’s safety post-discharge. The nurse has a duty to explore
all resources available to the client and the family. Providing discharge instructions to the
client’s family disregards the refusal to learn total care. Requesting the discharge prescription be
cancelled is not cost-effective nursing care if the client is medically stable. Arranging home
transportation for the client does not address the family’s refusal to learn client care.
Concepts tested

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Question 544
The client arrives to the unit in active labor and is accompanied by a minor child. The client does
not speak English, but the child does. Another nurse can understand and speak the client’s
dominant language and is willing to serve as an interpreter. Which action will the nurse
perform first?
A Call the other nurse to serve as an interpreter.
B Ask the client’s child to translate until the interpreter arrives.
C Review facility policy on use of staff as interpreters.
D Use hand gestures to communicate until the interpreter arrives.

Question Explanation
Correct Answer is C
Rationale: The nurse’s first action would be to review facility policy on use of staff as
interpreters. Providing culturally competent care is important and includes attempting to
overcome language barriers; however, facility policy and legal considerations should be made
first. It is not acceptable to have a child be responsible for translating pertinent medical
information. Based on facility protocol, another nurse may be called to serve and assist as an
interpreter. Using hand gestures to communicate may be an effective intervention, but not the
first action the nurse should perform.
Concepts tested

Question 545
A nurse is working with an unlicensed assistive personal (UAP) to care for a client who is three
days postoperative an abdominal hysterectomy. The UAP reports to the nurse the client’s
dressing is saturated with sanguineous drainage. Which task should the nurse delegate to the
UAP?
A Reinforce the dressing.
B Check to see if the client needs to void.
C Verify that the incision is intact.
D Obtain vital signs.

Question Explanation
Correct Answer is D
Rationale: When caring for a client who is postoperative abdominal hysterectomy and is
exhibiting signs of bleeding, the nurse should delegate the UAP the task of obtaining vital signs.
Checking to see if the client has to void, which bladder distention can increase pressure on the
surgical incision, should be done by the nurse. Assessing the incision and reinforcing the
dressing should be done by the nurse.
Concepts tested

Question 546
The nurse is ambulating the client down the hall and notices the client with an unsteady gait
when ambulating and needed a hand to hold so as not to fall. Which clinical documentation
would be appropriate for the nurse to make?

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A Immediately after getting the client safely back to bed, enters in the computer, “Client had
unsteady gait when ambulating requiring 1 person assist to avoid falling.”
B After ambulating the client, enters in the computer, “Client ambulated daily down the hall
safely with 1-person assist.”
C At the end of the shift the nurse enters into the computer, “Client ambulated down the hall
requiring 1-person assist.”
D Immediately after ambulating the client, enters in the computer, “Client reports feeling
unsteady when ambulating with 1 person assist.”

Question Explanation
Correct Answer is A
Rationale: When documenting care, the nurse should document at the time of care delivered,
what was observed, the outcome, and evaluation. Documentation should occur immediately after
care, including what the nurse assessed and which intervention was implemented. The
documentation should be complete and not include assumptions.
Concepts tested

Question 547
The nurse is interested in improving falls on the orthopedic unit. The nurse understands that
which action needs to be taken first?
A Put together a team.
B Gather data on falls.
C Research evidence-based practice.
D Create a questionnaire.

Question Explanation
Correct Answer is A
Rationale: The model for improvement known as rapid cycle testing can be used to implement
processes improvement. According to this model, the formation of the team should be the first
step in implementing change using this method. The research on best practices for preventing
falls and the data for falls specific to the unit are all responsibilities that can be assigned once the
team is built. Creating a questionnaire is actually not recommended in the process unless it can
be evaluated for reliability and validity.
Concepts tested

Question 548
A healthcare provider requests home care services for a client who needs assistance with
activities of daily living. How will the nurse initiate the request?
A Print out the latest laboratory report.
B Fill out a referral form.
C Scan the medical record.
D Complete a medication reconciliation.

Question Explanation
Correct Answer is B

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Rationale: A referral form provides the home care service with the necessary information to
evaluate the client’s needs. The nurse should follow the referral process according to facility
policy. A laboratory report is not relevant to the client’s need for home care services. Scanning
the medical record is not indicated at this time. The first step in a referral process is to fill out a
facility referral form for evaluation of the client’s needs. A medication reconciliation is a
standard process upon admission and at discharge; however, this step is not indicated for the
provider’s home care request.
Concepts tested

Question 549
The nurse is present when the healthcare provider obtains consent for a surgical procedure. What
information does the nurse anticipate will be provided to the client?
A Risks, benefits, and alternatives of the intervention
B Names of the healthcare providers who will be present for the procedure
C Types of medications administered during the procedure
D Number of people who undergo the procedure each year

Question Explanation
Correct Answer is A
Rationale: Informed consent is the process in which a health care provider educates a patient
about the risks, benefits, and alternatives of a given procedure or intervention. The Joint
Commission requires documentation of all the elements of informed consent "in a form, progress
notes or elsewhere in the record." The following are the required elements for documentation of
the informed consent discussion: (1) the nature of the procedure, (2) the risks and benefits and
the procedure, (3) reasonable alternatives, (4) risks and benefits of alternatives, and (5)
assessment of the patient's understanding of elements 1 through 4. The other options are not
components of informed consent although this information may be discussed.
Concepts tested

Question 550
The nurse is caring for a client who is being discharged home and the client’s sister asks if she
can have a copy of the client’s chart. Which statement by the nurse is appropriate?
A “I will print out the full electronic medical record for you before discharge.”
B “Documentation can be provided by the medical records department if the client requests.”
C “Medical records cannot be accessed by anyone other than healthcare providers.”
D “I can tell you anything that you would like to know, but I cannot give you the record.”

Question Explanation
Correct Answer is B
Rationale: The health insurance portability and accountability act (HIPAA) requires that clients’
medical information remains confidential. The client is the only person that can request a copy of
their medical information. Verbal sharing of private medical information also violates HIPAA if
the client does not consent.
Concepts tested

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Question 551
A nurse manager conducts a staff meeting on client self-determination. Which statement made
by a staff member indicates further teaching on advocacy is required?
A “It is important to make ethical decisions for our clients.”
B “A nurse can be involved in the client’s decision making.”
C “Clients should be presented with all possible treatment options.”
D “A client can choose to delegate decisions about their medical care.”

Question Explanation
Correct Answer is A
Rationale: Client self-determination is the ability of the client to make their own decisions
regarding their medical care. The nurse’s role is to facilitate challenging decisions for the client,
not make the decision for them. A nurse is involved in the client’s decision making by providing
and clarifying medical information and listening to the client’s concerns. All treatment options
should be presented to the client to allow them to make an informed decision about their medical
care. The client has the right to delegate medical decisions to a person they trust.
Concepts tested

Question 552
The registered nurse is caring for a client who is diagnosed with type II diabetes and has
impaired mobility. Which of the following actions can be delegated to the licensed
practical/vocational nurse?
A Develop the plan of care.
B Teach the client about symptoms of hypoglycemia.
C Complete a comprehensive head to toe assessment.
D Administer the prescribed pramlintide subcutaneously.

Question Explanation
Correct Answer is D
Rationale: The Five Rights of Delegation are right task, right circumstance, right person, right
directions and communication, and right supervision and evaluation. Professional nurses are
responsible for delegating nursing activities, but although RNs may delegate elements of care,
they do not delegate the nursing process itself. Nursing care or tasks that should never be
delegated, except to another RN, include initial and ongoing nursing assessment, determination
of the diagnosis and plan of care, evaluation, and client education. LPNs/LVNs can administer
subcutaneous medications.
Concepts tested

Question 553
The nurse is caring for a client who has diabetes mellitus. Which of the following findings
should be reported to the provider immediately?
A Low carbohydrate intake
B Nocturia
C Ambulation refusal by the client
D Confusion

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Question Explanation
Correct Answer is D
Rationale: Any signs of hypoglycemia, such as new onset confusion, diaphoresis, dizziness, or
low capillary glucose levels, should be reported to the provider. The client’s intake and activity
level is important but does not need to be reported to the provider. Nocturia is an abnormal
finding but is not a cause for concern.
Concepts tested

Question 554
The nurse is evaluating a licensed practical nurse’s (LPN) ability to make appropriate decisions
while performing assigned tasks. Which statement by the LPN indicates sound judgement?
Question 4 Answer Choices
A “I was planning to report the abnormal findings after I finish my other tasks.”
B “I wanted to let you know that the client’s heart rate is high.”
C “I assumed you were taking vitals since I couldn’t find the blood pressure cuff.”
D “I will administer all of the client’s oral medications later today.”

Question Explanation
Correct Answer is B
Rationale: The LPN should report collected data to the registered nurse in a timely fashion,
especially if there are abnormal findings. Delaying tasks until later in the day and stating that
they did not complete a task because of an assumption shows poor judgement.
Concepts tested

Question 555
The nurse is developing discharge plans for a client who had a total knee arthroplasty and
requires crutches for ambulation. Which statement by the client would indicate to the nurse the
need for home health assistance?
A “My family will rotate driving me to appointments.”
B “I have a chair in a walk-in shower.”
C “I live in a two-story home.”
D “My family will be gone during the day.

Question Explanation
Correct Answer is C
Rationale: It is recommended that the client premedicates prior to activities of daily living (ADL)
to ease the pain that may be associated after a total knee arthroplasty (TKA). Post-medication
treatment will not help the client endure the pain that may be associated with the ADL. This
statement would require further review with the nurse. It is recommended that the client initially
ask for assistance/support when bathing and use a shower chair. In addition, the client should
perform hygiene in the morning instead of the evening when they have more energy.
Concepts tested

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Question 556
The preoperative nurse is witnessing a client sign consents for surgery. The client states, “I am
not sure if I should have the surgery.” Which statement would be appropriate for the nurse to
make?
A “You should talk to your family about your concerns.”
B “I will let your healthcare provider know your feelings.”
C “This is a hard decision for you to make.”
D “Tell me more about what makes you think you do not want the surgery.”

Question Explanation
Correct Answer is D
Rationale: The nurse’s role with informed consent is to the witness the client’s signature of the
consent. If the client expresses concerns, the nurse should gather more information about the
client’s feelings. The nurse should alleviate the client’s anxiety by allowing the client to discuss
their feelings and concerns. The nurse should notify the healthcare provider if the client refuses
the surgery or has specific questions about the surgery.
Concepts tested

Question 557
A precepting nurse tells a graduate nurse, “A client may ask you how many years of experience
you have.” Which response by the graduate nurse indicates an understanding of client rights?
Question 7 Answer Choices
A “Clients do not need to know how much experience we have.”
B “Clients should be redirected to focus on their treatment plan.”
C “Clients have a right to know when a nurse is in training.”
D “Clients can request a different provider at any time.”

Question Explanation
Correct Answer is C
Rationale: A client has a right to know the identity and title of their healthcare providers. A
graduate nurse has the knowledge competency that can be shared with the client. A client can
request to know the experience of their healthcare providers. Ignoring a client’s question does
not build rapport. Clients have a right to express their concerns. However, requesting a new
provider does not address the scenario.
Concepts tested

Question 558
The nurse is assisting a client who is on strict bedrest off a bedpan. The nurse notes the client’s
skin on the coccyx is reddened and non-blanchable. The nurse should collaborate with which
member of the healthcare team for this client?
A Wound care nurse
B Registered dietician
C Physical therapist
D Charge nurse

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Question Explanation
Correct Answer is A
Rationale: A certified wound care nurse is a nurse that has become certified in treating wounds
(CWCN), continence care (CCCN), ostomies (COCN), or all three, making them a fully certified
wound ostomy and continence nurse (CWOCN). They receive consultations for treatment and
monitoring of wounds/ostomies, provide direct care, educate patients, families, and nurses, and
manage wound care programs. The primary nurse should collaborate with the wound care nurse
to develop a plan of care that is evidence-based and in accordance with facility protocol.
Concepts tested

Question 559
The nurse is caring for a client who is scheduled to have a surgical procedure. The client states
that they don’t know if they want to have the surgery. Which action by the nurse is appropriate at
this time?
A Notify the surgeon of the client’s concerns.
B Reassure the client that they need the procedure.
C Ask the client to sign an informed consent.
D Tell the client that the OR nurse will discuss their concerns.

Question Explanation
Correct Answer is A
Rationale: If a client states that they are unsure if they want to go through with a surgical
procedure, the nurse should notify the provider of the client’s wishes. The surgeon is responsible
for discussing treatment options, risks, and benefits with the client. The nurse can educate the
client, but should not push a client to have a procedure that they do not want to have. Putting off
the client’s concerns and stating that someone else will address them is not appropriate.
Concepts tested

Question 560
The nurse is conducting a telehealth visit for a client in their home. During the assessment, the
client’s neighbor joins the conversation and asks, “What’s wrong with my friend? Should I take
her to the hospital now?” What is the most appropriate response by the nurse?
A “Your neighbor is fine, don’t worry.”
B “I cannot tell you about their condition.”
C “You should ask their spouse about their condition.”
D “Here is my contact information for any questions you may have.”

Question Explanation
Correct Answer is B
Rationale: The nurse must remember that the client has a right to confidentiality, and information
should only be shared with the client’s consent. The nurse should tell the neighbor that the nurse
cannot say anything about the client’s condition. Asking the neighbor to call the nurse for
information or to ask the client’s spouse are not the correct responses as they do not maintain
HIPAA protocol or the client’s right to confidentiality and privacy.
Concepts tested

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Question 561
The nurse is caring for client in acute respiratory distress who had an atrial blood gas level
collected. . When reviewing the results, the nurse should understand that PAO2 indicates which
finding?
A Partial pressure of alveolar oxygen
B Partial pressure of arterial oxygen
C Partial pressure of carbon dioxide
D Partial pressure of arterial carbon dioxide

Question Explanation
Correct Answer is B
Rationale: Arterial blood gas is a common diagnostic modality ordered for clients in respiratory
distress. The abbreviation of PO2 refers to partial alveolar oxygen pressure.
Concepts tested

Question 562
The nurse is reviewing the plan of care for assigned clients. Which client should the nurse
identify as having the highest risk for endocarditis?
A The client with uncontrolled hypertension who has a peripheral IV
B The client with atherosclerosis who has a positive stress test
C The client with renal failure who has a non-tunneled dialysis catheter
D The client with lung cancer who has a prescription for oral opioid

Question Explanation
Correct Answer is C
Rationale: Endocarditis is an infection of the endocardium layer of the heart and heart valves.
The infectious organism enters the bloodstream which flows through the heart, infecting the
valves or endothelial tissue. A client with invasive devices, such as a non-tunneled dialysis
catheter that is placed in the subclavian, have a high risk for developing endocarditis. Other risk
factors include clients with congenital heart defects, cardiomyopathy, prior valve disease, or IV
drug use.
Concepts tested

Question 563
A nurse is assisting a charge nurse who has attempted to start an IV multiple times on a client
unsuccessfully. The client states, “My arm is in a lot of pain. Please stop.” The charge nurse
disregards the client’s statement and continues to attempt IV access. Which action does the nurse
take?
A Tells the client, “This is necessary for your medical treatment.”
B Tells the charge nurse, “Let’s give the client a break.”
C Leaves the room and informs the nurse manager.
D Comforts the client and continues to assist the charge nurse.

Question Explanation
Correct Answer is B

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Rationale: The nurse should suggest to the charge nurse to stop the IV attempts. The nurse must
advocate for the client and respect their request to stop the procedure. Telling the client that the
procedure is necessary for medical treatment disregards the client’s pain and refusal to continue
providing consent. Leaving the room to inform the nurse manager leaves the client unattended
and allows the charge nurse to continue the IV attempts against the client’s wishes. Comforting
the client and continuing to assist the charge nurse disregards the client’s concerns and refusal of
treatment.
Concepts tested

Question 564
The nurse provides a brochure with discharge instructions for a client with a limited
understanding of English. When asked if the client has any questions, the client responds in a
different language. How does the nurse respond?
A “Would you like me to review the brochure with you again?”
B “An interpreter is available to assist you.”
C “Please sign the education form to confirm your understanding.”
D “Do you have a family member that can translate for you?”

Question Explanation
Correct Answer is B
Rationale: The nurse recognizes that the client may or may not understand the teaching due to
the response in a different language. The best response by the nurse would be to reach out for
assistance after review of facility protocol with aid of an interpreter. Due to the language barrier,
reviewing the brochure with the client may not be effective and not the best response. Having the
client sign the patient education document to confirm understanding would not confirm client
understanding. It is not acceptable to have another family member to be responsible for
translating pertinent medical information.
Concepts tested

Question 565
The nurse working with an unlicensed personal assistant (UAP) to care for a client who has soft,
bilateral wrist restraints placed. Which task should the nurse the perform?
A Observe the client’s capillary refill.
B Assist the client in the bathroom every hour.
C Assess the client’s skin underneath the restraints.
D Set up the client’s meal trays and provide help with eating.

Question Explanation
Correct Answer is C
Rationale: A client who is in soft wrist restraints will require an assessment of skin and
circulation, which is the responsibility of the nurse. The nurse can delegate to the UAP assisting
the client to the bathroom and with eating and drinking.
Concepts tested

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Question 566
The nurse is providing an SBAR shift report on a client who is postoperative right knee
replacement. Which of the following information should the nurse include in the assessment
section of the report?
A The client has a prescription for ambulation.
B The client has a history of hypertension.
C The client will need a referral for home health care.
D The client has a dressing that is dry and intact.

Question Explanation
Correct Answer is D
Rationale: SBAR is the standard format for providing and receiving a report on client care,
which organizes client care into sections: situation, background, assessment, and
recommendation. The situation section focuses on what is occurring with the client, such as
prescriptions or interventions that need to be implemented. The background provides information
on what caused the current situation and includes the client’s past history. Assessment includes
information about the nurse’s impression of the problem, such as findings observed or measured
by the nurse. Recommendation explains what would need to be done for the client, such as
further referrals or follow-up care.
Concepts tested

Question 567
The nurse is currently evaluating COPD readmission rates in the Emergency Department. After
identifying that most of the clients do not read discharge instructions, the nurse suggests which
next step?
A Collaborating with the pharmacy for discharge medication
B Making follow up appointments for clients prior to discharge
C Educating the staff on the importance of updating language preferences
D Translating discharge instructions into multiple languages

Question Explanation
Correct Answer is C
Rationale: Proper discharge planning should begin on admission. Avoiding reactionary discharge
planning is one way to improve the effectiveness of discharge planning. Educating the staff to
update language preferences on admission would identify any language barriers. Educating the
client in the native language helps to decrease miscommunication. The discharge instructions
should be given in the client’s preferred language as well as medication labels from the
pharmacy, if possible. Making follow up appointments for clients may prove to be difficult due
to social issues, such as transportation.
Concepts tested

Question 568
A client has been referred to a skilled nursing facility for long-term medical care. The facility is
requesting information on the client’s pharmacological history and current treatment. Which will
the nurse provide?

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A The medication administration record
B The client’s medical record
C A list of the client’s home medications
D A medication reconciliation form

Question Explanation
Correct Answer is D
Rationale: A medication reconciliation form provides information on the client’s history of
medications and current prescriptions. A medication reconciliation form should be provided with
every referral or transfer to another facility or unit. The medication administration record only
provides documentation of the current medications. The medical record provides information on
the client’s entire treatment. The facility is only requesting information on pharmacological
treatment. A list of the client’s home medications only provides pharmacological history, not
current treatment.
Concepts tested

Question 569
The healthcare provider has identified the need for an infusion of packed red blood cells. When
obtaining informed consent, what information should be included?
A Risks of transfusion related adverse effects
B Identity of the blood donor
C Information about the components of blood
D The process for crossmatching blood products

Question Explanation
Correct Answer is A
Rationale: In all health care facilities, informed and voluntary consent is needed for admission,
for each specialized diagnostic or treatment procedures, and for any experimental treatments or
procedures. The following are the required elements for documentation of the informed consent
discussion: (1) the nature of the procedure, (2) the risks and benefits and the procedure, (3)
reasonable alternatives, (4) risks and benefits of alternatives, and (5) assessment of the patient's
understanding of elements 1 through 4. The identity of the donor is not available and is not
shared. The client does not require a lesson on the components of blood during the informed
consent process nor how blood is crossmatched.
Concepts tested

Question 570
The nurse is admitting a new client to the emergency room who states that they have a large
amount of cash in their wallet and valuable jewelry on them. Which action by the nurse is
appropriate?
A Asking the client the total value of the items
B Telling the client that they need to keep all items in their pockets
C Placing the items in a belonging bag out of the client’s view
D Documenting each of the client’s items on a valuables inventory

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Question Explanation
Correct Answer is D
Rationale: When a client has personal items, it is important to document what items they have
with them and store them appropriately. In the event that a client states that they are missing an
item, the nurse can look back on the valuables inventory to determine what items the client had
upon admission. Items should either be in the client’s view or safely stored after inventory.
Asking the total value of the items is not appropriate.
Concepts tested

Question 571
After a stressful shift at the hospital, the nurse writes the following post on their personal social
media account: "Today was a rough day. One of my clients was in a terrible car crash and
hemorrhaged. I felt so bad for the family." Which consequence could result from the nurse
posting this information online?
A The nurse could be terminated from employment at the hospital for breach of client
confidentiality.
B The information was posted without mention of personal identifiers, so legally no
consequences can follow.
C The nurse could be reprimanded for not first clearing the post with the hospital’s
administration team.
D The nurse could be asked to post a disclaimer that they do not represent the hospital on this
social media account.

Question Explanation
Correct Answer is A
Rationale: Many health care facilities have adopted a social media policy. It is important to
understand that nurses can be terminated (i.e., fired) for posting personal information about
clients online, because this is an invasion of privacy. In addition to being a Health Insurance
Portability and Accountability Act (HIPAA) violation, the Health Information Technology for
Economic and Clinical Health Act (HITECH Act) gives state’s attorneys the right to pursue
violations of client privacy. Maintaining confidentiality is an important aspect of professional
behavior. Sharing personal information or gossiping about others violates nursing ethical codes
and practice standards.
Concepts tested

Question 572
The nurse is assigned to care for four clients in the emergency department. Which client should
the nurse see first?
A A 22-year-old with acute asthma with episodes of bronchospasms
B A 34-year-old with a tension pneumothorax and tracheal deviation
C A 59-year-old with suspected viral pneumonia and atelectasis
D A 45-year-old with spontaneous pneumothorax and a respiratory rate of 28

Question Explanation
Correct Answer is B

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Rationale: Tension pneumothorax occurs when there is an accumulation of air under pressure in
the pleural space. This causes compression of the lungs and decreases venous return to the heart.
Tracheal deviation indicates a significant volume of air is trapped in the chest cavity, causing a
mediastinal shift. This is a medical emergency. In tension pneumothorax, the tracheal deviation
is away from the affected side. This situation also results in sudden air hunger, agitation,
hypotension, pain in the affected side and cyanosis with a high risk of cardiac tamponade and
cardiac arrest. This patient is the most critical and should be seen first.
Concepts tested

Question 573
The nurse in a family practice office is teaching a client about establishing advance directives for
health care. Which statement by the client indicates that further teaching is needed?
A "It is a legal document that becomes a part of my health care record."
B "My wishes for end-of-life treatment are stated in writing."
C "I will need to identify someone to be my health care proxy."
D "It will describe how my things should be divided between my family members."

Question Explanation
Correct Answer is D
Rationale: An advance health care directive is also known as a living will. It is a legal document
in which a person specifies their wishes concerning medical treatments at the end-of-life, when
they are unable to make those decisions. Advance care planning involves sharing personal values
and wishes with loved ones and selecting someone (called a medical power of attorney or health
care proxy) who will eventually make medical decisions on the client's behalf. A living will does
not expire; it remains in effect unless it is changed. A living will does not include information
regarding assets or a person's estate.
Concepts tested

Question 574
An 85-year-old client is admitted to a home health care agency following a hospitalization. The
client needs assistance with activities of daily living (ADLs). During the admission process, the
nurse develops a plan of care for this client. Place the following steps in the case management
process in the correct order:
1. Identification of nursing problem
2. Complete referrals for assistance with ADLs
3. Reassessment of health status and ADL ability.
4. Evaluation of progress towards the client’s home care goals.
5. Assessment of biophysical and sociocultural considerations.
A 1,5,2,4,3
B 5,1,2,3,4
C 2,1,5,3,4
D 2,5,1,4,3

Question Explanation
Correct Answer is B

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Rationale: Case management is a collaborative process that follows the nursing process and
assesses, plans, implements, coordinates, monitors and evaluates options and services to meet an
individual's health needs. When a client is admitted to a home health care agency, an assessment
is conducted to ensure continuity of care between the hospital and the home health agency. The
nurse should follow the nursing process and first assess the biophysical (i.e., physiologic) and
sociocultural (i.e., interpersonal) considerations. Then the nurse can use this information to
identify nursing problems. Once the problems are identified the nurse can make referrals as
appropriate. After these referrals have been implemented, the nurse should reassess the client’s
health status and ADL abilities. Finally, the nurse should evaluate the client’s progress toward
their home care goals.
Concepts tested

Question 575
The nurse manager suspects a staff nurse may be suffering from substance use disorder (SUD).
Which initial action by the nurse manager would be best?
A Meet with the nurse about the suspicions in a private meeting.
B Consult with human resources staff and follow their recommendations.
C Schedule a meeting with other staff members to collect information.
D Counsel the nurse about substance abuse and suggest treatment options.

Question Explanation
Correct Answer is B
Rationale: The best initial action is to consult with the human resources department to determine
a plan of action regarding this situation. The nurse manager should follow the proper procedures
for objectively documenting and reporting the nurse's behavior. The nurse manager could also
consult the Employee Assistance Program (EAP) if one is available. Attempts should be made to
help the nurse with SUD by providing resources for counseling and treatment for this disease,
but those interventions would come later.
Concepts tested

Question 576
The new graduate nurse interviews for a nursing position on a hospital unit that uses a shared
governance model. Which description best illustrates this concept?
A The hospital’s executive team determines the standards of nursing care.
B The manager of the nursing unit develops and implements changes on the unit.
C Nurses and physicians collaborate to discuss client care standards.
D Nurses work together to implement changes and share responsibility for client outcomes.

Question Explanation
Correct Answer is D
Rationale: Shared governance or self-governance is a method of organizational design. It
promotes the empowerment of nurses and gives them responsibility for client care issues and
outcomes. Chaired by senior clinical nursing staff, these groups are empowered to establish and
maintain standards of nursing care and practice on their unit. The committees review and
establish standards of care, develop policy and procedures, resolve client satisfaction issue,

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and/or develop new documentation tools. It is important to focus on client outcomes to ensure
high-quality care is delivered on the nursing unit.
Concepts tested

Question 577
The nurse on a post-surgical unit observes an unlicensed assistive person (UAP) caring for a
client who had a transurethral resection of the prostate (TURP). Which action by the UAP
requires immediate intervention by the nurse?
A The UAP adjusts the rate of the irrigation bag for the client’s continuous bladder irrigation.
B The UAP applies a moisture barrier cream to the client's excoriated perianal area.
C The UAP assists the client to the bathroom to shave his face with an electric razor.
D The UAP empties the indwelling catheter bag and records the amount of output.

Question Explanation
Correct Answer is A
Rationale: Unlicensed assistive personnel (UAP) can perform a number of delegated nursing
tasks, such as emptying an indwelling urinary catheter bag, applying moisture barrier cream after
peri-care, assisting a client to the bathroom and helping a client shave with an electric razor. The
UAP should not complete tasks that require nursing assessment. Since adjusting the irrigation
rate requires nursing assessment, it should only be done by the nurse.
Concepts tested

Question 578
The nurse in an emergency room is planning care for a client who is unconscious and arrived by
ambulance from a long-term care facility. The paramedics have given the nurse copies of
paperwork from the client’s facility. Which is the best way for the nurse to determine who
should make health care decisions for this client?
A Call the emergency contact person listed in the client’s paperwork.
B Contact the client’s primary care physician by phone.
C Review a notarized original copy of the client’s advance directives.
D Ask the primary health care provider in the emergency room.

Question Explanation
Correct Answer is C
Rationale: The client’s advance directives specify the client's wishes about what actions are to
be taken should the client become unable to make health care decisions. This client is
unconscious, thus unable to make decisions. Typically, clients from long-term care facilities
have advance directives in place, and the facility sends this document with them if they leave the
facility for any reason. The advance directive often includes a living will and the power of
attorney to whom will make the health care decisions for the client. The nurse should seek out
this document when planning care for this client to ensure the client’s wishes are followed.
Concepts tested

Question 579
The nurse is precepting a new nurse employee and explains the standards of nursing
documentation. Which statement by the new nurse employee indicates teaching was effective?
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A "It is best to use general statements such as 'status unchanged' when writing client care
notes."
B "I will summarize client comments in my own words to keep documentation concise."
C "I will leave blank spaces in the written notes section so staff can add notes later if needed."
D "I will document objective assessments and interventions at the time of client care."

Question Explanation
Correct Answer is D
Rationale: The medical record is a legal document. Documentation should include all steps of
the nursing process. It must be complete, accurate, concise and in chronological order. Inaccurate
or incomplete documentation will raise red flags in a court of law and may indicate the nurse
failed to meet the standards of care. The nurse should emphasize complete and accurate
documentation at all times in the medical record.
Nurses should avoid generalized statements. Specific information about the client should be
included, along with complete descriptions of care provided. Nurses should not leave blank
spaces in written notes sections. This leaves a place where someone could add incorrect
information at a later time. Notes should be chronological. Client comments should be quoted,
verbatim and placed in quotation marks when appropriate. Nurses should only enter objective
information and objective descriptions of client behavior.
Concepts tested

Question 580
The triage nurse in an emergency room identifies that a 16-year-old client, who is legally
married, has signed the consent form for medical treatment. Which action should the nurse take?
A Ask the client to wait until a parent or legal guardian can be contacted.
B Accept the consent form and proceed with the triage process.
C Refer the client to a pediatric hospital’s emergency department.
D Obtain consent for treatment over the phone from the client’s spouse.

Question Explanation
Correct Answer is B
Rationale: Under the Statutory Guidelines for Legal Consent for Medical Treatment, a minor
may gain the legal status of an "emancipated minor" through marriage. Therefore, this married
client has the legal capacity of an adult. The triage nurse should allow the client to sign the
consent form for treatment and proceed with the triage process. This client legally can consent to
medical treatment independently, as an emancipated minor.
Concepts tested

Question 581
Which of these activities can the nurse assign to an unlicensed assistive person (UAP)?
A Care for a stable client.
B Reinforce teaching to the client.
C Provide basic care to the client.
D Create a plan of care for the client.

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Question Explanation
Correct Answer is C
Rationale: UAPs' limited scope includes (but may not be limited to) assisting with ADLs such as
bathing, feeding, toileting, obtaining vital signs, input and output (I/O), performing point of care
(POC) tests, such as a blood sugar check or 12-lead electrocardiogram, and recording height and
weight. UAPs cannot reinforce teaching, create a plan of care or assume nursing care for a client
– even if the client is stable.
Concepts tested

Question 582
Where can the nurse find the most reliable guidelines regarding the appropriate delegation of
tasks to unlicensed assistive personnel (UAP)?
A The American Nurses Credentialing Center (ANCC)
B That state's nurse practice act (NPA)
C The National Council of State Boards of Nursing (NCSBN)
D The American Nurses Association (ANA)

Question Explanation
Correct Answer is B
Rationale: When questions arise regarding who can delegate what activities to which unlicensed
provider groups, it is the nurse practice acts (NPAs) of individual states that establish the legal
definitions of appropriate delegation practices. Because regulations differ among states, each
nurse must identify and understand the regulations for the state in which they practice.
Concepts tested

Question 583
The nurse observes another nurse walking away from their computer with a client's electronic
medical record (EMR) still visible on the screen. What should the nurse do first?
A Complete an incident report about the potential client privacy violation.
B Notify the nurse manager of the incident.
C Speak with the nurse about always closing the EMR.
D Walk over to the computer and close the client's medical record.

Question Explanation
Correct Answer is D
Rationale: All of the nurse's actions are appropriate, but in order to prevent unauthorized
personnel from seeing any of the client's protected health information, the nurse
should first close the client's EMR, which is still visible on the screen.
Concepts tested

Question 584
The nurse is handing-off the care of a client admitted with pneumonia to the nurse for the next
shift. Using the S.B.A.R. method, what client information should the nurse include in the hand-
off report,?
A Pain, oxygen requirements, insurance information and vital signs

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B IV access, admitting diagnosis, allergies and antibiotics given
C Admitting diagnosis, vital signs, room number and insurance information
D Marital status, vital signs, religious affiliation and admitting diagnosis

Question Explanation
Correct Answer is B
Rationale: S.B.A.R. stands for situation, background, assessment and recommendation. Situation
in the model refers to the client's main problem. Background refers to the client's basic
information, such as admitting diagnosis, allergies, etc. Assessment refers to objective and
subjective data the nurse collects that helps to define the client's problem. Recommendation is
the nurse's suggested solution(s) to the problem. Insurance information, marital status and
religious affiliation are not shared when using the S.B.A.R. model of communication.
Concepts tested

Question 585
A client is being prepped for a surgical procedure and the nurse is reviewing the consent form
with the client. The client asks, "Is there any other way to take care of this without having
surgery?" What should the nurse do next?
A Tell the client if they don't want the surgery, they don't have to have it.
B Reassure the client that the surgery is the best treatment option.
C Notify the operating room and cancel the surgery.
D Notify the surgeon that the client has additional questions about the surgery.

Question Explanation
Correct Answer is D
Rationale: The client should only sign the consent form after all their questions are answered.
Notify the appropriate health care provider if the client needs additional information about the
surgery. Once the client has all the necessary information, they can then decide not to sign the
informed consent form and the surgery can be cancelled. Offering false reassurance violates the
client's right to autonomy. Cancelling the surgery is premature at this time.
Concepts tested

Question 586
A client's family member calls for an update on the client's condition. What should the nurse
do first before providing information to the caller?
A Check with the client and obtain permission to provide the caller with the requested
information.
B Ask the family member who is currently visiting the client if it is okay to release the
information.
C Call the physician to verify the client's condition before updating the caller.
D Decline the caller's request and notify the nurse supervisor of a potential HIPAA violation.

Question Explanation
Correct Answer is A

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Rationale: The nurse must have permission from the client to release information to the caller. If
the client is unable to give permission and has a power of attorney for health care (POAH), then
information shall only be given to the POAH. Family members can obtain updates from that
person. Remember, it is difficult to know who is calling over the phone. The nurse should also be
familiar with the organization's policy on requests for information over the phone.
Concepts tested

Question 587
The new nurse understands that patient-centered care, according to QSEN, should include which
nursing actions? Select all that apply.
A Adhering to Institutional Review Board (IRB) guidelines.
B Recognizing the boundaries of therapeutic relationships.
C Respecting and encouraging individual expression of client values.
D Communicating what care was provided and is needed at each transition in care.
E Participating in designing systems that support effective teamwork.

Question Explanation
Correct Answer is B, C, D
Rationale: The QSEN project defines the knowledge, skills and attitudes (KSAs) for six key
areas or required competencies for new nurses. KSAs required for patient-centered care include
for the nurse to: Elicit patient values, preferences and expressed needs as part of the clinical
interview, implementation of care plan and evaluation of care; communicate patient values,
preferences and expressed needs to other members of the health care team; and provide patient-
centered care with sensitivity and respect for the diversity of human experience. Designing
systems that support effective teamwork fits under the Teamwork and Collaboration QSEN
category. Adherence to IRB guidelines is found under the Evidence-based Practice (EBP) QSEN
competency.
Concepts tested

Question 588
The nurse on a post-surgical orthopedic unit receives nursing report on a group of adult clients.
Which client should the nurse see first?
A A client who has not had a bowel movement since before surgery.
B A client who has some bloody drainage on the surgical dressing
C A client who has a respiratory rate of 8 breaths/min.
D A client whose reported pain level is 8 out of 10.

Question Explanation
Correct Answer is C
Rationale: Post-surgical clients usually require opioid medications for adequate pain relief.
These clients should be monitored for CNS and respiratory depression, a common side effect of
this class of drugs. The client with a respiratory rate of 8 breaths per minute is likely
experiencing this complication, therefore the nurse should see this client first. The other clients
may also need to be seen, but their circumstances are expected and non-urgent.
Concepts tested

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Question 589
The charge nurse observes a new nurse inserting an indwelling urinary catheter on a female
client who is experiencing urinary retention. After the nurse inserts the catheter, no urine outflow
appears. Which action should the charge nurse take?
A Remove the catheter and have the nurse get a new catheter and insertion kit.
B Remove and re-lubricate the catheter and assist the nurse with re-insertion.
C Leave the catheter in place and check for urine output in 15 minutes.
D Ask the nurse to withdraw and redirect the catheter anteriorly toward the pubic bone.

Question Explanation
Correct Answer is A
Rationale: If no urine appears after inserting a catheter into a female client, the catheter may be
in the vagina. The nurse should calmly remind the nurse about this circumstance and offer
assistance. This client is experiencing urinary retention, so urine outflow should occur
immediately with catheter insertion. It would not be appropriate to leave the catheter in when
there is no outflow. No outflow suggests the catheter is not in the urethra. The nurse should
remove the catheter and retrieve a new catheter and insertion kit; then the charge nurse should
assist with correct catheter insertion. A catheter that has been inserted into the vagina should not
be redirected into the urethra. This can lead to a urinary tract infection for the patient. A new
catheter should be used with each insertion attempt.
Concepts tested

Question 590
The charge nurse in the emergency department receives a radio call from Emergency Medical
Services (EMS) stating that there has been a large structure fire with multiple victims. Which
action should the charge nurse take first, before the victims start to arrive?
A Call for a medical evacuation helicopter to be on standby.
B Prepare the trauma room and lay out supplies.
C Activate the disaster plan
D Notify the nursing supervisor and request additional staff.

Question Explanation
Correct Answer is D
Rationale: The ED charge nurse needs to assess, supervise and coordinate staff to maintain full
readiness of the ED. The first priority for the ED charge nurse to notify the nursing supervisor
that additional nursing staff will be needed. Preparing the trauma room will be next. It is
unknown if a medical evacuation helicopter is needed at this point and more data would need to
be collected about the victims to make this determination. A hazardous materials
decontamination plan is used for mass casualty incidents that involve exposure to toxic
chemicals.
Concepts tested

Question 591
The nurse is caring for a client who has bilateral soft wrist restraints in place. Which task can the
nurse delegate to the unlicensed assistive personnel (UAP)?

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A Assist the client with activities of daily living
B Monitor the client’s physical safety
C Document the client's mental status
D Evaluate the need for continued use of restraints

Question Explanation
Correct Answer is A
Rationale: The UAP can only be delegated tasks within their scope of practice, thus they should
be able to assist with activities of daily living (ADLs). The nurse is responsible for documenting
the client’s status every hour, as well as their mental status. The nurse is also responsible for
monitoring the client’s physical safety.
Concepts tested

Question 592
The nurse in a long-term care facility is planning care for a client who has a colostomy in place.
Which task is appropriate to delegate to the unlicensed assistive person (UAP)?
A Teach the client and family about proper colostomy care.
B Empty the colostomy bag contents and report the output amount.
C Measure the size, shape and color of the stoma.
D Change the colostomy wafer and bag apparatus.

Question Explanation
Correct Answer is B
Rationale: Unlicensed assistive personnel or person (UAP) may assist with the care of a client
with a colostomy. The UAP can perform simple tasks within their scope of training. The UAP
can empty a colostomy bag and report the output amount to the nurse. This is a simple task that
does not require assessment, teaching or action outside of their scope of practice (e.g., changing
the colostomy wafer). Measuring the size, shape and color of the stoma is an assessment and
should be done by the nurse. Teaching as well as changing the colostomy wafer and apparatus is
outside the scope of the UAP and must be done by the nurse.
Concepts tested

Question 593
A nurse is assigned to triage clients who are brought to the emergency department after a bus
accident. Which client would be cared for first?
A The 56-year-old with external rotation and shortening of the left lower extremity
B The 35-year-old with an abrasion on the right anterior and lateral side of the chest
C The 9-year-old with dilated pupils and cessation of breathing 10 minutes ago
D The 18-year-old who is diaphoretic and tachycardic and has a board-like abdomen

Question Explanation
Correct Answer is D
Rationale: Triage categories used during a mass casualty incident often use color-coding to
prioritize care. The person in greatest need of immediate care (category - red) is the person with
a board-like abdomen because this would indicate internal bleeding. The next person requiring

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urgent care (category - yellow) would be the individual with the shortened leg that is externally
rotated, indicating a probable broken hip. The person with the chest abrasions is not currently
having any difficulty breathing and can have treatment delayed for hours or even days (category
- green). The individual who stopped breathing 10 minutes ago and whose pupils are fixed and
dilated would not be treated because this person has already died (category - black).
Concepts tested

Question 594
The nurse is caring for a client who requires an orthotic due to a musculoskeletal disorder.
Which of the following tasks can the nurse delegate to an unlicensed assistive person
(UAP)? Select all that apply.
A Help the client with putting on the orthotic.
B Evaluate the client's response to ambulatory activity.
C Report any redness or signs of skin breakdown.
D Assist the client with transferring from the bed to a chair.
E Encourage the client's independence in self-care.

Question Explanation
Correct Answer is A, C, D, E
Rationale: The nurse cannot delegate any part of the nursing process. Monitoring the client's
response to interventions requires evaluation, a task that can only be performed by the nurse. The
other options are typically within the scope of a UAP and can be assigned and performed
independently by the UAP.
Concepts tested

Question 595
The nurse is caring for a postoperative client following an abdominal hernia repair. Which
intervention should the nurse implement to promote peristalsis?
A Administer the prescribed opioid analgesic
B Encourage the client to ambulate.
C Alternate solid with full liquid foods.
D Instruct the client to cough and deep breathe.

Question Explanation
Correct Answer is B
Rationale: Decreased intestinal peristalsis with the possible development of a postoperative ileus
can occur as a result of drug therapy, anesthesia/analgesia, operative manipulation, and increased
sympathetic nervous system excitation from stress after any surgery but is most common after
open abdominal procedures. Nursing intervention to promote peristalsis include monitoring,
ensuring adequate hydration, promotion of mobility/early ambulation, managing pain
with nonopioid interventions, and when appropriate, pharmacologic management.
Concepts tested

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Question 596
During a discussion with the nurse manager, a staff nurse confides that she is attracted to a client
regularly assigned to her. Which of the following actions should be implemented following this
discussion?
A The nurse waits until after discharge to tell the client about her feelings
B The nurse reassigns all personal care of the client to the nursing assistant
C The nurse continues to provide care for the client
D The nurse transfers the care of the client to another nurse

Question Explanation
Correct Answer is D
Rationale: Nurses must practice in a manner consistent with professional standards and be
knowledgeable about professional boundaries. A nurse's challenge is to be aware of feelings and
to always act in the best interest of the client, avoiding inappropriate involvement. In this case,
the nurse did all the right things—aware of her feelings, she consulted with her supervisor and
together they decided it would be best if this client were no longer assigned to this nurse. If the
nurse had acted on her feelings, this would have been a boundary violation and she could have
been subject to board of nursing disciplinary action.
Concepts tested

Question 597
The registered nurse (RN) is making staffing assignments at the start of a new shift. Which of the
following clients is appropriate for the RN to assign to the licensed practical nurse (LPN)?
A An older adult client with a diagnosis of hypertension and self-reported nonadherence to their
medication regimen.
B A preoperative client with a history of asthma awaiting an adrenalectomy.
C A client with a diagnosis of peripheral vascular disease (PVD) with an ulceration of the lower
leg.
D A new admission with a history of diagnosis of transient ischemic attacks and syncope.

Question Explanation
Correct Answer is C
Rationale: The registered nurse is responsible for the management of the patient care. The
licensed practical nurse (LPN) has a scope of practice that limits some of the actions of the LPN.
The client with PVD is stable with a chronic condition and is appropriate to assign to an LPN.
The preoperative client will likely require teaching, which is in the scope of the RN. The client
with TIAs and syncope, as well as the client with hypertension are potentially unstable and
should not be assigned to the LPN.
Concepts tested

Question 598
The nurse is assigned to care for four clients on a medical-surgical floor. After receiving report,
which client should the nurse assess first?
A The client with chronic renal failure who just returned from dialysis.
B The client with asthma who is now ready for discharge.

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C The client with peptic ulcer disease who has been vomiting all day.
D The client with pancreatitis who was admitted yesterday.

Question Explanation
Correct Answer is C
Rationale: A perforated peptic ulcer may result in nausea, vomiting and abdominal distention or
board-like abdomen. This might be a life-threatening situation. The client should be assessed
immediately for initial findings of shock with notification of the health care provider. The other
clients would be considered stable with minimal risk of an emergency.
Concepts tested

Question 599
The charge nurse is making assignments for a registered nurse (RN), a licensed practical nurse
(LPN) and an unlicensed assistive person (UAP). Which assignment would make best use of the
LPN's skills and abilities?
A Irrigate a wound and reapply a dressing.
B Admit a client from the emergency department.
C Assist with ambulating a client for the first time after surgery.
D Test a stool specimen for occult blood.

Question Explanation
Correct Answer is A
Rationale: Although LPNs learn about the nursing process and can assess clients, the role of the
LPN is typically supportive. The RN would be responsible for admitting a client and for
assessing the client's ability to stand and walk after surgery. Both UAPs and LPNs can collect
specimens; however the UAP cannot perform procedures requiring sterile technique. Therefore,
the UAP could test the stool for occult blood and the LPN would perform the dressing change.
Concepts tested

Question 600
The registered nurse (RN) is working on a medical-surgical unit with a licensed practical nurse
(LPN) and an unlicensed assistive person (UAP). Which of these activities is most appropriate
for the RN to delegate to the UAP?
A Provide discharge instructions.
B Measure and record urine output.
C Perform a dressing change.
D Assess a client's orientation.

Question Explanation
Correct Answer is B
Rationale: Basic and routine client care, such as measuring urine output, are activities typically
within the level of training of a UAP and can therefore be delegated to the UAP. Only the RN
can 'assess' and teach or provide discharge instructions.
Concepts tested

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Question 601
An RN who usually works in a spinal rehabilitation unit is reassigned to the emergency
department for a shift. Which of these clients should the charge nurse assign to this reassigned
RN?
A A middle-aged client who says, "I took too many diet pills" and "my heart feels like it is
racing out of my chest."
B A young adult who has been on pain medications for terminal cancer with an initial
assessment finding of pinpoint pupils and a respiratory rate of 10
C An elderly client who reports having taken a "large crack hit" 10 minutes prior to walking into
the emergency room
D A young adult who says, "I hear songs from heaven. I need money for beer. I quit drinking
two days ago for my family. Why are my arms and legs jerking?"

Question Explanation
Correct Answer is B
Rationale: The ED charge nurse should not assign the most critical and acutely ill clients, who
require complex and highly-specialized care, to the nurse from spinal rehab. Instead, the ED
charge nurse should assign clients whose conditions are more stable. The young adult (with a
chronic condition) is exhibiting findings consistent with narcotic use/abuse/overdose. Even
though this is an acute situation, this client's condition is more stable than the others, especially
since the effects of the pain medication can be quickly reversed using naloxone. The other clients
(the older adult who recently used crack cocaine, someone who is tachycardic or someone who
may be experiencing DTs) all have potentially life-threatening conditions.
Concepts tested

Question 602
A client has a nasogastric tube after colon surgery. Which of these tasks is appropriate for the
nurse to assign to an unlicensed assistive person (UAP)?
A Monitor the type and amount of nasogastric tube drainage.
B Perform nostril and mouth care every two hours or as ordered.
C Monitor the client for nausea or other gastric complications.
D Irrigate the nasogastric tube with the ordered solution.

Question Explanation
Correct Answer is B
Rationale: When delegating the nurse needs to consider the scope of practice of the UAP. The
UAP can perform tasks that are routine with expected outcomes, such as personal hygiene. Thus,
performing nostril and mouth care is an appropriate task for the UAP. Irrigating the nasogastric
tube, monitoring the client for complications and monitoring drainage all may have unexpected
outcomes, and are part of the role of the nurse and should not be assigned to the UAP.
Concepts tested

Question 603
The nurse is caring for a client with an intravenous (IV) infusion for pain control. Which of the
following can the nurse delegate to the unlicensed assistive person (UAP)?

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A Check the IV site for drainage and loosen tape when in the room.
B Readjust the rate on the pump by 2 mL/minute.
C Monitor the client for the degree of pain relief.
D Assist the client with ambulation after supervising a gown change.

Question Explanation
Correct Answer is D
Rationale: When giving assignments to a UAP, the nurse should communicate clearly and
specifically what the task is, what should be reported to the nurse and when it should be reported.
Implementation of routine tasks with expected outcomes should be delegated to UAPs. The other
options are actions that PNs or RNs could do.
Concepts tested

Question 604
The nursing team consists of a registered nurse (RN), licensed practical nurse (LPN) and a
certified nursing assistant (CNA). When making assignments, which team member should the
nurse assign to measure and document vital signs for medically-stable clients?
A Unit secretary or clerk
B Licensed practical nurse
C Registered nurse
D Certified nursing assistant

Question Explanation
Correct Answer is D
Rationale: Certified nursing assistants (CNAs) are unlicensed assistive personnel (UAP) who
perform routine tasks that have predictable outcomes, which is why CNAs can be assigned to
measure and document vital signs for medically stable clients. Before making this assignment,
the charge nurse must know that the CNA has received the appropriate training and is competent
to perform the activity. Also, a fully-qualified nurse must be available to provide supervision
during the performance of any assigned task.
Concepts tested

Question 605
A nurse is recalling the steps in the nursing process. During the evaluation phase for a client, the
nurse should focus on which aspect?
A The client's status, progress toward goal achievement and ongoing reevaluation.
B Setting short- and long-term goals to ensure continuity of care from hospital to home.
C Select interventions that are measurable and achievable within selected timeframes.
D Findings of physical and psychosocial stressors of the client and in the family.

Question Explanation
Correct Answer is A
Rationale: The evaluation step of the nursing process focuses on the client's status, progress
toward goal achievement and ongoing reevaluation of the plan of care. The other possible
answers focus on some of the other steps of the nursing process.

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Concepts tested

Question 606
The nurse is planning care for a client admitted with uncontrolled hyperglycemia. Which
activities can the nurse delegate to the unlicensed assistive person (UAP)? Select all that apply.
A Apply moisturizing cream between the client's toes.
B Report any skin lesions or breakdown to the nurse.
C Cut the client's toenails short and trim the corners with cuticle scissors.
D Soak the client's feet in warm water prior to performing nail care.
E After bathing, ensure that the client's skin is completely dry.
F Check the client's blood sugar before meals and at bedtime.
G Administer insulin, but do not aspirate for blood prior to injecting.

Question Explanation
Correct Answer is B, E, F
Rationale: When collaborating with the UAP, it is important to delegate activities that are
appropriate for the UAP to perform and appropriate for the client and their condition. In clients
who suffer from diabetes, blood sugar monitoring, skin care and foot care are essential. The UAP
should check the client's blood sugar before meals and at bedtime. However, the UAP should not
administer insulin. While providing hygiene care, the UAP should dry the skin and apply
moisturizing lotion. However, lotion should not be applied between the toes due to the risk of
macerating injuries. When providing foot care, soaking the feet is contraindicated and nails
should be cut straight across to prevent injury
Concepts tested

Question 607
The nurse is caring for a client who is the mother of a close friend. The friend asks the nurse for
an update about their mother's condition on a social networking website. How should the
nurse best respond?
A Do not disclose any information to the friend on the social networking website.
B Do not disclose any information to the friend on the social networking website.
C Answer the question on the social networking website because only trusted contacts can
access the information.
D Respond on the social networking website, directing the friend to ask the question in person.

Question Explanation
Correct Answer is A
Rationale: A nurse cannot disclose information about a client except to those who are directly
involved in the care of the client. Also, clients must be informed about how their personal health
information will be used and given the opportunity to object to or restrict the use or release of
information. Nurses cannot use social networking websites, like Facebook, to disclose patient
information, even with the use of privacy settings or when no names are used. Each health care
organization has strict policies prohibiting the disclosure of protected health information.
Concepts tested

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Question 608
The hospital is planning to downsize and eliminate a number of staff positions as a cost-saving
initiative. In order to prepare for the "unfreezing" phase of change, which approach would
be best for the nurse manager to take?
A Clarify what the changes mean to the community and the hospital
B Discuss with the staff how to deal with any defensive behavior
C Explain to the unit staff why change is necessary
D Assist the staff for an acceptance of the new changes

Question Explanation
Correct Answer is C
Rationale: The first phase of change, unfreezing, begins with awareness of the need for change.
This can be facilitated by the manager who clearly understands the need and stands behind it and
explains this to the staff. The phase is completed when the staff comprehend the need for change.
Concepts tested

Question 609
The nurse is caring for a client who is two days post-reconstructive nasal surgery. Which task
would be most appropriate to delegate to the unlicensed assistive person (UAP)?
A Observe for restlessness or changes in breathing patterns
B Suggest that the client ask for pain medication every few hours
C Remind the client to report increased pain or changes in comfort
D Ask the client if the medication for pain was effective

Question Explanation
Correct Answer is C
Rationale: Any activity that requires independent, specialized nursing knowledge, skill or
judgement cannot be assigned to the UAP. Only the RN can assess and evaluate the client's level
of pain or teach the client about pain management. However, the UAP can reinforce the nurse's
teaching about pain management.
Concepts tested

Question 610
The nurse is participating in a quality improvement (QI) project with a focus on improving pain
management on a surgical unit. Which actions should be included in this QI project? Select all
that apply.
A Reviewing pain management protocols for evidence-based practice
B Developing a team approach for the entire health care team to participate in the process
C Designing a research study to produce evidence supporting the current protocol
D Determining pain management interventions proposed by the pharmacy department
E Reviewing client satisfaction data related to pain management

Question Explanation
Correct Answer is A, B, E

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Rationale: Generally, quality improvement (QI) projects are directed at improving processes and
client outcomes. For this particular project, actions are focused on pain management and should
include reviewing evidence-based practice and client satisfaction surveys in relation to pain and
pain management. A critical component of QI is teamwork and the team should include many
different members of the health care team and not just a particular team member or department.
A QI project is not the same as a traditional, quantitative research study.
Concepts tested

Question 611
The nurse is coordinating care for a postpartum client and her newborn with the unlicensed
assistive personnel (UAP). The mother is positive for human immunodeficiency virus (HIV).
The nurse should intervene if the UAP is observed doing which action?
A Assists the mother with breastfeeding positions
B Wearing gloves while changing the newborn's soiled diaper
C Places the infant on his or her back in the bassinet
D Assists the mother with ambulation to the bathroom

Question Explanation
Correct Answer is A
Rationale: Current research recommends that a mother who is HIV positive or has AIDS is
advised against breastfeeding because the virus can be transmitted through breast milk to the
infant. Therefore, the nurse should intervene when observing the UAP assisting the mother with
breastfeeding. It is correct to place an infant on his or her back to prevent sudden infant death
syndrome. Standard precautions should be followed when caring for any client; health care
providers should wear gloves when they anticipate contact with body secretions (changing a
soiled diaper).
Concepts tested

Question 612
A licensed practical nurse (LPN) from the float pool is sent to an adult medical-surgical unit.
With this newly added staff, the charge nurse needs to revise assignments for the shift. Which
clients are appropriate to assign to the float pool LPN?
A A trauma victim newly admitted with a diagnosis of quadriplegia and a client one day
postoperative after a radical neck dissection
B A middle-aged client who has a gastrostomy tube and has been diagnosed with hemiplegia and
a client with a below-the-knee amputation (BKA) who will begin physical therapy )
C A geriatric client with newly diagnosed type 2 diabetes and a client who is positive for human
immunodeficiency virus with a diagnosis of pneumonia
D A young adult client with a history of schizophrenia who is experiencing alcohol withdrawal
syndrome and a client diagnosed with chronic renal failure and anemia

Question Explanation
Correct Answer is B

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Question 613
The nurse is caring for a 69-year-old client who is experiencing hyperglycemia. Which activity
or task is appropriate to delegate to the unlicensed assistive personnel (UAP)?
A Record dietary intake
B Review the initial signs of hyperglycemia with the client's family
C Monitor the client for altered levels of consciousness (LOC)
D Assess the condition of the client's skin on the lower extremities

Question Explanation
Correct Answer is A
Rationale: The UAP can perform routine activities with predictable outcomes, such as recording
dietary intake. Although the UAP can usually assist clients with personal hygiene and would be
able to identify a change in LOC (for example, the client does not respond appropriately to
questions), their role is to inform the nurse about changes in the client's condition. The nurse
must follow up on this information and perform a focused assessment, communicate changes in
the client's condition with the health care team, and then develop a revised plan of action for
client care.
Concepts tested

Question 614
A 72-year-old client who has osteomyelitis requires a six-week course of intravenous antibiotics.
In planning for home care, what is the priority approach by the nurse?
A Determine if there are adequate handwashing facilities in the home
B Investigate the client's insurance coverage for home IV antibiotic therapy
C Assess the client's ability to participate in self-care and/or the reliability of a caregiver
D Select the appropriate venous access device for the long-term IV medication

Question Explanation
Correct Answer is C
Rationale: The cognitive ability of the client, as well as the availability and reliability of a
caregiver, must be assessed to determine if home care is a feasible option. The other approaches
are correct and would be pursued after this initial approach.
Concepts tested

Question 615
The nurse is using the SBAR technique to communicate with the health care provider. Which
phrase would be associated with background (B)?
A "The client's treatments are..."
B "Vital signs are..."
C "I would like you to..."
D "I'm not sure what the problem is, but the client's condition is deteriorating."

Question Explanation
Correct Answer is A

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Rationale: The correct option gives the health care provider background information about the
client, including age, primary diagnosis, treatments, etc. Stating that the client's condition is
deteriorating is the situation (S). Stating, "I would like you to..." is the request or
recommendation (R). Vital signs are part of the assessment (A). Using SBAR is an effective
technique used to improve communication with other members of the health care team. This in
turn helps to foster a culture of safety.
Concepts tested

Question 616
The nurse is about to administer medication to a client when the client states, "I do not want to
take that medication today." Which statement is the nurse's best response?
A "That's OK; it's all right to skip your medication now and then."
B "Is there any particular reason why you don't want to take your medicine?"
C "I will have to call your doctor and report this."
D "Do you understand the consequences of refusing your prescribed treatment?"

Question Explanation
Correct Answer is B
Rationale: When a new problem is identified, it is important for the nurse to collect accurate
information directly from clients. This is crucial to ensure that clients' needs are adequately
identified in order to select the best nursing care approaches. The nurse should pursue a
conversation with the client to reveal any reasons for the medication refusal. It may be that the
client has developed untoward side effects.
Concepts tested

Question 617
A newly appointed nurse manager is having difficulties with time management. Which advice
from an experienced manager should the new manager implement first?
A Complete each task before beginning another activity
B Keep a time log of your day in hourly blocks for at least one week
C Set daily goals and establish priorities for each hour and every day
D Ask for additional assistance when you feel overwhelmed

Question Explanation
Correct Answer is B
Rationale: Begin by applying the nursing process to the problem of time management. The initial
step would be to assess current activities. This allows the nurse manager to establish a baseline
of how his/her time is spent. This also aids in identifying where changes can be made.
Concepts tested

Question 618
The charge nurse in a critical care unit is making assignments for a group of nurses. One of the
nurses usually works on an oncology unit but was "floated" to the critical care unit due to
staffing needs. Which of the following clients is most appropriate to assign to the oncology
nurse?

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A A client on a continuous infusion of diltiazem
B A client 4 hours post-thoracic surgery
C A client on mechanical ventilation due to COVID-19
D A client admitted with a pulmonary embolism

Question Explanation
Correct Answer is D
Rationale: A nurse who is unfamiliar with clients typically found in a critical care unit should be
assigned the most hemodynamically stable, least critically ill client. Although all of the clients
require close monitoring, the client with the pulmonary embolism appears the most stable at this
time. The other clients require specialized nursing skills and knowledge and should not be
assigned to the oncology nurse.
Concepts tested

Question 619
An experienced nurse manager is explaining a reward-feedback system to a new manager. Which
statement best describes the characteristic of an effective reward-feedback system?
A Specific feedback is given as close to the event as possible.
B Staff are given feedback in equal amounts over time.
C Performance goals should be higher than what is attainable.
D Positive statements should precede a negative statement.

Question Explanation
Correct Answer is A
Rationale: Feedback is most useful when given immediately. Positive behavior is strengthened
through immediate feedback, and it is easier to modify problem behaviors if what constitutes
appropriate behavior is clearly understood.
Concepts tested

Question 620
The nurse manager uses a block scheduling plan for staffing. Staff members have asked for many
changes and exceptions to the schedule over the past few months, and the nurse manager is
considering self-scheduling. Which type of effect does the nurse manager anticipate with self-
scheduling?
A Improved team morale
B Reduced overtime payouts
C Improved quality of care
D Decreased staff turnover

Question Explanation
Correct Answer is A
Rationale: Nurses in direct care positions are more satisfied when opportunities exist for
autonomy and control. The nurse manager becomes the facilitator rather than the decision-maker
of the schedule for unit needs when self-scheduling exists. Peer pressure and teamwork are the
driving forces during self-schedule approaches.

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Concepts tested

Question 621
The nurse is caring for a client who is being treated for complications of a chronic disease on a
medical-surgical unit. The nurse understands that which people can have access to the client's
medical record? Select all that apply.
A The client's spouse or another close family member
B The person who has health care power of attorney
C The facility researcher collecting data for a study to which the client consented
D The emergency department nurse who originally admitted the client and now wants to know
the client's current status
E The nursing instructor planning clinical assignments
F The certified nursing assistant documenting vital signs

Question Explanation
Correct Answer is B, C, E, F
Rationale: Safeguarding client privacy requires strict adherence to the ethical standards of
confidentiality and need-to-know access. Only those individuals who are directly involved in the
client's care should have access to his or her information. The ED nurse is no longer directly
involved in the client's care and should not have access to information about the client. Without
valid authorization, such as health care power of attorney, a spouse or other family members
cannot access the client's medical records.
Concepts tested

Question 622
The unlicensed assistive person (UAP) reports to the nurse that a client has a blood pressure of
78/46 mmHg and a pulse of 116 beats per minute. Which action should the nurse take first?
A Go to the client and perform a quick, focused assessment
B Activate the facility's rapid response team
C Increase the rate of the client's continuous IV infusion
D Instruct the UAP to place the client in a modified Trendelenburg position

Question Explanation
Correct Answer is A
Rationale: The nurse should follow the nursing process and first see the client right away and
perform a quick, focused assessment including the level of consciousness, breathing, and cardiac
status. The assessment findings will help the nurse in making a clinical decision on what step
would be most appropriate to take next.
Concepts tested

Question 623
The surgical nurse is caring for a client following a cholecystectomy. Which task would be
appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)?
A Assess the return of bowel sounds or passing flatus
B Document amount of output in the surgical drainage collection device

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C Record amount of drainage on the surgical dressing
D Palpate for abdominal distention

Question Explanation
Correct Answer is B
Rationale: The emptying, measuring, and recording drainage from a postoperative drain may be
delegated to the UAP who has demonstrated competence in performing this task. While the nurse
is responsible for all care-related decisions, the UAP can typically perform tasks that have
predictable outcomes. The other tasks or activities require nursing knowledge, skill, or judgment
and cannot be assigned to the UAP.
Concepts tested

Question 624
The unlicensed assistive personnel (UAP) reports to the nurse that the oral temperature of a post-
surgical client is a 101°F (38.3°C). An hour ago the client's temperature was 99°F (37.2°C).
Upon entering the client's room, the nurse observes a cup of hot coffee at the bedside. Which
instructions are appropriate for the nurse to give to the UAP?
A Chart this temperature elevation on the flowsheet, and retake the temperature in 2 hours
B Provide the client with only cold water and juices to drink every hour
C Encourage the client to drink more oral fluids to prevent dehydration
D Recheck the oral temperature 15 minutes after removing the hot coffee from the bedside

Question Explanation
Correct Answer is D
Rationale: A recheck of the oral temperature is needed to eliminate the possibility of an artificial
elevation of temperature from the hot coffee. Hot or cold liquids, smoking, eating, chewing gum,
and talking can all elevate or lower the temperature if done within 10 minutes of the temperature
being taken. Waiting to take the temperature for 15 minutes will help the temperature return to
its normal reading and facilitate an accurate reading. The nurse should avoid premature
assumptions about explanations for findings, and the initial action is to do an assessment of the
client.
Concepts tested

Question 625
The charge nurse in a long-term care facility is reviewing assignments for the shift. Which task is
appropriate to delegate to a certified nursing assistant (CNA)?
A Provide oral suctioning for an unresponsive client
B Apply a dry dressing to a skin tear
C Calculate and record intake and output
D Teach another CNA how to perform passive range-of-motion exercises

Question Explanation
Correct Answer is C
Rationale: CNAs are considered unlicensed assistive personnel (UAP) and are trained to perform
a number of tasks or basic nursing skills, including calculating and recording intake and output.

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Although CNAs can wash and apply emollients on skin, they should not apply dressings. A CNA
should not suction a client's mouth. Although CNAs can perform passive range-of-motion
exercises, they cannot teach others how to do this.
Concepts tested

Question 626
While walking past a client's room, the nurse hears an unlicensed assistive person (UAP) talking
to another UAP. Which statement made by the UAP would require the nurse to intervene?
A "Since I am late for lunch, would you perform my client's blood glucose test?"
B "If we work together, we can get all of the client care completed."
C "This client seems confused; we need to watch the client closely."
D "I'll come back and make the bed after I go to the lab."

Question Explanation
Correct Answer is A
Rationale: Only registered nurses (RNs) and licensed practical or vocational nurses (LPN/VNs)
can assign tasks and activities. UAPs cannot re-assign tasks or activities to other UAPs. Nurses
are accountable for all nursing care; if UAPs cannot complete assignments, they should notify
the nurse, who will reassign the task.
Concepts tested

Question 627
The nurse on a medical-surgical unit is working with a team that consists of several other nurses
and one unlicensed assistive person (UAP). Which tasks can the nurse delegate to the
UAP? Select all that apply.
A Ambulate a client in the hallway twice a shift
B Assist a client in skeletal traction with meals and snacks
C Provide information about a low-sodium diet prior to discharge
D Obtain a daily weight on a client before breakfast
E Give a client on bed rest due to severe anemia a bed bath

Question Explanation
Correct Answer is A, B, D, E
Correct Rationale: Unlicensed assistive personnel (UAP) are trained to assist with activities of
daily living, such as bathing and dressing, collecting specimens, measuring weight, and assisting
with ambulation. Teaching or providing discharge information can only be performed by a nurse.
Concepts tested

Question 628
The triage nurse is evaluating several clients in a hospital's emergency department. Which client
should be seen first?
A An adolescent who has soot over the face and shirt
B A middle-aged man with second-degree burns over the right hand
C A toddler with singed ends of long hair that extends down to the waist
D A 5-month-old infant who has audible wheezing and grunting

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Question Explanation
Correct Answer is D
Rationale: The nurse should use the A-B-C prioritization approach when determining which
client to see first. The age and the findings suggest this client is at immediate risk for respiratory
complications. The other clients are at a lesser risk for respiratory problems.
Concepts tested

Question 629
The charge nurse is reviewing assignments for the shift. The care team consists of a registered
nurse (RN), a licensed practical nurse (LPN), and several unlicensed assistive personnel (UAP).
Which of these clients would be most appropriate to assign to the RN?
A A 24-year-old newly diagnosed with type 1 diabetes mellitus who is scheduled for discharge
B A 60-year-old with a history of asthma and reported shortness of breath during the previous
shift
C An 80-year-old who is postoperative day 1 following a right hip replacement
D A 56-year-old admitted with atrial fibrillation who converted to normal sinus rhythm without
cardioversion

Question Explanation
Correct Answer is A
Rationale: LPNs can care for clients whose conditions are not too complex or variable and if
there is a low likelihood of an emergency. Also, RNs are responsible for providing client
education; LPNs can only reinforce the plan of care and information already taught by the RN.
Although the condition of the client scheduled for discharge would be considered "stable," the
RN is responsible for discharge teaching and ensuring continuity of care after discharge;
therefore, the 24-year-old client is most appropriate to assign to the RN.
Concepts tested

Question 630
The hospital has a mentor program for novice nurse managers. Which of these approaches
is most likely to result in a positive experience for both mentor and mentee?
A The mentor is randomly assigned by administration.
B The mentee seeks clarification as needed.
C A teacher-coach role is used by the mentor.
D The mentee accepts feedback objectively.

Question Explanation
Rationale: The mentor should adopt the role of teacher-coach. Teaching and coaching are
essential elements of the professional role and will facilitate the transition from one role to
another, e.g., from staff nurse to nurse manager. The mentor will also assist the novice manager
to manage unfamiliar clinical situations and achieve a level of comfort in solving
clinical/management problems.
Concepts tested

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Question 631
There is an order for a 25-year-old client, who is unresponsive after suffering a traumatic brain
injury, to be transferred from the hospital to a long-term care facility today. Which staff member
should the charge nurse assign to care for this client?
A Registered nurse (RN)
B Licensed practical nurse (LPN)
C Unlicensed assistive person (UAP)
D Nursing student in final semester before graduation

Question Explanation
Correct Answer is A
Rationale: The Registered Nurse (RN) is responsible for facilitating continuity of care for clients
and their families during the transfer from one health care setting to another. The transfer to a
long-term care facility often requires referrals and coordinating information from many different
providers about treatments, therapies and medications. The charge nurse should assign this client
to a RN.
Concepts tested

Question 632
An inpatient client asks the nurse to call the police and states: "I need to report that I am being
abused by a nurse." Which action should the nurse take?
A Calmly focus on reality orientation to time, place and person.
B Assist with the report of the client's complaint to the police.
C Obtain more details of the client's claim of abuse by a nurse.
D Document the statement on the client's chart and report it to the nursing manager.

Question Explanation
Correct Answer is C
Rationale: The advocacy role of the professional nurse, as well as the legal duty of the
reasonable prudent nurse, requires the investigation of claims of abuse or violation of rights. The
nurse is legally accountable for actions delegated to others. The application of the nursing
process requires that the nurse gather more information, assessment before interventions and
before documenting or reporting the complaint.
Concepts tested

Question 633
The clinic nurse is assisting with medical billing. The nurse uses the Diagnosis Related Group
(DRG) manual for which purpose?
A To determine reimbursement for a medical diagnosis.
B To identify findings related to a medical diagnosis.
C To classify nursing problems from the client's health history.
D To implement nursing care based on case management protocols.

Question Explanation
Correct Answer is A

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Rationale: DRGs are the basis of prospective payment plans for reimbursement for Medicare
clients. Other insurance companies often use it as a standard for determining payment. The nurse
uses this manual to determine reimbursement for medical diagnoses.
Concepts tested

Question 634
The nurse is working with an unlicensed assistive person (UAP). Which newly admitted client
would be most appropriate to assign to the UAP?
A An 81-year-old client diagnosed with severe depression
B A 47-year-old client diagnosed with obsessive-compulsive disorder
C A 15-year-old client diagnosed with dehydration and anorexia
D A 22-year-old client withdrawing from heroin, who is reporting seeing spiders

Question Explanation
Correct Answer is B
Rationale: The unlicensed assistive person (UAP) can be assigned to a client with a chronic
condition after an initial assessment is performed by the nurse. The client with obsessive-
compulsive disorder (OCD) is most appropriate to assign to the UAP. This client has minimal
risk of medical instability. The other clients will require closer monitoring by the nurse due to
the potential for medical complications or increased safety concerns.
Concepts tested

Question 635
A new task force has been created at a hospital to address a recent increase in client falls. The
first meeting is scheduled with members from several departments. Which statements by the
nurse leader will increase meeting effectiveness? Select all that apply.
A "During our meeting today, we will share the information we have on client falls."
B "Today I will review the problem with client falls on our units."
C "Please introduce yourselves and your departments."
D "Let's discuss when we should meet next and what information we will bring."
E "This meeting can go as long as needed to get things done."
F "Let's focus on the number of client falls first and then we can talk about staffing."

Question Explanation
Correct Answer is A, C, D, F
Rationale: The leader increases meeting effectiveness by not permitting one person to dominate
the discussion, encouraging brainstorming, encouraging others to further develop ideas and
helping to engage the team in future discussions. An effective team leader will periodically
summarize the information and ensure that all ideas are recorded for all to see (e.g. on a
whiteboard) and then follow up with written minutes of the meeting. Beginning and ending on
time is also important to keep everyone focused on the task at hand and to demonstrate respect
for team members' other commitments.
Concepts tested

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Question 636
Two members of the interdisciplinary team are arguing about the plan of care for a client. Which
strategy could be used to de-escalate the situation?
A Tell the team members they must calm down and be reasonable.
B Adjourn the meeting and reschedule when everyone has calmed down.
C Bring the communication focus back to the client
D Interrupt, apologize for the interruption and change the subject.

Question Explanation
Correct Answer is C
Rationale: Bringing the subject of the communication back to the client refocuses attention on
the client's care, instead of the manner of communication. It is an effective de-escalation strategy
because it is an example of effective communication and collaboration. The other options are
non-productive and may even make the situation worse.
Concepts tested

Question 637
The charge nurse is making assignments for the upcoming shift. Which client would
be most appropriate to assign to a licensed practical nurse (LPN)?
A A 76-year-old client who has cystitis, and is being treated with an indwelling urinary catheter.
B A 53-year old client who is confused since surgery 2 days ago.
C A 64-year-old client diagnosed with a possible transient ischemic attack who has neurological
abnormalities.
D A 31-year-old client with multiple lacerations from a recent trauma and requires complex
dressing changes.

Question Explanation
Correct Answer is A
Rationale: The most stable client is the one diagnosed with cystitis. This client, who has
predictable outcomes and minimal risk for complications, would be most appropriate to assign to
the licensed practical nurse (LPN). The other clients require more complex care, specialized
nursing knowledge, and skill or judgment that the registered nurse (RN) should provide.
Concepts tested

Question 638
At the beginning of the shift, the nurse is reviewing the status of each of the assigned clients in
the labor and delivery unit. Which of these clients should the nurse see first?
A A 25-year-old client who is primipara, with cervical dilation of 1 cm and who is experiencing
contractions 15 minutes apart.
B A 17-year-old client who is 18 weeks pregnant with a report of no fetal heart tones and
coughing up frothy sputum.
C A 34-year-old client with a history of 2 prior vaginal term births and who is 2 cm dilated.
D A 28-year-old client who is grand multipara, 4 cm dilated and 50% effaced.

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Question Explanation
Correct Answer is B
Rationale: The 17-year-old client is likely experiencing an actual complication of left-sided
heart failure and a possible stillborn birth. The other clients have expected findings, or potential,
but not actual, complications. The nurse should see the client who is coughing up frothy
sputum first.
Concepts tested

Question 639
The charge nurse of a hospital inpatient unit is asked to list the clients who can potentially be
discharged. Which one of these clients is most appropriate for discharge?
A A 29-year-old client, diagnosed with type 1 diabetes since age 10, admitted 36 hours ago with
diabetic ketoacidosis
B A 77-year-old client with an implantable cardiac defibrillator who was admitted yesterday
after receiving multiple shocks
C A 16-year-old client who was admitted the previous evening with acetaminophen intoxication
D A 10-year-old pediatric client who was admitted earlier today with a diagnosis of suspected
bacterial meningitis

Question Explanation
Correct Answer is A
Rationale: The client with type 1 diabetes is the only client with a chronic condition who has
been treated for more than a day and whose condition is the most stable; therefore, this client
is most appropriate for discharge. The other clients' conditions are either unstable and/or more
acute.
Concepts tested

Question 640
The nurse manager informs the nursing staff that the clinical nurse specialist will be conducting a
research study about staff attitudes toward client care. All staff are invited to participate in the
study, if they wish. This type of research participation affirms which ethical principle?
A Justice
B Beneficence
C Anonymity
D Autonomy

Question Explanation
Correct Answer is D
Rationale: The principle of autonomy means individuals must be free to make independent
decisions about participation in research without coercion from others. Anonymity means the
person's identity is not revealed. Beneficence is the state or quality of being kind, charitable,
beneficial or a charitable act. Justice relates to fairness.
Concepts tested

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Question 641
A nurse in a rural community uses telehealth to provide care and education to clients in remote
locations. What are the perceived benefits of using telehealth?
A Telehealth empowers clients to take a greater interest in their illness.
B Telehealth removes the time and distance barriers from the delivery of care.
C Telehealth standardizes electronic sharing of health information data.
D Telehealth greatly reduces health care costs for the clients who use it.

Question Explanation
Correct Answer is B
Rationale: Telehealth is the use of technology to deliver health care, health information or health
education at a distance. People in rural areas and homebound clients can communicate with
primary health care providers via telephone, email or video consultation, thereby removing the
barriers of time and distance for access to care.
Concepts tested

Question 642
The nurse is planning care for a newly admitted 78-year-old client who is diagnosed with severe
dehydration. Which task would be appropriate for the nurse to assign to an unlicensed assistive
person (UAP)?
A Monitor client's ability for movement in the bed from side to side.
B Check skin turgor every 4 hours and change the client's adult diaper.
C Report hourly outputs of less than 30 mL/hr within 15 minutes of the check.
D Converse with the client to determine if the mucous membranes are impaired.

Question Explanation
Correct Answer is C
Rationale: When assigning tasks to an unlicensed assistive person (UAP), the nurse must
communicate clearly about each delegated task with specific instructions on what must be
reported and when. Because the nurse is responsible for all care-related decisions, only routine
tasks should be assigned to UAPs because such tasks do not require clinical judgment and
decision-making. Measuring hourly urine output and reporting the amount to the nurse is an
appropriate task to delegate to a UAP.
Concepts tested

Question 643
A group of nurse managers is tasked with making several important staffing decisions. Which
statement describes the advantage of using a decision grid to make decisions?
A It is the fastest way for group decision-making
B It is both a visual and a quantitative method of decision-making.
C It allows data to be graphed for easy interpretation.
D It is the only truly objective way to make a decision in a group.

Question Explanation
Correct Answer is B

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Rationale: A decision grid allows the group to visually examine alternatives and evaluate them
quantitatively or more objectively. It does not necessarily make the decision-making faster or
interpretation easier. There are other tools available to aid in decision-making by a group.
Concepts tested

Question 644
The nurse is caring for a client diagnosed with anemia and confusion. Which task could the nurse
assign to an unlicensed assistive person (UAP)?
A Suggest foods that are high in iron and prepare a list for the client.
B Assess and document skin turgor and skin color changes.
C Test a stool sample for occult blood and report the results.
D Report mental status changes and level of mental clarity.

Question Explanation
Correct Answer is C
Rationale: Unlicensed assistive personnel or persons (UAP) perform routine tasks that have
known or expected outcomes because these tasks typically do not require nursing judgment or
decision-making. Any nursing intervention that requires independent, specialized nursing
knowledge, skill or judgment cannot be assigned to UAP.
Concepts tested

Question 645
The nurse is planning a family care conference for a client who will be returning home with new
medical needs. Which of these aspects of the discharge planning evaluation should
receive priority consideration?
A Family's understanding of the client's health care needs
B Client's health insurance and prescription coverage
C Availability of community-based services
D Coordination of follow-up care with interdisciplinary team

Question Explanation
Correct Answer is A
Rationale: Family members must be willing and able to provide the required care at the times
needed and understand the client's health care needs before the client is discharged home. The
discharge planning evaluation will take into account a wide variety of information, such as the
home environment, and the availability of community-based services (such as support groups,
hospice, or medical equipment and related supplies, etc.) Family members should understand the
financial implications of discharge, including health insurance and prescription coverage.
Concepts tested

Question 646
The nurse is caring for a client with a diagnosis of cirrhosis of the liver and ascites. What should
the nurse emphasize to the unlicensed assistive personnel (UAP) about providing care for this
client?

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A The client is to ambulate as tolerated and be positioned in semi-Fowler's position when in
bed.
B The client should ambulate as tolerated, resting in bed with legs elevated between walks.
C The client may ambulate and sit in a chair as tolerated.
D The client should remain on bed rest in the semi-Fowler's position.

Question Explanation
Correct Answer is B
Rationale: Encourage alternating periods of ambulation and bed rest with legs elevated to
mobilize edema and ascites. Encourage and assist the client to gradually increase the duration
and frequency of walks.
Concepts tested

Question 647
The nurse from a women's wellness health clinic is temporarily assigned to an adult medical unit.
Which of these client assignments would be most appropriate for this nurse?
A A client admitted for a barium swallow after a transient ischemic attack.
B A client who was in a motor vehicle accident who has an external fixation device on their leg
C A newly admitted client with a diagnosis of pancreatic cancer and severe dehydration
D A newly diagnosed client with type 2 diabetes mellitus who is learning about foot care

Question Explanation
Correct Answer is B
Rationale: The nurse from the wellness clinic should be assigned to the client with the leg
fracture. This client is the most stable and providing care for this client has predictable
outcomes. The contraindications in the other clients are: "newly diagnosed," "after a transient
ischemic attack (TIA)," and "newly admitted...severe dehydration." All of these clients have a
health concern that's less stable than the client who has a stable fracture.
Concepts tested

Question 648
An internal disaster has occurred at the hospital. The nurse manager is reviewing the clients the
charge nurse identified to be discharged. Which client identified by the charge nurse would
require the nurse manager to intervene?
A A 24-year-old client in the second day of treatment for an overdose of acetaminophen
B A 75-year-old client admitted two days ago with an acute exacerbation of ulcerative colitis.
C A 17-year-old client diagnosed with sepsis 5 days ago and whose vital signs are within normal
limits.
D A 40-year-old client known to have had an uncomplicated myocardial infarction 4 days ago

Question Explanation
Correct Answer is A
Rationale: An overdose of acetaminophen requires close observation for several days. Also, the
duration of the course of treatment for the oral antidote N-acetylcysteine (NAC) is approximately
72 hours. NAC will protect the liver if given within 8 hours after an acute ingestion. When

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compared with the other clients, the client who overdosed on acetaminophen is the least stable
and should not be discharged.
Concepts tested

Question 649
While being admitted for surgery, a client refuses to sign the surgical consent form. Which
nursing actions should the nurse take? Select all that apply.
A Notify the health care provider.
B Have a family member sign the consent form.
C Convince the client to sign the consent form.
D Document the client's refusal in the medical record.
E Inform the unit charge nurse.

Question Explanation
Correct Answer is A, D, E
Rationale: The nurse should document the client's refusal to sign the consent form in the medical
record. The nurse is responsible for notifying the charge nurse to keep them informed of the
client's decision. The health care provider should be notified so they can discuss the
consequences of not having the surgery and potential treatment alternatives with the client. It is
not in the nurse's scope to convince a client to have a procedure they have the right to refuse.
Unless the client has been deemed incompetent, the nurse should not have anyone sign on their
behalf when they have refused treatment because this could create a claim of battery.
Concepts tested

Question 650
The emergency room nurse is triaging several clients. Which client should be seen by the health
care provider first?
A A young adult client who sustained a singed beard, eyebrows and hair from a camp fire
B A 2-month-old infant who has bulging fontanels and is crying loudly
C An older adult client with complaints of frequent liquid stools
D A middle-aged client with intermittent epigastric pain after eating

Question Explanation
Correct Answer is A
Rationale: The nurse should use the airway-breathing-circulation (ABC) prioritization approach
to determine which client should be seen first. The client who suffered singed facial hair from a
camp fire is at highest risk for airway problems due to the high likelihood of inhalation injury to
the upper and lower airway. This injury is caused by the inhalation of hot air, steam, or
smoke. The singed facial hair is a telltale sign of a potential inhalation injury. Pulmonary edema
tends to appear around 12 to 48 hours after the injury and manifests as acute respiratory distress
syndrome (ARDS). None of the other clients are exhibiting symptoms that pertain to the airway
or breathing; therefore, the young adult client should be seen first.
Concepts tested

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Question 651
A client requests not to be interrupted before 10 am because it interferes with their time to
meditate. Which action should the nurse take first?
A Document the client's request in the medical record.
B Meet with the client to formulate a mutually agreeable schedule.
C Notify the dietary department about the client's request.
D Adjust administration times for prescribed medications.

Question Explanation
Correct Answer is B
Rationale: The nurse should communicate with the client to help determine how their meditation
practice can be incorporated into the morning schedule. This is the first step in the nursing
process and will help the nurse develop an individualized plan of care that incorporates respect
for the client's personal choices and preferences.
Concepts tested

Question 652
A nurse is planning for her new role as the nurse manager of a 30-bed inpatient medical unit in a
busy acute care hospital. Which strategy should the nurse use to help with time management?
A Limit direct care of clients to 2 to 3 hours per day
B Set daily, prioritized goals of management tasks
C Plan to work a few extra hours on weekends
D Delegate tasks and skip unimportant meetings

Question Explanation
Correct Answer is B
Rationale: Time management strategies include setting goals and prioritization of not only
management tasks but issues that arise on a daily basis on the unit. This is similar to time
management of direct care for clients where the nurse prioritizes which clients to see first or
which tasks to perform first. Still providing direct care would be a poor use of the manager's
time. Direct client care should be done by a nurse manager only in extreme circumstances. The
nurse manager will be expected to attend all required meetings and working "extra hours" does
not help with managing time and completing management tasks within the expected work week.
Concepts tested

Question 653
The licensed practical nurse (LPN) from the pediatric unit is reassigned to work on an adult
ortho-neuro unit. Which client assignment would be most appropriate for this nurse?
A The client in balanced traction admitted three days ago after a motor vehicle accident
B The client who is one day post total knee arthroplasty experiencing shortness of breath
C The client with a newly applied long leg cast experiencing uncontrolled pain
D The client who experienced a stroke and is ready to be transferred to a long term care facility

Question Explanation
Correct Answer is A

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Rationale: The licensed registered nurse (RN) can assign clients to the LPN as long as the care
required is not too complex and there is a low likelihood of an emergency. The most stable client
is the client in balanced traction who was admitted three days ago. The client experiencing
shortness of breath and uncontrolled pain are unstable and need further assessment by the RN.
Admitting or discharging a client is a complex process and requires the knowledge and skills of
the RN.
Concepts tested

Question 654
The nurse expresses concerns to colleagues regarding their nurse manager. The nurse states that
the manager makes all the decisions and rarely seeks input from staff. What is
the best description of the nurse manager's management style?
A Autocratic leadership
B Transformational leadership
C Participative leadership
D Laissez-faire leadership

Question Explanation
Correct Answer is A
Rationale: The manager's leadership style is that of autocratic. Autocratic leadership is a
management style where one person controls all decisions and rarely seeks input from others.
Leaders who follow this style make choices based on their own beliefs and do not involve others
nor seek suggestions or advice. Transformational leadership aims to improve employee morale
and promoting inclusion by creating a vision for their employees and communicating often.
Laissez-Faire leadership allows employees to choose their actions freely and does not provide
sufficient supervision. Participative leadership encourages employees to participate in decision-
making but then makes the final decision for the group based on suggestions and feedback.
Concepts tested

Question 655
During a lunch break, nurse colleagues discuss their nursing practice. Which of the following
statements best represents nursing practice guidelines?
A The healthcare agency is ultimately responsible for developing practice guidelines for licensed
nurses.
B National nursing associations are responsible for developing specific regulations for licensed
registered nurses (RNs) and licensed practice nurses (LPNs).
C Specific regulations for licensed registered nurses (RNs) and licensed practical nurses (LPNs)
will vary from state to state.
D The federal government ensures the safety of clients by developing nursing practice
guidelines.

Question Explanation
Correct Answer is C
Rationale: Nursing guidelines and regulations are developed to protect those who are receiving
care. It is the state's duty to ensure licensed nurses provide safe, competent nursing care. Boards
of nursing are state governmental agencies that are responsible for licensing nurses in each state
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and enforcing the rules and regulations of the nurse practice act. Nursing scope of practice may
vary from state to state. It is the responsibility of the licensed nurse to be aware of their state’s
scope of practice. The other statements are not true in regards to nursing practice guidelines.
Concepts tested

Question 656
The hospital case management nurse is reviewing the medical record of an 86-year-old client
who is scheduled to transfer to a transitional care program after discharge from the hospital. The
client has had four inpatient hospitalizations in the last 2 months. What is the primary purpose of
the transitional care program?
A Reduce readmissions to the hospital
B Reduce insurance cost
C Provide respite for the client's spouse
D Increase satisfaction with nursing care

Question Explanation
Correct Answer is A
Rationale: Transitional care, or the care clients receive as they move between health care
settings, involves bridging care gaps across different health care settings, including
hospitalizations and outpatient visits. Hospital-based transitional care interventions aim to
smooth the transition from the inpatient to the outpatient setting and prevent unnecessary
readmissions and adverse events. Older adults who complete a transitional care program after
being discharged from the hospital are much less likely to be readmitted to the hospital. The
client clearly has had frequent hospitalizations and would very likely benefit from a transitional
care program.
Concepts tested

Question 657
Which statement describes factors that help build personal power in an organization?
A Credibility to one's position is enhanced when professional dress and demeanor are employed
B High visibility and formal power are maintained with a confrontational style
C Longevity in an organization, associating with people in power positions, and a history as
someone who does not back down.
D Goals are met with the use of networking, mentoring, and coalition building

Question Explanation
Correct Answer is D
Rationale: Networking, mentoring, and coalition building are positive uses of personal power to
meet goals.
Concepts tested

Question 658
The home health nurse is caring for client diagnosed with diabetes mellitus and arthritis. The
client is having difficulties drawing up insulin. Which of the following resources would be most
appropriate for the nurse to refer the client to?

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A Activity therapist from the community center
B Social worker from the local hospital
C Occupational therapist from the home health agency
D Another client diagnosed with diabetes mellitus

Question Explanation
Correct Answer is C
Rationale: In order for the client to administer their insulin, they would need to fill the correct
syringe with the right amount of insulin, decide where to give the injection, and know how to
give the injection. Another client with diabetes would not be appropriate. It would be considered
a violation of Health Insurance Portability and Accountability Act (HIPAA). In addition, the
other client is not a health care worker. A social worker would help the client identify
community resources that are needed for their health care (i.e. support services, transportation,
meal services, etc.). An activity therapist would plan and coordinate recreation programs for
patients in hospitals or long-term care facilities. Activities include trips, social activities, and arts
and crafts. An occupational therapist can assist a client to improve the fine motor skills needed to
prepare an insulin injection. The other resources would not be helpful in this situation.
Concepts tested

Question 659
The nurse has been managing the care of a home health client for six weeks. In order to
determine the quality of care being provided to the client by a home health aide, what should be
the priority action by the nurse?
A Check the documentation of the home health aide for accuracy
B Investigate if the home health aide is prompt and stays an appropriate length of time
C Ask the client if they are satisfied with the care given by the home health aide
D Determine if the home health aide's care is consistent with the plan of care

Question Explanation
Correct Answer is D
Rationale: Home health care allows clients to receive care in the home. Clients receive quality
care from home health aides, who are supervised closely by registered nurses. The client's
feedback is important, as it could impact their plan of care. The client's engagement in the plan
of care is recommended. It is important that the nurse investigates accuracy of documentation,
promptness, and length of stay by the home health aide. These are essential characteristics of a
health care worker. These characteristics could also impact employment, as they are a
component of professional behavior. Although the nurse must investigate all of these things, the
first priority is an evaluation of the adherence to the plan of care. The plan of care is based on the
reason for referral, the provider's orders, the initial nursing assessment, and the client's responses
to the planned interventions. It is what justifies care of the client.
Concepts tested

Question 660
The nurse is teaching a client about a procedure to be done in the home. The client requires an
interpreter. When using the interpreter, the nurse should take which of the following approaches?

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A Face the client while presenting the information as the interpreter talks in the native
language.
B Speak directly to the interpreter while presenting information, but allow the client time to ask
questions.
C Talk to the interpreter in advance and leave the client and interpreter alone.
D Include a family member in the teaching session, and speak only to them.

Question Explanation
Correct Answer is A
Rationale: Communication is the cornerstone of an effective teaching plan, especially when the
nurse and client do not share the same culture. Interpreter services reduce liability, increase client
satisfaction and improve client outcomes. Even if the nurse uses an interpreter, it is still critical
that the nurse use personal spacing, eye contact, and touch that are acceptable to the client.
Therefore, to face the client and present the information to them, allows the interpreter to
translate the content. Facing the client also allows nonverbal communication to take place
between the nurse and client. This could also be perceived as a sign of respect. It would be
important to allow a family member to be present during the session, to help reinforce content
with the client. However, the family member should not relay critical information to the client
firsthand. Leaving the interpreter and client alone is not appropriate. The nurse needs to be
present to field questions in real-time and ensure that the interpreter relays all pieces of
information accurately.
Concepts tested

Question 661
The nurse is caring for a client who asks the nurse to use a treatment method that the client read
about on the internet. Which of the following responses by the nurse would be most appropriate?
A "You shouldn't really use the internet for health care information. Most of it is incorrect."
B "Can you tell me more about the website where you read the information?"
C "I am willing to give it a try. Does it say what the success rate is for using this treatment?"
D "Why are you questioning your doctor's order? She is an expert in the field."

Question Explanation
Correct Answer is B
Rationale: Clients are internet savvy and often search the internet for medical information about
their conditions and request information from others using social media. Since there is a lot of
information on the internet, clients need the expertise of nurses and other health care providers to
direct clients to information that are reliable, current and evidence-based. Many health care
organizations have a list of vetted mobile apps and internet sites clients can use.
Asking the client an open-ended question about the origin of the information is a therapeutic
communication approach and allows the nurse to determine the quality of the information and
demonstrate respect for the client's autonomy.
The other responses are non-therapeutic and will most likely make the client feel guilty for
taking the initiative to learn more about their health.
Concepts tested

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Question 662
The nurse is admitting a client with pneumonia to the medical-surgical unit. When would it
be most appropriate for the nurse to initiate discharge planning for this client?
A When the client is informed of their date of discharge
B Upon admission to the hospital
C Immediately after the client's condition is stabilized
D When the client or family demonstrates readiness to learn

Question Explanation
Correct Answer is B
Rationale: With decreased lengths of stay, discharge plans must be incorporated into the initial
plan of care upon admission to an emergency department or hospital unit. Thus, is the thought
"discharge planning begins on admission."
Concepts tested

Question 663
After working with a client, an unlicensed assistive personnel (UAP) tells the nurse, "I have had
it with that demanding client. I just can't do anything that pleases him. I'm not going in there
again." Which response by the nurse is most appropriate?
A "He may be scared and taking it out on you. Let's talk to figure out what to do next."
B "He has a lot of problems. You need to have patience with him."
C "I will talk with him and try to figure out what to do or what the problem is."
D "Ignore him and get the rest of your work done. Someone else can care for him."

Question Explanation
Correct Answer is A
Rationale: The first response doesn't address the client's problems and belittles the UAP's
feelings. The second response omits the UAP from the issue and excludes her from the plan of
care. The third response encourages the UAP to ignore the problem, and it also doesn't fix the
problem and excludes the UAP from the plan of care. The UAP should be encouraged to
contribute to the plan of care, to help solve the problem. The client should also be encouraged to
express their feelings. The nurse and UAP need to collaborate and make sure the client's needs
are being met.
Concepts tested

Question 664
The nurse is auditing documentation in clients' medical records. Which entry in a client's
progress notes is the most complete?
A Client expresses anxiety about a low-salt diet
B Client's urinary output adequate for the past shift
C Demerol 75 mg administered for severe abdominal pain
D Dark green drainage 100 mL from nasogastric tube at 0600

Question Explanation
Correct Answer is D

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Rationale: Documentation reflects the client's condition and the care they've received during
their hospitalization. Documentation needs to be complete, accurate and objective.
Reimbursement from third-party payers is facilitated when documentation is accurate, reliable
and valid. Nurses need to adhere to good documentation standards, as it minimizes a nurse's
chance of being named in a malpractice lawsuit. The word "anxiety" in the answer choice could
be defined more specifically, along with the inclusion of information about the nurse's response.
The medication order lacks the route, frequency and the client's response to the medication. The
description of the nasogastric drainage is the most specific and factual. The criteria for
"adequate" urinary output needs to be defined.
Concepts tested

Question 665
The new nurse manager is preparing for a meeting with the staff to come up with ideas for how
to reduce the number of falls on the unit. Which approach would be best for the nurse manager
to use?
A Show a presentation on fall data
B Have the staff engage in brainstorming
C Conduct an anonymous staff survey
D Present a research article

Question Explanation
Correct Answer is B
Rationale: Brainstorming combines a relaxed, informal approach to problem solving with lateral
thinking. It encourages people to come up with thoughts and ideas. The goal of brainstorming is
to gather as many ideas as possible without judgment that slows the creative process and may
discourage innovative ideas. Therefore, having the staff engage in brainstorming during the
meeting would be the best approach.
Concepts tested

Question 666
The nurse knows that a client's information should be kept confidential. In which of these
situations shall the nurse make an exception to this practice?
A When a visitor insists that they have been given permission by the client
B When the client threatens to harm themself or another individual
C When the healthcare provider (HCP) decides the family has a right to know
D When the client's family member offers information about the client

Question Explanation
Correct Answer is B
Rationale: Client information is kept private unless the client states verbally or in writing that
their information can be shared with another individual. In addition, if the client becomes
incapacitated and they have a next of kin or health care proxy, their information can be shared
with one of these individuals. The only exception to this rule is if the client threatens to harm
themself or another individual. The Tarasoff ruling or duty to warn, instructs health care workers
that if a client threatens to harm themself or another individual, they must warn the intended
victim and contact the police.
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Concepts tested

Question 667
A health care provider asks the nurse to assist with obtaining consent for central line placement,
in a client who is deaf. While the health care provider explains the procedure and risks to the
client and family member, the client and family member text each other using their cell phones.
What is the most appropriate nursing action?
A Stand next to the client and verify that the information in the texts is accurate
B Obtain interpreter services for the client.
C Request the health care provider allow extra time to explain information
D Remind the health care provider to ask one question at a time

Question Explanation
Correct Answer is B
Rationale: Communication is critical in health care settings. Under the Americans with
Disabilities Act (ADA), hospitals must provide effective means of communication for patients
who are deaf or hard of hearing. When obtaining informed consent from a client, it is important
for the provider to speak slowly and ask one question at a time. However, interpreter services are
needed for clients who are deaf. The client must understand the procedure and risks associated
with the procedure in order to give informed consent. Interpreter services for clients who are deaf
can be provided through video remote interpreting, closed captioning and texting. The client's
family should not be relied on to interpret medical information. Family members may be unable
to accurately interpret in the emotional situation that often exists during a client's hospitalization.
Concepts tested

Question 668
The nurse is preparing to discharge a client who has suffered full thickness burns to the chest and
upper extremities. Which home care instructions should the nurse include as part of the discharge
education to the client and family? Select all that apply.
A "Eat five to six small meals that are high-protein, low carbohydrate."
B "Avoid the use of emollients on affected skin and over scarred areas."
C "Arrange for physical therapy if you develop any problems with range of motion."
D "Notify the health care provider if you experience changes in sleep or mood."
E "Wear protective sleeves over your arms to prevent additional injury."

Question Explanation
Correct Answer is D, E
Rationale: Full thickness burns destroy multiple layers of skin, including their underlying
structures (i.e blood vessels, nerves, sweat glands, etc). The overall goals of the rehabilitation
phase with clients who have suffered these types of burns include injury prevention, prevention
of loss of range of motion, and mental health wellness. The client should be instructed to use
emollients on scarred skin to prevent it from becoming too dry, which can restrict movement.
Hypermetabolism can last up to a year and requires the client to have a balanced diet that is high
in both carbohydrates and protein. Wounds and scarred areas should be covered to prevent injury
to the area while it heals. Physical therapy is a process that starts in the acute care setting and

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continues for months, and sometimes even years, after the start of therapy. Depression and
anxiety are common and should be brought to the attention of the health care provider.
Concepts tested

Question 669
The psychiatric nurse is caring for a client who was voluntarily admitted to the hospital 2 days
ago for suicidal ideation. Today, the client states, "I demand to be released now!" Which
response by the nurse is most appropriate?
A "Let's discuss your decision to leave and then we can prepare you for discharge."
B "You can be released only if you sign a no suicide contract before you leave."
C "You have a right to sign out as soon as we get the health care provider's discharge order."
D "You cannot be released because you are still at risk of being suicidal."

Question Explanation
Correct Answer is A
Rationale: Clients who are voluntarily admitted to the hospital have the right to demand and
obtain release. Ideally clients should be given discharge instructions before they leave the
hospital. However, clients have the right to sign themselves out of the hospital at any time,
including against medical advice (AMA). The most appropriate response would be to engage the
client in therapeutic communication and find out their current state of mind and risk for suicide.
If the nurse felt that the client still represented a risk for suicide, a petition for
an involuntary admission/hospitalization should be initiated. The other responses are not
therapeutic or appropriate.
Concepts tested

Question 670
A nurse is working on a hospital medical-surgical unit. Which tasks can the nurse delegate to
unlicensed assistive personnel? Select all that apply.
A Insertion of an indwelling urinary catheter
B Educating a client about dietary modifications
C Monitoring and documentation of client intake and output
D Application of barrier cream to the perineal area
E Assisting a client with ambulation two days post-operatively

Question Explanation
Correct Answer is C, D, E
Rationale: The nurse can delegate tasks to unlicensed assistive personnel (UAP) when it follows
within the UAP's scope of practice. Application of barrier cream to the perineal area, assisting a
client with ambulation, and monitoring and documentation of client intake and output are all
within the UAP's scope of practice and can appropriately be delegated by the nurse. UAPs are
unable to insert an indwelling urinary catheter, as this is considered an invasive procedure that
should be done by the nurse. Additionally, UAP are not able to provide patient education or
teaching.
Concepts tested

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Question 671
The nurse is administering medication to a client who does not speak English. Which of the
following strategies should the nurse implement to ensure the client understands the purpose of
the medication? Select all that apply.
A Use the translation phone line to interpret information between the client and nurse.
B Communicate through a facility-approved interpreter.
C Use correct medical terminology during instructions.
D Maintain eye contact with the client, even when speaking to an interpreter
E Plan to take a longer amount of time than usual for medication administration.

Question Explanation
Correct Answer is A, B, D, E
Rationale: There are several tools available for the nurse to help the client who does not speak
English. These include translation phone lines and facility-approved interpreters. The nurse
should maintain eye contact with the client throughout the communication and should be
prepared for the encounter to take additional time. Medical terminology should be kept to a
minimum during communication with clients in general, but especially for clients with limited
English proficiency.
Concepts tested

Question 672
The nurse is caring for a homeless client recently diagnosed with type 2 diabetes. Which actions
demonstrate that the nurse is advocating for the patient? Select all that apply.
A Consult a social worker to help the client apply for Medicaid.
B Arrange for a family member to provide housing for the client.
C Provide a list of area pharmacies that offer free or reduced-price medications.
D Arrange for a follow-up appointment at a free clinic.
E Arrange for home delivery of prepared meals.

Question Explanation
Correct Answer is A, C, D
Rationale: The nurse as an advocate needs to understand the client's current situation. It would
not be possible for a homeless individual to receive scheduled meal delivery services. Family
members should not be approached. The nurse could arrange appointments at a free clinic and
refer the client to area pharmacies that provide free or reduced-price medications. The social
worker should be consulted to help the client apply for Medicaid, as well as for other available
social services.
Concepts tested

Question 673
The nurse is planning the discharge of an 80-year-old female client. Which of the following
indicates the client needs to be discharged to a skilled nursing facility instead of home? Select all
that apply.
A The client is not able to manage her activities of daily living (ADL).
B The client needs intensive rehabilitation after hip replacement surgery.

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C The client is able to prepare simple meals by herself.
D The client has a complex surgical dressing change
E The client is afraid to go home by herself.

Question Explanation
Correct Answer is A, B, D
Rationale: After a hospital stay, the client may not be able to return to self-care at home and
referrals to a skilled nursing facility may be necessary. Some of the criteria for admission to a
skilled nursing facility include not being able to manage her own ADL and requiring a complex
dressing change. Intensive rehabilitation is better accomplished at a skilled nursing facility.
Being afraid to go home by herself will need to be addressed prior to discharge but is not a
criterion for admission to a skilled nursing facility. If the client is able to prepare her own meals,
it is a sign that the client could stay at home.
Concepts tested

Question 674
While caring for a client after lumbar spine surgery, which action can the nurse on the ortho-
spine unit delegate to the unlicensed assistive person (UAP)?
A Log roll the client from side to side every two hours.
B Check the client's ability to plantar and dorsiflex the foot.
C Determine the client's readiness to ambulate.
D Ask about pain control with the patient-controlled analgesia (PCA).

Question Explanation
Correct Answer is A
Rationale: Repositioning a client is included in the training of UAPs. UAPs working on a
specialty unit, such as ortho-spine, will be familiar with how to maintain alignment for a
postoperative spinal surgery client. Evaluating the effectiveness of pain management, assessing
neurologic function such as plantar and dorsiflexion and evaluating a client's readiness to
ambulate after surgery require higher level nursing education and scope of practice and,
therefore, cannot be delegated to UAPs.
Concepts tested

Question 675
The nurse receives report on the following four clients. Which client should the nurse see first?
A A client with acute urinary retention who has orders to insert an indwelling catheter
B A client with a stage 3 pressure ulcer who is due for a scheduled dressing change
C A client who had a hysterectomy performed 12 hours ago and is nauseous
D A client who had an above the knee amputation and has a temperature of 101.3°F (38.5°C)

Question Explanation
Correct Answer is A
Rationale: The client with acute urinary retention should be seen first. The client needs to have
an indwelling urinary catheter inserted to relieve bladder distention. If acute urinary retention is

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left untreated, then bladder damage, incontinence or kidney failure can result. The other client
problems (e.g., nausea, fever and dressing change) are of lower importance.
Concepts tested

Question 676
The nurse is reviewing vital signs documented in the electronic health record for a group of
clients. Based on this data, which client should the nurse see first?
A A client diagnosed with atrial fibrillation who has a heart rate of 110 beats per minute.
B A client diagnosed with mitral valve insufficiency who has a blood pressure of 152/88.
C A client diagnosed with infective endocarditis who has a temperature of 101.8°F (39°C).
D A client diagnosed with heart failure who has a SpO2 of 82%.

Question Explanation
Correct Answer is D
Rationale: The nurse should see the client with heart failure and a SpO2 of 82% first. The client
with heart failure could be experiencing life-threatening pulmonary edema, and the SpO2 of 82%
indicates dangerously low oxygenation.

An elevated temperature in a client with infective endocarditis is a clinically significant but not
unexpected finding. A heart rate of 110 beats per minute in a client with atrial fibrillation is
concerning, but it does not reflect the same life-threatening clinical finding as the low SpO2 in
the client with heart failure. While elevated and of concern, a blood pressure of 152/88 is not as
high of a priority for the nurse to address as a dangerously low oxygen level.
Concepts tested

Question 677
The nurse is caring for a group of adult clients on a neurological unit in an acute care hospital.
Which client should the nurse see first?
A A client admitted several hours ago with a subdural hematoma due to an unwitnessed fall at
home
B A client admitted with hepatic encephalopathy who has an elevated ammonia level
C A client admitted with a transient ischemic attack, who has a bubble study echocardiogram
ordered
D A client admitted two days ago with an ischemic stroke who has a blood pressure of 158/64

Question Explanation
Correct Answer is A
Rationale: After an unwitnessed fall, the nurse must consider the possibility of head injury. Due
to the elevated risk for worsening bleeding and increased intracranial pressure because of the fall
and pre-existing head injury, the client with a subdural hematoma should be seen first. A blood
pressure of 158/64 in a client with an ischemic stroke would not represent an urgent situation,
and an elevated ammonia level would not be unexpected for a client with hepatic
encephalopathy. While the results of an echocardiogram with a bubble study would be relevant
to the care of client with a transient ischemic attack (TIA), this client is not showing signs of a
worsening condition requiring urgent assessment.
Concepts tested
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Question 678
A 65-year-old male client diagnosed with prostate cancer rates his pain level at 6 on a 0 to 10
scale. The client refuses all pain medication except for acetaminophen, which does not relieve
his pain. Which action should the nurse take first?
A Talk with the client's family about the situation.
B Ask the client further about the refusal of pain medication.
C Report the situation to the health care provider.
D Document the situation in the client’s medical record.

Question Explanation
Correct Answer is B
Rationale: Beliefs regarding pain are determined by sociocultural norms, including age and
gender. Nurses should investigate the meaning of pain to each client within a cultural
explanatory framework. Astute observations and careful assessments must be completed to
determine the level of pain the client is experiencing. Any action should be documented in the
client’s record, but this should occur after first speaking to the client. Should the client continue
to have pain, the nurse may need to speak to the family and the health care provider.
Concepts tested

Question 679
The nurse is caring for an adolescent who requires an informed consent for a procedure. Under
which circumstance can a minor client sign the consent?
A The client's guardian refuses to sign the consent.
B Both of the client's parents are deceased.
C The client has been deemed emancipated.
D The client is under the care of a foster family.

Question Explanation
Correct Answer is C
Rationale: Informed consent is a legal document that gives permission for invasive or high-risk
procedures such as blood transfusions and surgery. An informed consent for a procedure is
signed by the provider performing the procedure, the client and a witness. The legal age to give
consent in the United States is 18. An emancipated minor is younger than the legal age to give
consent but has been recognized to have the legal capacity to make an informed consent. The
only situation a minor client can sign for consent is if they have been deemed emancipated. A
minor cannot sign for consent if their guardian refuses. A minor whose parents are deceased or
who is under the care of a foster family is assigned a legal representative who would sign the
informed consent.
Concepts tested

Question 680
The home health nurse is developing a plan of care for a child with Duchenne muscular
dystrophy. Which other disciplines should the nurse consider collaborating with to slow the
progression and prevent complications of the disease? Select all that apply.

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A Physical therapy
B Orthopedist
C Pulmonologist
D Dietitian
E Speech therapy
F Nephrologist

Question Explanation
Correct Answer is A, B, C, D, E
Rationale: Duchenne muscular dystrophy (DMD) is the most severe and common muscular
dystrophy caused by a genetic mutation that results in degeneration of muscle fibers. The disease
is progressive causing weakness and wasting of skeletal muscles resulting in disability and
deformity. Clinical manifestations include trouble getting into a sitting or standing position,
difficulty walking, frequent falls and delayed growth. Complications of DMD include respiratory
compromise, cardiac failure, disuse atrophy and contractures. The goal of care is to slow the
progression of the disease and implement interventions to help prevent complications. The care
team should include physical therapy, speech therapy, cardiology, pulmonology, orthopedist and
a dietitian. Nephrology is not part of the care team for management of DMD.
Concepts tested

Question 681
The nurse is reviewing vital signs documented in the electronic health record for a group of
clients. Based on this data, which client should the nurse see first?
A A client diagnosed with atrial fibrillation who has a heart rate of 110 beats per minute.
B A client diagnosed with mitral valve insufficiency who has a blood pressure of 152/88.
C A client diagnosed with infective endocarditis who has a temperature of 101.8°F (39°C).
D A client diagnosed with heart failure who has a SpO2 of 82%.

Question Explanation
Correct Answer is D
Rationale: The nurse should see the client with heart failure and a SpO2 of 82% first. The client
with heart failure could be experiencing life-threatening pulmonary edema, and the SpO2 of 82%
indicates dangerously low oxygenation.

An elevated temperature in a client with infective endocarditis is a clinically significant but not
unexpected finding. A heart rate of 110 beats per minute in a client with atrial fibrillation is
concerning, but it does not reflect the same life-threatening clinical finding as the low SpO2 in
the client with heart failure. While elevated and of concern, a blood pressure of 152/88 is not as
high of a priority for the nurse to address as a dangerously low oxygen level.
Concepts tested

Question 682
The nurse is caring for a group of adult clients on a neurological unit in an acute care hospital.
Which client should the nurse see first?

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A A client admitted several hours ago with a subdural hematoma due to an unwitnessed fall at
home
B A client admitted with hepatic encephalopathy who has an elevated ammonia level
C A client admitted with a transient ischemic attack, who has a bubble study echocardiogram
ordered
D A client admitted two days ago with an ischemic stroke who has a blood pressure of 158/64

Question Explanation
Correct Answer is A
Rationale: After an unwitnessed fall, the nurse must consider the possibility of head injury. Due
to the elevated risk for worsening bleeding and increased intracranial pressure because of the fall
and pre-existing head injury, the client with a subdural hematoma should be seen first. A blood
pressure of 158/64 in a client with an ischemic stroke would not represent an urgent situation,
and an elevated ammonia level would not be unexpected for a client with hepatic
encephalopathy. While the results of an echocardiogram with a bubble study would be relevant
to the care of client with a transient ischemic attack (TIA), this client is not showing signs of a
worsening condition requiring urgent assessment.
Concepts tested

Question 683
A new nurse manager is responsible for interviewing applicants for a staff nurse position. Which
of the following interview strategies would be the best approach by the nurse manager?
A Obtain an interview guide from human resources
B Ask personal information of applicants
C Use simple questions requiring a "yes" or "no" answer
D Vary the interview style for each candidate

Question Explanation
Correct Answer is A
Rationale: The nurse manager is an active part of the interview process. As a result, they need to
know what interview questions to ask a potential employee. The manager should not ask yes or
no questions. Instead, they should ask about the candidate's experience, why they would be
valuable to the company and what they would do in certain situations. The new manager should
obtain an interview guide from human resources (HR) for consistency in reviewing each
applicant. An interview guide used for each candidate enables the nurse manager to be more
objective in decision-making. The nurse manager should use resources available in the agency
before the manager attempts to develop one from scratch. Although it's nice to give a variety of
questions, standardized questions and style should be used to compare applicant responses and
behaviors. The manager should not ask personal information of applicants to ensure they can
meet job demands. Asking certain personal questions is prohibited.
Concepts tested

Question 684
The nurse is caring for a client who is two days post-surgery and notes that the client is
experiencing a new and sudden onset of confusion. There is an order to discharge the client to go
home today. What would be the best action for the nurse to take?
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A Educate the client's family on how to create a calm and safe environment for the client
B Inform the client's health care provider about the change in the client's condition
C Collaborate with the dietitian to identify ways to increase protein in the client's diet
D Encourage the client to schedule a follow-up appointment with their primary care provider

Question Explanation
Correct Answer is B
Rationale: Delirium is considered a temporary, but acute condition, which is often characterized
by sudden confusion, agitation and disorganized thinking. Factors that have been known to
precipitate delirium include pain, dehydration, surgical procedures and opioid administration.
Clients who are at highest risk for developing delirium are older hospitalized clients and clients
who are admitted to intensive care units. All answer choices are plausible, but the best action for
the nurse to take, would be to inform the health care provider of the client's change in condition.
It is imperative that delirium is recognized early, as its causes are potentially reversible. Part of
the client's plan of care would be to also instruct the client and family to schedule a follow-up
visit with the primary care physician (PCP), develop a safe home environment and to maintain
ample protein intake to facilitate wound healing.
Concepts tested

Question 685
A registered nurse who is functioning as the charge nurse is determining shift assignments. What
is the best approach to determine which client assignments are appropriate for the licensed
practical nurse (LPN)?
A Determine how many unlicensed assistive personnel (UAP) are available to help the LPN with
client care
B Ask the LPN about prior experience caring for clients with various diagnoses
C Consider the LPN's scope of practice
D Refer to the list of technical tasks the LPN is trained to perform

Question Explanation
Correct Answer is C
Rationale: LPN scope of practice is the best method to consider when assigning care. While the
RN is responsible for ensuring a delegated assignment is completed appropriately and correctly,
the LPN must be able to perform the skills or tasks independently and within their scope of
practice.
Concepts tested

Question 686
The nurse is reviewing client assignments at the beginning of the shift. Which task could be
assigned to an unlicensed assistive person (UAP)?
A Clean and apply a dressing to a small pressure ulcer on the leg
B Empty a client's colostomy bag
C Stay with a client during the self-administration of insulin
D Monitor a client's response to passive range of motion exercise

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Question Explanation
Correct Answer is B
Rationale: If the UAP has demonstrated competency in the task, s/he may empty a client's
colostomy bag. This is an uncomplicated, routine task with an expected outcome. The other tasks
involve one or more parts of the nursing process and cannot be assigned to an UAP.
Concepts tested

Question 687
Upon completing an admission, the nurse identifies that an older adult client does not have an
advance directive. Which action should the nurse take?
A Refer this issue to the nurse manager and the risk manager
B Give the client written information about advance directives
C Document this information on the chart
D Assume that the client wishes full resuscitation efforts

Question Explanation
Correct Answer is B
Rationale: For each admission, nurses should request a copy of a client's current advance
directive. If there is none, the nurse must provide written information about what an advance
directive implies. It is then the client's choice to sign the forms. Note that a standard is for non-
direct care providers to witness these forms; a social worker or other health care professional
would need to witness a client's signature.
Concepts tested

Question 688
A client is scheduled for a transesophageal echocardiogram (TEE). Prior to the procedure, which
activity could be delegated to the unlicensed assistive person (UAP)?
A Provide basic instructions about the procedure
B Obtain a signed consent
C Assess the client's psychological state
D Remove the pitcher of water from the bedside table

Question Explanation
Correct Answer is D
Rationale: Removing the water pitcher would be an appropriate task because the client would be
NPO. The health care provider is responsible for instructions about the procedure and needs to
address client questions or concerns. The nurse is typically responsible to obtain a signed consent
form and to assess the client both physically and psychologically before the procedure.
Concepts tested

Question 689
A client continuously calls out to the nursing staff when anyone passes the client's door. He has
various requests for assistance. The charge nurse should implement which intervention?
A Assign a nursing staff member to visit the client at regular intervals
B Reassure the client that a staff person will check frequently to see if the client needs anything

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C Keep the client's room door cracked to minimize the distractions of people passing by the
room
D Arrange for each staff member to go into the client's room to check on needs every hour on
the hour

Question Explanation
Correct Answer is A
Rationale: Regular, frequent, planned contact by a designated staff member is the best approach
to provide a continuity of care and communicate to the client that care will be available as
needed.
Concepts tested

Question 690
A client was recently discharged from a locked inpatient psychiatric facility. During a scheduled
outpatient appointment, the client states to the nurse, "I'm afraid I am going to get sick again."
Which response by the nurse is most likely to promote recovery?
A "You shouldn't fear a relapse because it can happen to anyone and we will be here to help
you."
B "I will provide you with a bus pass and referral to a support group that will help you learn
about managing your illness and medications."
C "If you take your medications exactly as your health care provider instructed, you won't get
sick again."
D "I think you are doing well but you can call for an appointment with your health care provider
if you think you need help."

Question Explanation
Correct Answer is B
Rationale: Relapse prevention is a priority focus for clients recovering from an acute mental
illness episode. Since education plus peer and community support rank high in helping prevent
relapse, the priority is to refer the client to after-care and support groups. Additionally, since
continuity of care involves access to care, the nurse should address the client's transportation
needs by offering them a bus pass so they can attend these meetings. Continuing to take
medications is important, but advice and reassurance without tangible follow up is not helpful to
clients in early recovery from an acute event. Reassurance and referral to a health care provider
may also be inadequate and does not demonstrate the nurse's concrete role in relapse prevention.
Telling the client not to fear relapse and providing false reassurance is non-therapeutic.
Concepts tested

Question 691
The ICU nurse works in a rural hospital that has a remote electronic ICU monitoring system
(eICU). What is one of the best reasons for having access to an eICU?
A Less staff is needed on site when a remote eICU is available
B Clients can ask the intensivist for a second opinion
C An ICU nurse and intensivist remotely monitor ICU clients around the clock
D An ICU nurse is on-call to answer questions when needed

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Question Explanation
Correct Answer is C
Rationale: Using cameras, microphones, and high-speed computer data lines, the eICU involves
having an experienced ICU nurse and practicing intensivist monitoring ICU clients in remote
locations around the clock. The eICU does not change the ratio of nurses to clients at the
bedside, but it does make the nurse's bedside time more productive and assistance from their
remote colleagues is only a push button away.
Concepts tested

Question 692
A staff nurse on a busy inpatient hospital unit observes a coworker placing a syringe with an
opioid medication into their pocket and going into an empty patient room. Which is
the best action for the nurse to take?
A Wait until things quiet down and then talk to the coworker about getting help.
B Ask another staff member for advice on what to do.
C Follow the coworker and confront them about their addiction.
D Report the observation to the nursing supervisor immediately.

Question Explanation
Correct Answer is D
Rationale: Although the nurse's observation appears to point toward a coworker who might be
diverting opioids, it is presumptive to jump to the conclusion that the coworker's action is
malicious. The best course of action is to follow facility protocol which typically consists of
notifying the next person in the chain of command such as a manager or supervisor. This should
be done immediately to give that person the opportunity to come to the unit right away and
assess the situation. If it turns out that the nurse's coworker appears impaired, they should be
immediately removed from the patient care area and drug tested.
Concepts tested

Question 693
The nurse is caring for a client who underwent a colon resection one day ago. There is an order
to assist the client with ambulation three times per shift while the client is awake. Which
instruction by the nurse is most appropriate when assigning this task to the unlicensed assistive
person (UAP)?
A "When assisting the client, be sure to ask about the intensity of the pain."
B "Have the client stand for at least two minutes before starting to walk."
C "Apply a gait belt around the client's waist if the client reports feeling dizzy."
D "Allow the client to sit on the side of the bed before assisting the client to stand and walk."

Question Explanation
Correct Answer is D
Rationale: The only appropriate statement is to allow the client to sit on the side of the bed first,
before standing and walking. It is not necessary to stand up for two minutes before starting to
walk. A gait belt should not be used since the client had abdominal surgery; besides, the UAP
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should not assist clients to stand and walk if they report feeling dizzy. The UAP cannot assess
clients (ask about the intensity of the pain).
Concepts tested

Question 694
The nurse manager considers changing staff assignments from 8-hour shifts to 12-hour shifts. A
staff-selected planning committee has approved the change, yet staff are not receptive to the
plan. Which action should the nurse manager take first?
A Explore how the planning committee evaluated barriers to the plan
B Design a different approach to deliver care with fewer staff
C Retain the previous staffing pattern for another six months
D Support the planning committee and post the new schedule

Question Explanation
Correct Answer is A
Rationale: A manager is ultimately responsible for delivery of care and yet has given a
committee chosen by staff the right to approve or disapprove the change. Planned change
involves exploring barriers and restraining forces before implementing change. To smooth
acceptance of the change, restraining factors need to be evaluated. The manager wants to build
the staff's skills at implementing change. Helping the committee evaluate its decision making is a
useful step before rejecting or implementing the change. When possible, all affected by the
change should be involved in the planning. The question is whether staff input has been
thoroughly taken into consideration. This also illustrates the application of the nursing process to
nonclient-care issues with assessment of the situation being the first step.
Concepts tested

Question 695
The registered nurse (RN) is responsible for a client in isolation. Which nursing activity can be
assigned to a licensed practical nurse (LPN)?
A Evaluating staff's compliance with infection control measures
B Observing for and removing risks in the client's room
C Assessing the client's attitude about infection control
D Reinforcing isolation precautions with visitors

Question Explanation
Correct Answer is D
Rationale: LPNs (and unlicensed assistive persons) can reinforce information that was originally
given by the RN. The other options are RN responsibilities and cannot be delegated.
Concepts tested

Question 696
A nursing student asks the nurse manager to explain the forces that drive health care reform. The
appropriate response by the nurse manager should include which approach?
A Increased numbers of older adults and of the chronically ill of all ages
B A steep rise in provider fees and in insurance premiums

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C The escalation of fees with a decreased reimbursement percentage
D High costs of diagnostic and end-of-life treatment procedures

Question Explanation
Correct Answer is C
Rationale: The percentage of the gross national product representing health care costs rose
dramatically with reimbursement based on fee-for-service. Reimbursement for Medicare and
Medicaid recipients based on fee-for-service also escalates health care costs.
Concepts tested

Question 697
The nurse continually avoids answering the call light of clients with alternative lifestyles. The
nurse's behavior is an example of which concept?
A Benevolence
B Stereotyping
C Discrimination
D Nonmaleficence

Question Explanation
Correct Answer is C
Rationale: Nurses are responsible for caring for individuals in a manner that demonstrates
benevolence and nonmaleficence. This nurse is discriminating against these clients by
continually not answering the call light. Stereotyping is defined as the thought that all members
of an ethnic group, culture, or race all act alike.
Concepts tested

Question 698
A new nurse is delegating tasks to the unlicensed assistive personnel (UAP). If delegated, which
task would require intervention by the nurse manager?
A Bathe a woman receiving brachytherapy with an internal radon device
B Assist an elderly client to the restroom
C Feed a 2-year-old with a broken arm
D Empty the urethral collection bag and provide perineal care

Question Explanation
Correct Answer is A
Rationale: Caring for a client receiving brachytherapy with a radon implant and the associated
hardware is complex. Additionally, movement of this client and exposure of healthcare workers
to the radiation should be limited. The other tasks are simple and within the expectations of a
UAP's duties.
Concepts tested

Question 699
The charge nurse is informed about a conflict between two unlicensed assistive personnel (UAP)
on the unit. Which approach is most appropriate to achieve effective conflict resolution?

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A Encourage the UAPs to '"vent" their anger.
B Require the UAPs to meet 1-on-1 until they reach a compromise.
C Explain the consequences of not resolving their differences.
D Deal directly with the conflict affecting the workplace.

Question Explanation
Correct Answer is D
Rationale: When managing conflict in the workplace, it is most important to deal with the issue
directly. The conflict occurs, it should not be minimized or ignored. When there is a conflict,
people tend to feel angry and although "venting" may feel good, is is usually counterproductive.
Forcing the UAPs to reach a compromise is not appropriate. If necessary, potential consequences
of not resolving the conflict between the UAPs should be discussed.
Concepts tested

Question 700
After receiving report on the following clients, which client should the nurse assess first?
A A client diagnosed with peptic ulcer disease (PUD) who reports feeling dizzy
B A client diagnosed with emphysema with questions about a new medication
C A client who underwent a partial gastrectomy and reports feeling lightheaded
D A client reporting gastric distress after taking ibuprofen

Question Explanation
Correct Answer is A
Rationale: Dizziness with PUD may indicate hemorrhaging. This client should be assessed
including a symptom assessment and vital signs. The findings in the other options are expected
and not life-threatening. A client may feel lightheaded due to dehydration and pain management
related to a gastrectomy. Ibuprofen is a nonsteroidal anti-inflammatory drug, which has a
common side effect of gastrointestinal symptoms. While educating the client on the new
medication is important, it is not a priority for assessment.
Concepts tested

Question 701
The nurse who travels with an agency is uncertain about what tasks can be performed when
working in a different state. It would be best for the nurse to check which resource?
A The American Nurses Association's Social Policy Statement
B With a nurse colleague who has worked in that state two years ago
C The state nurse practice act in which the assignment is made
D The policies and procedures of the assigned agency in that state

Question Explanation
Correct Answer is C
Rationale: The state Nursing Practice Act is the governing document of the scope of practice in
any given state. The assigned agency policy would not govern what the Registered Nurse can do
in a state and while a nursing colleague may be knowledgeable, the nurse should review the
primary legal document to ensure understanding. The American Nurses Association's Social

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Policy Statement provides information on the profession of nursing through the Social Contract
theory.
Concepts tested

Question 702
The home health aide calls the nurse to report information about a client. Which information
should be the highest priority for the nurse?
A "The family wants to discontinue the home meal service called Meals on Wheels.
B "The partner says the client has gotten slower when doing things every other day."
C "The urine in the urinary catheter bag is of a deeper amber, almost brown color."
D "The client reports not sleeping well for the past week."

Question Explanation
Correct Answer is C
Rationale: Home health aides often report diverse client information to nurses through phone
calls and electronic documentation. The nurse who develops the plan of care for a specific client,
and supervises the aide, must identify potential danger signs that require immediate action and
follow-up. The information of highest priority is the abnormal color of the urine from the client's
urinary catheter which can be indicative of a urinary tract infection or other renal-urinary
problem. The other options may need further assessment but are not the priority.
Concepts tested

Question 703
The interdisciplinary team is meeting to discuss the discharge plan for a client following total hip
replacement surgery. Which assessment finding is most important for the team to address?
A The adult daughter will be responsible for shopping and driving the client after discharge
B The client does not like the taste of the oral potassium supplement medication.
C The partner expresses some discomfort with the dressing change.
D The home is a two-story and all bedrooms and bathrooms are located upstairs.

Question Explanation
Correct Answer is D
Rationale: Nurses are charged with the responsibility to advocate for clients. Because of the
intimate work with clients, nurses often discover critical information that will impact discharge
planning. It is important to share these insights with the health care team to ensure the client's
needs are met after discharge. A client who has undergone major orthopedic surgery can expect
some mobility impairment after discharge. The nurse should ask questions regarding the physical
characteristics of the home including stairs, location of essential rooms, bathroom set up, pets
and carpeting. Therefore, it is most important to identify and address any potential safety issues
in the client's home.
Concepts tested

Question 704
The nurse is obtaining the health history for a client with the help of an interpreter. To promote
clear communication with the client, which of these actions is appropriate for the nurse to use?

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A Arrange the setting so the interpreter and client can be easily seen by the nurse
B Provide the interpreter with a list of questions to address and stay with the client
C Ask the client to speak slowly and clearly with pauses after every statement
D Look at the interpreter when communicating the needed questions

Question Explanation
Correct Answer is A
Rationale: The nurse should look directly at the client when speaking to the client with an
interpreter. The nurse should observe the client for nonverbal cues while the client answers the
questions. This is best achieved by arranging the setting so the nurse, interpreter and client can
easily see each other. It is important to note that the nurse is interviewing the client. It would be
inappropriate for the nurse to write a list of questions for the interpreter. Additionally, the client
should speak in their normal tone and speed for the interpreter.
Concepts tested

Question 705
Which nursing practice best reduces the chance of communication errors that could lead to
negative client outcomes?
A Speak using a professional tone on the telephone
B Document nursing care at the end of the shift
C Maintain respectful working relationships with all staff
D Use standardized forms for client handoffs Correct Answer

Question Explanation
Correct Answer is D
Rationale: Nurses should use standardized forms to improve communication between
caregivers. A standardized form will decrease the risk of omitting pertinent information
concerning the client's care. The options of maintaining a respectful working relationship and
using a professional tone while speaking on the telephone are good practice, but not as vital as
standardized forms. Documenting nursing care at the end of the shift is incorrect. Documentation
should be done immediately following the provision of care. This will decrease the likelihood of
omitting important information.
Concepts tested

Question 706
The nurse is working in a health care setting that utilizes an electronic medical record (EMR) for
documentation. Which actions will reduce the risk for inappropriate access to confidential client
information? Select all that apply.
A The nurse writes down their current password on a list that's kept in the manager's office.
B The nurse changes their personal password for the EMR more frequently than required.
C The nurse reviews only the medical records of assigned clients during their shift.
D The nurse utilizes the automatic sign-off to close the medical record after a period of
inactivity.
E The system administration department monitors all medical records accessed by staff
members

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Question Explanation
Correct Answer is B, C, E
Rationale: Practices that support EMR security include frequently changing passwords (using a
combination of letters, numbers and symbols) and not sharing passwords with others. The
information technology department typically monitors all access to an EMR and tracks
unauthorized log-ins. The nurse should only review medical records for their assigned clients.
Best practice is to sign or log off when leaving the computer screen and not rely on an automatic
timeout because this can leave the system temporarily open for others to view/access confidential
client information.
Concepts tested

Question 707
The nurse manager of an emergency department is planning for the arrival of a high number of
clients due to a mass casualty event nearby. Which style of leadership would be most appropriate
under these circumstances?
A Apply an integrative leadership approach
B Assume an autocratic, decision-making role
C Adopt a transformational, nondirective approach
D Engage in collaborative practice

Question Explanation
Correct Answer is B
Rationale: A manager should change their leadership style to fit the circumstances. During an
emergency or crisis situation, decisions will have to be made fast and the manager will not have
time to solicit input from staff; therefore, an autocratic or authoritarian leadership style
is most appropriate in this situation. The other leadership styles would be appropriate in different
situations, but not an emergency or crisis situation.
Concepts tested

Question 708
The charge nurse makes assignments for the nursing team, which consists of registered nurses
(RNs) and licensed practical nurses (LPNs). Which client should be assigned to the LPN?
A A 65 year-old scheduled for discharge after angioplasty and stent placement
B A 49 year-old diagnosed with a new onset atrial fibrillation with a rapid ventricular response
C A 58 year-old with a history of hypertension, diagnosed with possible angina Correct Answer
D A 35 year-old who is 12 hours post cardiac catheterization

Question Explanation
Correct Answer is C
Rationale: LPNs should not be assigned clients that are unstable or require in-depth assessment
and education. The LPN scope of practice does not include new admissions or the administration
of blood products. For these options, the most stable client is the 58-year-old diagnosed with
possible angina. An RN would need to provide education or frequent assessments on the other
clients.
Concepts tested
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Question 709
A health care system utilizes decentralized scheduling on all the nursing units. What is the
primary advantage of this management strategy?
A Allows requests for special privileges
B Considers client and staff needs
C Conserves time spent on planning
D Frees the nurse manager to handle other priorities

Question Explanation
Correct Answer is B
Rationale: Decentralized scheduling takes into consideration specific unit, client, and staff needs.
Staffing is decided based on priorities at the unit (micro) level, not the health care system
(macro) level.
Concepts tested

Question 710
A staff nurse reports to the nurse manager that an unlicensed assistive personnel (UAP)
consistently does not perform assigned work duties. Which of these statements should the nurse
manager make initially?
A "I will arrange for a conference with you, the UAP, and myself within the next week."
B "I can assure you that I will look into the matter in due time."
C "I would like for you to directly approach the UAP about the problem the next time it
occurs."
D "I will add this concern to the agenda for the next unit meeting so all the staff can discuss it."

Question Explanation
Correct Answer is C
Rationale: It is the nurse manager's role to help staff manage conflict among themselves. If the
two staff members cannot resolve the issue, the next step would be to arrange for a private
conference with the nurse manager and the staff involved in the conflict. Assuring the matter will
be dealt with in due time does not address the issue directly. It would not be appropriate to
discuss a conflict between two members in a group (staff meeting) setting as trust could break
down and confidential information could be disclosed.
Concepts tested

Question 711
There are perceived inequities about weekend scheduling on a nursing unit being discussed at a
staff meeting. What action should the nurse manager take at this point?
A Help staff understand the complexity of scheduling issues
B Allow the staff to change assignments
C Facilitate a discussion about staffing alternatives
D Clarify reasons for current assignments

Question Explanation
Correct Answer is C

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Rationale: Part of the nurse manager's role is to be a change agent. By facilitating a discussion
about scheduling alternatives, the staff becomes part of the solution, and it gives them an
opportunity to voice varied perspectives. They become part of the decision-making process. This
type of discussion will also help the staff understand the complexity of scheduling issues and the
rationale for the current assignments. Allowing the staff to change assignments is a temporary
solution and may not meet the needs of the unit.
Concepts tested

Question 712
The nurse manager has interviewed several nurses for a staff position. The most qualified nurse
is one with a sensory impairment. In order to better understand the issue of reasonable
accommodations, the nurse manager meets with the director of human resources. Which
approach would be most appropriate?
A Consult with the facility attorney to determine any potential liability
B Recommend to the nurse to consider applying at another facility
C Inform the nurse with the disability that the position is not a good fit
D Determine the type of accommodations the nurse would require

Question Explanation
Correct Answer is D
Rationale: In the United States, the Americans with Disabilities Act (ADA) is designed to allow
individuals with motor, cognitive, psychiatric, or sensory impairment equal access to
employment opportunities. Employers must evaluate an applicant's ability to perform the job on
a case-by-case basis and cannot discriminate on the basis of a disability. Employers are required
to make "reasonable accommodations." An example of this would be installing a ramp for
someone who uses a wheelchair. The other approaches are not appropriate and could be
considered "discriminatory" and illegal.
Concepts tested

Question 713
The charge nurse is planning assignments on a surgical unit. Which activity should the charge
nurse assign to the unlicensed assistive personnel (UAP)?
A Assist with meals and monitor ability to swallow following a mild stroke
B Apply compression stockings and ambulate in hall three times a day
C Change post-op hip dressing after removal of a drainage tube
D Review dietary needs with client prior to transfer to long-term care facility

Question Explanation
Correct Answer is B
Rationale: UAP can be assigned routine tasks that have predictable outcomes. Many of the tasks
a UAP can do involve activities of daily living (ADLs), such as personal hygiene (shaving,
bathing, oral hygiene, hair care, and toileting), assisting with dietary needs, and measuring vital
signs. Sometimes a UAP may be allowed to change a dry, nonsterile dressing. Although UAP
routinely assist clients with delivering and setting up food trays, UAP cannot assess a client's
ability to swallow. Client teaching prior to discharge is a nursing responsibility.
Concepts tested
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Question 714
The nurse is making assignments for the unlicensed assistive personnel (UAP). Which activity
should the nurse assign to the UAP?
A Adjust the rate of a gastric tube feeding
B Ask a client receiving chemotherapy about pain
C Check the blood pressure of a two-hour postoperative client
D Record a history on a newly admitted client

Question Explanation
Correct Answer is C
Rationale: UAPs must be assigned tasks that are routine, have expected outcomes, and require no
nursing judgment or decision-making situations. Vital signs on stable clients are commonly
assigned to unlicensed staff.
Concepts tested

Question 715
An unlicensed assistive personnel (UAP) who usually works on the pediatric unit is assigned to
work on an adult medical-surgical unit. Which question should the charge nurse ask prior to
assigning duties and tasks to the UAP?
A "When are you available for us to review your competency checklist?"
B "How long have you been a UAP?"
C "Do you think you will be comfortable caring for adult clients?"
D "What type of client care did you give in pediatrics?"

Question Explanation
Correct Answer is A
Rationale: The UAP must be competent to accept assigned tasks. Using a checklist developed by
the health care organization is the most objective and comprehensive way to determine the
UAP’s skill set. The length of time in a position and determining the comfort level of the UAP
does not guarantee competency. Client care in pediatrics may not necessarily be relevant in an
adult unit.
Concepts tested

Question 716
The registered nurse (RN) is giving instructions to an unlicensed assistive personnel (UAP)
regarding care activities for a new admission. Which directive provides the best information
about assigned tasks?
A "Before 12 pm today, ambulate the client, and replace the sequential compression device
(SCD) afterward."
B "You will need to frequently take an oral temperature for the client, and report the results to
me immediately if it is too high."
C "Let me know how the new admission is doing, and tell me if you need any help."
D "Beginning at 8 am, empty the urinary catheter bag hourly, and write the amount and time on
the whiteboard."

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Question Explanation
Correct Answer is D
Rationale: When assigning tasks, directions must be clear, concise, correct, and complete.
Emptying the catheter bag and recording the amount hourly starting at 8 am meets these
guidelines. The options related to ambulation and measuring the client's temperature are vague
and incomplete. The option about the new admission is also vague and requires assessing the
client; only RNs can assess clients.
Concepts tested

Question 717
The charge nurse assigns the unlicensed assistive personnel (UAP) to measure vital signs. Clear
written and verbal instructions were given to the UAP not to take the blood pressure on the left
arm of a client. The charge nurse later observes a blood pressure cuff on this client's left arm.
Which of these statements is accurate?
A The UAP is covered by the charge nurse's license.
B The charge nurse did not appropriately make assignments.
C The charge nurse has no accountability for this situation.
D The UAP is responsible for following instructions given by the charge nurse.

Question Explanation
Correct Answer is D
Rationale: The UAP is responsible for carrying out the activity correctly once instructions have
been clearly communicated verbally and in writing. The licensed nurse does retain accountability
for the delegation of the assignment and the tasks assigned. Taking vital signs falls within the
parameter of tasks that can be assigned to a UAP. The UAP is not covered under the nurse’s
license.
Concepts tested

Question 718
During the admission process, the staff nurse realizes that the information on the identification
(ID) bracelet does not match the information on the client's admission face sheet. What action
should the nurse take?
A Communicate with staff that the patient must be identified using the admission face sheet only
B Contact the admissions department to create a new ID bracelet
C Use a permanent marker to change the incorrect information on the ID bracelet
D Write the corrected information on the whiteboard in the client's room

Question Explanation
Correct Answer is B
Rationale: The admissions department has the responsibility to verify the client’s identity, apply
the correct bracelet or another identifier to the client, and keep all records in the system accurate
and consistent. The other options are unsafe practices that could lead to error and patient harm.
Concepts tested

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Question 719
The charge nurse is making assignments on the day shift for a registered nurse (RN), a licensed
practical nurse (LPN), and a certified nursing assistant (CNA). Which assignments are
appropriate for a client who fell during the night, has a skin tear on the arm, a hematoma on the
hip, and is scheduled for an X-ray of the hip? Select all that apply.
A Assign medication administration to the LPN
B Assign the CNA to assist with personal hygiene tasks
C Assign wound care to the RN
D Assign complete care to the LPN
E Assign the LPN to report confusion or headache

Question Explanation
Correct Answer is A, B, C, E
Rationale: Since the client fell during the night, the RN should do the complete care and the
wound care as these are opportunities to assess the patient’s mental and physical status. The RN
can assign certain duties to LPNs if the care is not too complex, and there is a low likelihood of
complications resulting in an emergency. The LPN can administer medication and should report
observations and data collection information to the RN. If the client remains stable, the CNA can
assist the client with personal care activities.
Concepts tested

Question 720
The home health nurse is caring for the client diagnosed with diabetes mellitus and arthritis. The
client is having difficulties drawing up insulin. Which of the following resources would be most
appropriate for the nurse to refer the client to?
A Activity therapist from the community center
B Social worker from the local hospital
C Occupational therapist from the home health agency
D Another client diagnosed with diabetes mellitus

Question Explanation
Correct Answer is C
Rationale: In order for the client to administer their insulin, they would need to fill the correct
syringe with the right amount of insulin, decide where to give the injection, and know how to
give the injection. Another client with diabetes would not be appropriate. It would be considered
a violation of the Health Insurance Portability and Accountability Act (HIPAA). In addition, the
other client is not a health care worker. A social worker would help the client identify
community resources that are needed for their health care (i.e. support services, transportation,
meal services, etc.). An activity therapist would plan and coordinate recreation programs for
patients in hospitals or long-term care facilities. Activities include trips, social activities, and arts
and crafts. An occupational therapist can assist a client to improve the fine motor skills needed to
prepare an insulin injection. The other resources would not be helpful in this situation.
Concepts tested

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Question 721
The nurse has been managing the care of a home health client for six weeks. In order to
determine the quality of care being provided to the client by a home health aide, what should be
the priority action by the nurse?
A Check the documentation of the home health aide for accuracy
B Investigate if the home health aide is prompt and stays an appropriate length of time
C Ask the client if they are satisfied with the care given by the home health aide
D Determine if the home health aide's care is consistent with the plan of care Correct Answer

Question Explanation
Correct Answer is D
Rationale: Home health care allows clients to receive care in the home. Clients receive quality
care from home health aides who are supervised closely by registered nurses. The client's
feedback is important as it could impact their plan of care. The client's engagement in the plan of
care is recommended. It is important that the nurse investigates the accuracy of documentation,
promptness, and length of stay by the home health aide. These are essential characteristics of a
health care worker. These characteristics could also impact employment, as they are a
component of professional behavior. Although the nurse must investigate all of these things, the
first priority is an evaluation of the adherence to the plan of care. The plan of care is based on the
reason for referral, the provider's orders, the initial nursing assessment, and the client's responses
to the planned interventions. It is what justifies the care of the client.
Concepts tested

Question 722
The nurse is teaching a client about a procedure to be done in the home. The client requires an
interpreter. When using the interpreter, the nurse should take which of the following approaches?
A Face the client while presenting the information as the interpreter talks in the native language
B Speak directly to the interpreter while presenting information, but allow the client time to ask
questions
C Talk to the interpreter in advance, and leave the client and interpreter alone
D Include a family member in the teaching session, and speak only to them

Question Explanation
Correct Answer is A
Rationale: Communication is the cornerstone of an effective teaching plan, especially when the
nurse and client do not share the same culture. Interpreter services reduce liability, increase client
satisfaction, and improve client outcomes. Even if the nurse uses an interpreter, it is still critical
that the nurse uses personal spacing, eye contact, and touch that are acceptable to the client.
Therefore, to face the client and present the information to them allows the interpreter to
translate the content. Facing the client also allows nonverbal communication to take place
between the nurse and client. This could also be perceived as a sign of respect. It would be
important to allow a family member to be present during the session to help reinforce content
with the client. However, the family member should not relay critical information to the client
firsthand. Leaving the interpreter and client alone is not appropriate. The nurse needs to be
present to field questions in real-time and ensure that the interpreter relays all pieces of
information accurately.
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Concepts tested

Question 723
The nurse is caring for a client who asks the nurse to use a treatment method that the client read
about on the internet. Which of the following responses by the nurse would be most appropriate?
A "You shouldn't really use the internet for health care information. Most of it is incorrect."
B "Can you tell me more about the website where you read the information?"
C "I am willing to give it a try. Does it say what the success rate is for using this treatment?"
D "Why are you questioning your doctor's order? She is an expert in the field."

Question Explanation
Correct Answer is B
Rationale: Clients are internet savvy and often search the internet for medical information about
their conditions and request information from others using social media. Since there is a lot of
information on the internet, clients need the expertise of nurses and other health care providers to
direct clients to information that is reliable, current, and evidence-based. Many health care
organizations have a list of vetted mobile apps and internet sites clients can use. Asking the
client an open-ended question about the origin of the information is a therapeutic communication
approach and allows the nurse to determine the quality of the information and demonstrate
respect for the client's autonomy. The other responses are non-therapeutic and will most likely
make the client feel guilty for taking the initiative to learn more about their health.
Concepts tested

Question 724
The nurse is admitting a client with pneumonia to the medical-surgical unit. When would it
be most appropriate for the nurse to initiate discharge planning for this client?
A When the client is informed of their date of discharge
B Upon admission to the hospital
C Immediately after the client's condition is stabilized
D When the client or family demonstrates readiness to learn

Question Explanation
Correct Answer is B
Rationale: With decreased lengths of stay, discharge plans must be incorporated into the initial
plan of care upon admission to an emergency department or hospital unit. Thus, is the thought
"discharge planning begins on admission."
Concepts tested

Question 725
After working with a client, an unlicensed assistive personnel (UAP) tells the nurse, "I have had
it with that demanding client. I just can't do anything that pleases him. I'm not going in there
again." Which response by the nurse is mostappropriate?
A "He may be scared and taking it out on you. Let's talk to figure out what to do next."
B "He has a lot of problems. You need to have patience with him."
C "I will talk with him and try to figure out what to do or what the problem is."

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D "Ignore him and get the rest of your work done. Someone else can care for him."

Question Explanation
Correct Answer is A
Rationale: The first response doesn't address the client's problems and belittles the UAP's
feelings. The second response omits the UAP from the issue and excludes her from the plan of
care. The third response encourages the UAP to ignore the problem, and it also doesn't fix the
problem and excludes the UAP from the plan of care. The UAP should be encouraged to
contribute to the plan of care to help solve the problem. The client should also be encouraged to
express their feelings. The nurse and UAP need to collaborate and make sure the client's needs
are being met.
Concepts tested

Question 726
The nurse is auditing documentation in clients' medical records. Which entry in a client's
progress notes is the most complete?
A Client expresses anxiety about a low-salt diet
B Client's urinary output adequate for the past shift
C Demerol 75 mg administered for severe abdominal pain
D Dark green drainage 100 mL from nasogastric tube at 0600

Question Explanation
Correct Answer is D
Rationale: Documentation reflects the client's condition and the care they've received during
their hospitalization. Documentation needs to be complete, accurate, and objective.
Reimbursement from third-party payers is facilitated when documentation is accurate, reliable,
and valid. Nurses need to adhere to good documentation standards as it minimizes a nurse's
chance of being named in a malpractice lawsuit. The word "anxiety" in the answer choice could
be defined more specifically along with the inclusion of information about the nurse's response.
The medication order lacks the route, frequency, and the client's response to the medication. The
description of the nasogastric drainage is the most specific and factual. The criteria for
"adequate" urinary output needs to be defined.
Concepts tested

Question 727
The new nurse manager is preparing for a meeting with the staff to come up with ideas for how
to reduce the number of falls on the unit. Which approach would be best for the nurse manager to
use?
A Show a presentation on fall data
B Have the staff engage in brainstorming
C Conduct an anonymous staff survey
D Present a research article

Question Explanation
Correct Answer is B

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Rationale: Brainstorming combines a relaxed, informal approach to problem-solving with lateral
thinking. It encourages people to come up with thoughts and ideas. The goal of brainstorming is
to gather as many ideas as possible without judgment that slows the creative process and may
discourage innovative ideas. Therefore, having the staff engage in brainstorming during the
meeting would be the best approach.
Concepts tested

Question 728
The nurse knows that a client's information should be kept confidential. In which of these
situations shall the nurse make an exception to this practice?
A When a visitor insists that they have been given permission by the client
B When the client threatens to harm themself or another individual
C When the healthcare provider (HCP) decides the family has a right to know
D When the client's family member offers information about the client

Question Explanation
Correct Answer is B
Rationale: Client information is kept private unless the client states verbally or in writing that
their information can be shared with another individual. In addition, if the client becomes
incapacitated and they have a next of kin or health care proxy, their information can be shared
with one of these individuals. The only exception to this rule is if the client threatens to harm
themself or another individual. The Tarasoff ruling, or duty to warn, instructs health care
workers that if a client threatens to harm themself or another individual, they must warn the
intended victim and contact the police.
Concepts tested

Question 729
The nurse is administering medication to a client who does not speak English. Which of the
following strategies should the nurse implement to ensure the client understands the purpose of
the medication? Select all that apply.
A Use the translation phone line to interpret information between the client and nurse
B Communicate through a facility-approved interpreter
C Use correct medical terminology during instructions
D Maintain eye contact with the client even when speaking to an interpreter
E Plan to take a longer amount of time than usual for medication administration

Question Explanation
Correct Answer is A, B, D, E
Rationale: There are several tools available for the nurse to help the client who does not speak
English. These include translation phone lines and facility-approved interpreters. The nurse
should maintain eye contact with the client throughout the communication and should be
prepared for the encounter to take additional time. Medical terminology should be kept to a
minimum during communication with clients in general but especially for clients with limited
English proficiency.
Concepts tested

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Question 730
The nurse is caring for a homeless client recently diagnosed with type 2 diabetes. Which actions
demonstrate that the nurse is advocating for the patient? Select all that apply.
A Consult a social worker to help the client apply for Medicaid
B Arrange for a family member to provide housing for the client
C Provide a list of area pharmacies that offer free or reduced-price medications
D Arrange for a follow-up appointment at a free clinic
E Arrange for home delivery of prepared meals

Question Explanation
Correct Answer is A, C, D
Rationale: The nurse as an advocate needs to understand the client's current situation. It would
not be possible for a homeless individual to receive scheduled meal delivery services. Family
members should not be approached. The nurse could arrange appointments at a free clinic and
refer the client to area pharmacies that provide free or reduced-price medications. The social
worker should be consulted to help the client apply for Medicaid as well as for other available
social services.
Concepts tested

Question 731
The nurse is planning the discharge of an 80-year-old female client. Which of the following
indicates the client needs to be discharged to a skilled nursing facility instead of home? Select all
that apply.
A The client is not able to manage her activities of daily living (ADL).
B The client needs intensive rehabilitation after hip replacement surgery.
C The client is able to prepare simple meals by herself.
D The client has a complex surgical dressing change.
E The client is afraid to go home by herself.

Question Explanation
Correct Answer is A, B, D
Rationale: After a hospital stay, the client may not be able to return to self-care at home, and
referrals to a skilled nursing facility may be necessary. Some of the criteria for admission to a
skilled nursing facility include not being able to manage her own ADL and requiring a complex
dressing change. Intensive rehabilitation is better accomplished at a skilled nursing facility.
Being afraid to go home by herself will need to be addressed prior to discharge but is not a
criterion for admission to a skilled nursing facility. If the client is able to prepare her own meals,
it is a sign that the client could stay at home.
Concepts tested

Question 732
While caring for a client after lumbar spine surgery, which action can the nurse on the ortho-
spine unit delegate to the unlicensed assistive person (UAP)?
A Log roll the client from side to side every two hours

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B Check the client's ability to plantar and dorsiflex the foot
C Determine the client's readiness to ambulate
D Ask about pain control with the patient-controlled analgesia (PCA)

Question Explanation
Correct Answer is A
Rationale: Repositioning a client is included in the training of UAPs. UAPs working on a
specialty unit, such as ortho-spine, will be familiar with how to maintain alignment for a
postoperative spinal surgery client. Evaluating the effectiveness of pain management, assessing
neurologic function, such as plantar and dorsiflexion, and evaluating a client's readiness to
ambulate after surgery require higher-level nursing education and scope of practice and,
therefore, cannot be delegated to UAPs.
Concepts tested

Question 733
The nurse receives reports on the following four clients. Which client should the nurse see first?
A A client with acute urinary retention who has orders to insert an indwelling catheter
B A client with a stage 3 pressure ulcer who is due for a scheduled dressing change
C A client who had a hysterectomy performed 12 hours ago and is nauseous
D A client who had an above the knee amputation and has a temperature of 101.3°F (38.5°C)

Question Explanation
Correct Answer is A
Rationale: The client with acute urinary retention should be seen first. The client needs to have
an indwelling urinary catheter inserted to relieve bladder distention. If acute urinary retention is
left untreated, then bladder damage, incontinence, or kidney failure can result. The other client
problems (e.g., nausea, fever, and dressing change) are of lower importance.
Concepts tested

Question 734
The nurse is reviewing vital signs documented in the electronic health record for a group of
clients. Based on this data, which client should the nurse see first?
A A client diagnosed with atrial fibrillation who has a heart rate of 110 beats per minute
B A client diagnosed with mitral valve insufficiency who has a blood pressure of 152/88
C A client diagnosed with infective endocarditis who has a temperature of 101.8°F (39°C)
D A client diagnosed with heart failure who has a SpO2 of 82%

Question Explanation
Correct Answer is D
Rationale: The nurse should see the client with heart failure and a SpO2 of 82% first. The client
with heart failure could be experiencing life-threatening pulmonary edema, and the SpO2 of 82%
indicates dangerously low oxygenation. An elevated temperature in a client with infective
endocarditis is a clinically significant but not unexpected finding. A heart rate of 110 beats per
minute in a client with atrial fibrillation is concerning, but it does not reflect the same life-
threatening clinical finding as the low SpO2 in the client with heart failure. While elevated and

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of concern, a blood pressure of 152/88 is not as high of a priority for the nurse to address as a
dangerously low oxygen level.
Concepts tested

Question 735
The nurse is caring for a group of adult clients on a neurological unit in an acute care hospital.
Which client should the nurse see first?
A A client admitted several hours ago with a subdural hematoma due to an unwitnessed fall at
home
B A client admitted with hepatic encephalopathy who has an elevated ammonia level
C A client admitted with a transient ischemic attack who has a bubble study echocardiogram
ordered
D A client admitted two days ago with an ischemic stroke who has a blood pressure of 158/64

Question Explanation
Correct Answer is A
Rationale: After an unwitnessed fall, the nurse must consider the possibility of head injury. Due
to the elevated risk for worsening bleeding and increased intracranial pressure because of the fall
and pre-existing head injury, the client with a subdural hematoma should be seen first. A blood
pressure of 158/64 in a client with an ischemic stroke would not represent an urgent situation,
and an elevated ammonia level would not be unexpected for a client with hepatic
encephalopathy. While the results of an echocardiogram with a bubble study would be relevant
to the care of the client with a transient ischemic attack (TIA), this client is not showing signs of
a worsening condition requiring urgent assessment.
Concepts tested

Question 736
A 65-year-old male client diagnosed with prostate cancer rates his pain level at 6 on a 0 to 10
scale. The client refuses all pain medication except for acetaminophen, which does not relieve
his pain. Which action should the nurse take first?
A Talk with the client's family about the situation
B Ask the client further about the refusal of pain medication
C Report the situation to the health care provider
D Document the situation in the client’s medical record

Question Explanation
Correct Answer is B
Rationale: Beliefs regarding pain are determined by socio-cultural norms, including age and
gender. Nurses should investigate the meaning of pain to each client within a cultural
explanatory framework. Astute observations and careful assessments must be completed to
determine the level of pain the client is experiencing. Any action should be documented in the
client’s record, but this should occur after first speaking to the client. Should the client continue
to have pain, the nurse may need to speak to the family and the health care provider.
Concepts tested

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Question 737
The nurse is caring for an adolescent who requires informed consent for a procedure. Under
which circumstance can a minor client sign the consent?
A The client's guardian refuses to sign the consent.
B Both of the client's parents are deceased.
C The client has been deemed emancipated.
D The client is under the care of a foster family.

Question Explanation
Correct Answer is C
Rationale: Informed consent is a legal document that gives permission for invasive or high-risk
procedures, such as blood transfusions and surgery. Informed consent for a procedure is signed
by the provider performing the procedure, the client, and a witness. The legal age to give consent
in the United States is 18. An emancipated minor is younger than the legal age to give consent
but has been recognized to have the legal capacity to make an informed consent. The only
situation a minor client can sign for consent is if they have been deemed emancipated. A minor
cannot sign for consent if their guardian refuses. A minor whose parents are deceased or who is
under the care of a foster family is assigned a legal representative who would sign the informed
consent.
Concepts tested

Question 738
The home health nurse is developing a plan of care for a child with Duchenne muscular
dystrophy. Which other disciplines should the nurse consider collaborating with to slow the
progression and prevent complications of the disease? Select all that apply.
A Physical therapy
B Orthopedist
C Pulmonologist
D Dietitian
E Speech therapy
F Nephrologist

Question Explanation
Correct Answer is A, B, C, D, E
Rationale: Duchenne muscular dystrophy (DMD) is the most severe and common muscular
dystrophy caused by a genetic mutation that results in the degeneration of muscle fibers. The
disease is progressive, causing weakness and wasting of skeletal muscles and resulting in
disability and deformity. Clinical manifestations include trouble getting into a sitting or standing
position, difficulty walking, frequent falls, and delayed growth. Complications of DMD include
respiratory compromise, cardiac failure, disuse atrophy, and contractures. The goal of care is to
slow the progression of the disease and implement interventions to help prevent complications.
The care team should include physical therapy, speech therapy, cardiology, pulmonology,
orthopedist, and a dietitian. Nephrology is not part of the care team for the management of
DMD.
Concepts tested

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Question 739
The nurse is reviewing vital signs documented in the electronic health record for a group of
clients. Based on this data, which client should the nurse see first?
A A client diagnosed with atrial fibrillation who has a heart rate of 110 beats per minute
B A client diagnosed with mitral valve insufficiency who has a blood pressure of 152/88
C A client diagnosed with infective endocarditis who has a temperature of 101.8°F (39°C)
D A client diagnosed with heart failure who has a SpO2 of 82%

Question Explanation
Correct Answer is D
Rationale: The nurse should see the client with heart failure and a SpO2 of 82% first. The client
with heart failure could be experiencing life-threatening pulmonary edema, and the SpO2 of 82%
indicates dangerously low oxygenation. An elevated temperature in a client with infective
endocarditis is a clinically significant but not unexpected finding. A heart rate of 110 beats per
minute in a client with atrial fibrillation is concerning, but it does not reflect the same life-
threatening clinical finding as the low SpO2 in the client with heart failure. While elevated and
of concern, a blood pressure of 152/88 is not as high of a priority for the nurse to address as a
dangerously low oxygen level.
Concepts tested

Question 740
A new nurse manager is responsible for interviewing applicants for a staff nurse position. Which
of the following interview strategies would be the best approach by the nurse manager?
A Obtain an interview guide from human resources
B Ask personal information of applicants
C Use simple questions requiring a "yes" or "no" answer
D Vary the interview style for each candidate

Question Explanation
Correct Answer is A
Rationale: The nurse manager is an active part of the interview process. As a result, they need to
know what interview questions to ask a potential employee. The manager should not ask yes or
no questions. Instead, they should ask about the candidate's experience, why they would be
valuable to the company, and what they would do in certain situations. The new manager should
obtain an interview guide from human resources (HR) for consistency in reviewing each
applicant. An interview guide used for each candidate enables the nurse manager to be more
objective in decision-making. The nurse manager should use resources available in the agency
before the manager attempts to develop one from scratch. Although it's nice to give a variety of
questions, standardized questions and styles should be used to compare applicant responses and
behaviors. The manager should not ask personal information of applicants to ensure they can
meet job demands. Asking certain personal questions is prohibited.
Concepts tested

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Question 741
The nurse is caring for a client who is two days post-surgery and notes that the client is
experiencing a new and sudden onset of confusion. There is an order to discharge the client to go
home today. What would be the best action for the nurse to take?
A Educate the client's family on how to create a calm and safe environment for the client
B Inform the client's health care provider about the change in the client's condition
C Collaborate with the dietitian to identify ways to increase protein in the client's diet
D Encourage the client to schedule a follow-up appointment with their primary care provider

Question Explanation
Correct Answer is B
Rationale: Delirium is considered a temporary but acute condition, which is often characterized
by sudden confusion, agitation, and disorganized thinking. Factors that have been known to
precipitate delirium include pain, dehydration, surgical procedures, and opioid administration.
Clients who are at the highest risk for developing delirium are older hospitalized clients and
clients who are admitted to intensive care units. All answer choices are plausible, but the best
action for the nurse to take would be to inform the health care provider of the client's change in
condition. It is imperative that delirium is recognized early as its causes are potentially
reversible. Part of the client's plan of care would be to also instruct the client and family to
schedule a follow-up visit with the primary care physician (PCP), develop a safe home
environment, and maintain ample protein intake to facilitate wound healing.
Concepts tested

Question 742
A nurse is working on a hospital medical-surgical unit. Which tasks can the nurse delegate to
unlicensed assistive personnel? Select all that apply.
A Insertion of an indwelling urinary catheter
B Educating a client about dietary modifications
C Monitoring and documentation of client intake and output
D Application of barrier cream to the perineal area
E Assisting a client with ambulation two days postoperatively

Question Explanation
Correct Answer is C, D, E
Rationale: The nurse can delegate tasks to unlicensed assistive personnel (UAP) when it follows
within the UAP's scope of practice. Application of barrier cream to the perineal area, assisting a
client with ambulation, and monitoring and documentation of client intake and output are all
within the UAP's scope of practice and can appropriately be delegated by the nurse. UAPs are
unable to insert an indwelling urinary catheter as this is considered an invasive procedure that
should be done by the nurse. Additionally, UAP are not able to provide patient education or
teaching.
Concepts tested

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Question 743
The psychiatric nurse is caring for a client who was voluntarily admitted to the hospital 2 days
ago for suicidal ideation. Today, the client states, "I demand to be released now!" Which
response by the nurse is most appropriate?
A "Let's discuss your decision to leave, and then we can prepare you for discharge."
B "You can be released only if you sign a no suicide contract before you leave."
C "You have a right to sign out as soon as we get the health care provider's discharge order."
D "You cannot be released because you are still at risk of being suicidal."

Question Explanation
Correct Answer is A
Rationale: Clients who are voluntarily admitted to the hospital have the right to demand and
obtain release. Ideally, clients should be given discharge instructions before they leave the
hospital. However, clients have the right to sign themselves out of the hospital at any time,
including against medical advice (AMA). The most appropriate response would be to engage the
client in therapeutic communication and find out their current state of mind and risk for suicide.
If the nurse felt that the client still represented a risk for suicide, a petition for
an involuntary admission/hospitalization should be initiated. The other responses are not
therapeutic or appropriate.
Concepts tested

Question 744
The nurse is preparing to discharge a client who has suffered full-thickness burns to the chest and
upper extremities. Which home care instructions should the nurse include as part of the discharge
education to the client and family? Select all that apply.
A "Eat five to six small meals that are high-protein, low carbohydrate."
B "Avoid the use of emollients on affected skin and over scarred areas."
C "Arrange for physical therapy if you develop any problems with range of motion."
D "Notify the health care provider if you experience changes in sleep or mood."
E "Wear protective sleeves over your arms to prevent additional injury."

Question Explanation
Correct Answer is D, E
Rationale: Full-thickness burns destroy multiple layers of skin, including their underlying
structures (i.e blood vessels, nerves, sweat glands, etc). The overall goals of the rehabilitation
phase with clients who have suffered these types of burns include injury prevention, prevention
of loss of range of motion, and mental health wellness. The client should be instructed to use
emollients on scarred skin to prevent it from becoming too dry, which can restrict movement.
Hypermetabolism can last up to a year and requires the client to have a balanced diet that is high
in both carbohydrates and protein. Wounds and scarred areas should be covered to prevent injury
to the area while it heals. Physical therapy is a process that starts in the acute care setting and
continues for months, and sometimes even years, after the start of therapy. Depression and
anxiety are common and should be brought to the attention of the health care provider.
Concepts tested

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Question 745
A health care provider asks the nurse to assist with obtaining consent for central line placement
in a client who is deaf. While the health care provider explains the procedure and risks to the
client and family member, the client and family member text each other using their cell phones.
What is the most appropriate nursing action?
A Stand next to the client and verify that the information in the texts is accurate
B Obtain interpreter services for the client
C Request the health care provider allow extra time to explain information
D Remind the health care provider to ask one question at a time

Question Explanation
Correct Answer is B
Rationale: Communication is critical in health care settings. Under the Americans with
Disabilities Act (ADA), hospitals must provide effective means of communication for patients
who are deaf or hard of hearing. When obtaining informed consent from a client, it is important
for the provider to speak slowly and ask one question at a time. However, interpreter services are
needed for clients who are deaf. The client must understand the procedure and risks associated
with the procedure in order to give informed consent. Interpreter services for clients who are deaf
can be provided through video remote interpreting, closed captioning, and texting. The client's
family should not be relied on to interpret medical information. Family members may be unable
to accurately interpret in the emotional situation that often exists during a client's hospitalization.
Concepts tested

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HEALTH PROMOTION AND
MAINTENANCE
Question 746
The nurse is assessing a female school-aged client. The client has large breast development, is in
the 95th percentile for height and weight, wears braces, and reports amenorrhea at this time.
Which of the following questions should the nurse ask to assess the client’s reaction to these age-
related changes?
A “Are you happy your teeth will look perfect when your braces are removed?”
B “Would you like to talk about your breast development?”
C “Do your friends talk about having their menses yet?”
D “How are you feeling about your height and weight?”

Question Explanation
Correct Answer D
Rationale: The child is in the 95th percentile for height and weight, which would indicate she is
taller and heavier than most females her age. The nurse should ask the child to describe her
feelings about her height and weight. The other questions are closed-ended that only require a
yes or no and do not facilitate communication about how the child feels.
Concepts tested

Question 747
A rehabilitation nurse is caring for a client who has left-sided neglect after experiencing a
cerebrovascular accident (CVA). Which of the following interventions would the nurse include
from the plan of care to address the client's motor and sensory deficits?
A Encourage the client to strengthen the unaffected side
B Remind the client to look to their left
C Have the client perform ADLs independently
D Assist the client to dress the unaffected side first

Question Explanation
Correct Answer is B
Rationale: Homonymous hemianopsia (blindness in half of the visual field in one or both eyes)
may occur from stroke and may be temporary or permanent. The affected side of vision loss
corresponds to the paralyzed side of the body leading to unilateral neglect. Interventions are
aimed at promoting safety and independence through prompts for visual scanning (look to the
affected side), encouraging the client to dress in front of a mirror to identify the affected side,
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and promoting the use and exercise of the affected side. Clients should work to perform ADLs
independently and dress the affected side first.
Concepts tested

Question 748
A nurse is performing psychosocial assessments on several clients in an obstetric clinic. Based
on the history obtained, which client is at risk for impaired coping during pregnancy?
A A client who verbalizes feeling irritable and has lost sexual desire towards her partner
B A client who lives in a multi-generational household and believes pregnancy is a transitional
period of illness
C A client with a history of sexual abuse who is highly involved in her church community
D A client with a history of depression who is married and has two other children

Question Explanation
Correct Answer is B
Rationale: Hormonal changes during pregnancy and cultural norms can decrease the client’s
ability to cope. Strong social support from family, friends, and community members can assist
the client during overwhelming mood swings. A client who believes pregnancy is an illness will
have difficulty coping and adjusting to her new lifestyle. Cultural beliefs should be assessed, and
unsafe practices should be further evaluated. Mood swings and loss of sexual desire are common
responses to hormonal changes during pregnancy. The nurse should encourage stress relieving
strategies. While previous history of sexual assault may cause anxiety during the birthing
process, a strong social support system can help the client cope. Although the client has a history
of depression, the client has a support system as indicated by a partner and children.
Concepts tested

Question 749
During a nonstress test conducted at 37 weeks gestation, the client reports fetal movement 3
times. The nurse notes that when the expectant mother reports fetal movement, the fetal heart
rate (FHR) increases 15 beats or more above the baseline. The nurse concludes that this test
finding is which of the following?
A FHR variability
B FHR decelerations
C A nonreactive pattern
D A reactive pattern

Question Explanation
Correct Answer is D
Rationale: Prenatal non-stress testing (NST) is a non-invasive method used to test fetal well-
being before the onset of labor. An NST functions as a part of the biophysical profile. NST can
be used from 32 weeks gestation to term to detect the presence of fetal movements and assess
fetal heart rate acceleration. The test is used to determine if a fetus is at risk for intrauterine death
or neonatal complications, usually secondary to high-risk pregnancies or suspected fetal
hypoxemia. NSTs are frequently used because of the low maternal and fetal risk. The NST
involves 20 minutes of monitoring the FHR while assessing the number, amplitude, and duration
of accelerations that usually correlate with fetal movement. A normal, reactive NST indicates
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fetal activity as evidenced by two or more accelerations peaking at 15 bpm or more above
baseline, each lasting 15 seconds or more, and all occurring within 20 minutes of beginning the
test. It is important to note that an abnormal stress test is not always ominous and can occur with
a sleeping fetus. If a test is not reactive, FHR should be monitored for at least 40 minutes to
account for the fetus's sleep cycle.
Concepts tested

Question 750
The nurse is caring for a gravida 2 para 1 client in the 10th week of her pregnancy who states,
“I've never urinated as often as I have for the past three weeks.” Which response would be most
appropriate for the nurse to make?
A “Having to urinate so often can be annoying. I suggest that you watch how much fluid you are
drinking and limit it.”
B “You shouldn't be urinating this frequently now; it usually stops by the time you're eight
weeks pregnant. We will check your urine for glucose.”
C “By the time you are 12 weeks pregnant, the frequency that you need to urinate will decrease,
but it is likely to return toward the end of your pregnancy.”
D “Women do not usually experience frequent urination in the first trimester. Are you
experiencing any burning sensations?”

Question Explanation
Correct Answer is C
Rationale: As the uterus grows, it presses on the urinary bladder, causing an increased frequency
of urination during the first trimester. This complaint lessens during the second trimester only to
reappear in the third trimester as the fetus begins to descend into the pelvis, causing pressure on
the bladder.
Concepts tested

Question 751
The nurse is preparing to discharge a client and her newborn after an uncomplicated delivery.
Which of the following statements should be included in the discharge teaching?
A “Babies should have six or more wet diapers per day.”
B “Put the baby to sleep with a blanket each night.”
C “Newborn sleep-wake patterns are the same as adult sleep patterns.”
D “Yellowing of the newborn’s skin is a normal finding.”

Question Explanation
Correct Answer is A
Rationale: Urine and stool output are clear indicators of an infant’s input and should be
monitored to ensure that the baby is urinating at least six times per day. The sleep-wake cycles of
an infant start opposite from adult sleep cycles and slowly shift to a daytime schedule. Babies
should sleep alone in a crib or bassinet. Yellowing of the newborn’s skin indicates high bilirubin
levels and should be further assessed by the healthcare provider.
Concepts tested

Question 752
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The nurse is caring for a client who is 28 weeks pregnant. Which of the following physical
changes should the nurse identify as an expected finding?
A Facial edema
B Kyphosis
C Lower extremity erythema
D Linea nigra

Question Explanation
Correct Answer is D
Rationale: Extra integumentary pigmentation during pregnancy can create a darkened vertical
line down the abdomen called linea nigra. Facial edema is an abnormal finding that requires
follow-up from the healthcare provider. Lordosis is expected in pregnancy, kyphosis is not, and
erythema of the lower extremities is an abnormal finding.
Concepts tested

Question 753
The nurse is assessing an adolescent client for psychosocial concerns after a recent parental
divorce. Which of the following statements by the client indicates that the divorce has had a
negative impact on their mental health?
A “The divorce has cost my family a ton of money.”
B “Living in two different houses is challenging.”
C “I hope that my parents can be happy again.”
D “It’s my fault that they got divorced.”

Question Explanation
Correct Answer is D
Rationale: When a child voices that they feel to blame for a situation that is out of their control
(such as a divorce or the death of a family member), it indicates to the nurse that the event had a
significant negative impact on the child. All the other responses do not indicate a mental health
concern.
Concepts tested

Question 754
The nurse is teaching a parenting class to clients at a community center. Which information
should be included in the education related to infant growth and development?
A “Most babies gain about 2 pounds every month until they reach 6 months old.”
B “Your baby should double birth height by their first birthday.”
C “Babies don’t start to hold their head up until about 4 months of age.”
D “You should see a doctor if your baby is not able to walk by 11 months old.”

Question Explanation
Correct Answer is A
Rationale: In the first six months of life, infants gain about 2 pounds per month; weight gain then
slows to about 1 pound per month for months 6-12. Height at one year old is typically 1.5 times
the infant’s birth height. Infants begin holding their head up around 2 months of age, and while

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some infants may walk at 11 months old, it is not a cause for concern if the baby is not walking
at this age.
Concepts tested

Question 755
The nurse is assessing a client for barriers to learning. Which of the following statements by the
client should the nurse identify as a barrier?
A “I hope you have a video for me to watch because that would be the best way for me to learn.”
B “I am very excited to learn today because I want to go home so I can continue living my
life.”
C “How long will it take for me to learn everything I need to know to take care of myself?”
D “When can we get started because I am very anxious about everything I need to know?”

Question Explanation
Correct Answer is D
Rationale: The nurse should recognize that pain, fatigue, depression, anxiety, or other physical or
psychological symptoms can interfere with the ability to maintain attention and participate in
learning. Requesting a video, expressing excitement, and willingness to care for self are all signs
of motivation and readiness to learn.
Concepts tested

Question 756
The nurse is screening clients at a community center for risk factors of hypertension. Which
reported activity places the client at a higher risk for developing hypertension?
A Drinking 1-2 glasses of wine per week
B Traveling out of state 1 time per month
C Exercising 2-3 days per week
D Smoking 1 pack of cigarettes per day

Question Explanation
Correct Answer is D
Rationale: Lifestyle choices that are risk factors for the development of hypertension include
drinking more than one glass/day of alcohol for females and two glasses/day of alcohol for
males, tobacco use, a sedentary lifestyle, and excessive dietary sodium intake often found in fast-
food restaurants meals. Frequent travel has not been identified as a risk factor for the
development of hypertension.
Concepts tested

Question 757
During a clinic visit, a 49-year-old female client tells the nurse, “I think I am beginning to
experience hot flashes.” The client asks the nurse what she can do to minimize menopausal
symptoms. Which of the following is an appropriate nursing response?
A “Incorporate yoga into your exercise routine.”
B “Long-term use of soy supplements can help you with your symptoms.”
C “Eat raw flaxseed with plenty of water.”

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D “Acupuncture can provide the same benefits as hormone therapy.”

Question Explanation
Correct Answer is A
Rationale: Research has shown that yoga and other meditation-based exercises can reduce the
frequency and intensity of menopausal symptoms, such as hot flashes, joint pain, and mood
disturbances. Long-term use of soy supplements has been associated with thickening of the
lining of the uterus. There are conflicting studies on whether flaxseed is effective in lowering
menopausal symptoms. Additionally, raw flaxseed can contain potentially toxic ingredients.
Research has shown that acupuncture is less effective than hormone therapy. Additionally,
acupuncture can cause infections and tissue damage if not performed correctly.
Concepts tested

Question 758
The nurse is taking care of a client with hemiplegia due to a stroke. Which activity of daily living
will the nurse encourage the client to perform?
A Brush their teeth
B Transfer from a bed to a chair
C Ambulate independently
D Tie their shoes

Question Explanation
Correct Answer is A
Rationale: The nurse should encourage independence as much as possible. The client should be
able to brush their teeth with the unaffected side. Transferring from a bed to a chair may require
assistive devices due to the client’s paralysis of one side of the body. Ambulating independently
is not a safe activity due to hemiplegia. The client may not be able to tie their own shoes due to
the paralysis of one side.
Concepts tested

Question 759
The nurse is screening clients for risk factors for glaucoma. Which of the following ethnicities
would have the highest risk?
A Caucasian
B Hispanic
C African American
D American Indian

Question Explanation
Correct Answer is C
Rationale: The African American race has the highest risk for glaucoma compared to Hispanics,
American Indians, and Caucasians.
Concepts tested

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Question 760
The nurse is assessing clients at a community center for lifestyle practices that increase the risk
of cancer. Which of the following findings should the nurse identify as a significant risk?
A Exercising 30 minutes per day
B Drinking two caffeinated beverages per day
C Consuming 2000 mg of sodium each day
D Using smokeless tobacco once a day

Question Explanation
Correct Answer is D
Rationale: Tobacco use in any form increases a client’s risk for cancer significantly. Fifteen
minutes of exercise and two caffeinated beverages do not increase the risk for cancer. The U.S.
Department of Health recommends that a person consume less than 2300 milligrams of sodium
per day, so 2000 milligrams is within these recommendations.
Concepts tested

Question 761
The nurse is gathering a client’s health history. Which of the following questions should be
included to assess the client’s lifestyle choices?
A “Do you have a family history of cardiovascular disease?”
B “How many times do you exercise per week?”
C “Does anyone in your household smoke tobacco?”
D “Are you able to perform all of your self-care independently?”

Question Explanation
Correct Answer is B
Rationale: The nurse should ask the client questions about activity, substance use, diet, sexual
health, alcohol use, etc. to assess the client’s lifestyle choices. All other responses are questions
about the client’s health but are not lifestyle-based questions.
Concepts tested

Question 762
The nurse is caring for a client who is requesting a prescription for oral contraceptives. Which of
the following conditions is considered a contraindication for this contraceptive method?
A Irregular menstruation
B Allergy to penicillin
C History of asthma
D Diabetic neuropathy

Question Explanation
Correct Answer is D
Rationale: Hormonal contraceptives are contraindicated for clients who have diabetic
neuropathy, diabetic retinopathy, diabetes for more than 20 years, vascular disease, history of

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stroke, VTE, liver tumors, heart disease, and other conditions. Asthma, penicillin allergy, and
irregular menstrual cycles are not contraindications.
Concepts tested

Question 763
A nurse is educating a female client about using basal body temperature to assist in determining
when ovulation will occur. Which of the following statements will the nurse include in the
teaching?
A “You will need to check your temperature each day before getting out of bed.”
B “Take your temperature in the evening each day, so you will get a true basal temperature.”
C “Take your temperature during the time that you believe you are ovulating.”
D “Choose a time that is convenient to take your temperature at the same time each day.”

Question Explanation
Correct Answer is A
Rationale: The basal body temperature (BBT) refers to the lowest temperature reached on
awakening. BBT is slightly lower in the follicular phase (the first half of the menstrual cycle)
and rises after ovulation and stays raised throughout the luteal phase (the second half of the
menstrual cycle). This rise in temperature happens in response to progesterone, which is released
after ovulation occurs. To measure basal temperature, the client must take her temperature every
morning at the same exact time before getting out of bed. The client must try not to move too
much, as any activity can raise the body temperature slightly.
Concepts tested

Question 764
The nurse is obtaining a health history from a female client who has a family history of breast
cancer. Which of the following findings would increase the client’s risk?
A The client breast-fed for one month after pregnancy.
B The client has a history of multiple episodes of mastitis.
C The client started menses at age 14.
D The client had her first full-term pregnancy at age 33.

Question Explanation
Correct Answer is D
Rationale: Risk factors for breast cancer can include late age (after age 30) at first full-term
pregnancy and early menarche (before age 12). Not breastfeeding increases the client’s risk for
ovarian cancer. Mastitis is not a risk factor for cancer.
Concepts tested

Question 765
A community health nurse is conducting a class on nutritional counseling. A client asks the nurse
the best way to prevent heart disease. What will the nurse include in the teaching plan?
A “When eating poultry, choose meats such as duck.”
B “Eat oily fish, such as salmon or trout.”

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C “Dairy should be eliminated from the diet.”
D “Use white rice when cooking with grains.”

Question Explanation
Correct Answer is B
Rationale: Fatty fish, such as salmon, trout, and herring, contain high amounts of omega-3 fatty
acids, which can increase high density lipoprotein (HDL) cholesterol levels. Duck and goose are
high in fat content. Chicken and turkey are a healthier poultry alternative. Dairy does not have to
be eliminated from the diet. Low-fat or fat-free options are acceptable. Brown rice is
recommended, as opposed to white rice, because it contains higher amounts of nutrients in the
grain.
Concepts tested

Question 766
The nurse is discussing expected body image changes with a male adolescent client during a
wellness visit. Which of the following client statements would indicate that the client is adjusting
to the changes?
A “I am not as tall as everyone else in my class, but at least my voice is deeper to show I am
maturing.”
B “I hope I get taller than I am, because all the girls like to pat my head and tell me how cute I
am.”
C “I shave my face every morning so I can smell like a man, even though I am not growing any
facial hair yet.”
D “I feel like everyone stares at me when we are showering in the locker room, which is because
I look different.”

Question Explanation
Correct Answer is A
Rationale: The adolescent developmental stage is identity versus role confusion, and to achieve
this development, it is important that the nurse assesses if the client is accepting the changed
body image as it occurs. The client recognizes that he is not the tallest but is able to feel
confident still about his voice being deeper. The comments about wanting to be taller, smelling
like a man, and being self-conscious about body parts looking different than his peers do not
indicate acceptance of his current body image.
Concepts tested

Question 767
During an annual physical, a 55-year-old client tells the nurse, “I have noticed an increase in
belching.” How does the nurse explain gastrointestinal changes to the client?
A “Your muscle tone decreases as you get older, and movement of food slows down.”
B “Your stomach produces more enzymes as you age and causes indigestion.”
C “Your metabolism decreases and causes you to eat more food.”
D “Your stomach capacity decreases, and food backs up.”

Question Explanation

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Correct Answer is A
Rationale: Aging causes biological changes in the gastrointestinal system and result in decreased
metabolism, decreased intestinal tone, and decreased gastric enzyme production. The decrease in
gastrointestinal activity can result in increased acid indigestion and belching. The stomach
produces fewer digestive enzymes with aging. A decrease in metabolism requires less caloric
intake, not more. Stomach capacity is influenced by the decrease in elasticity, not a physical
reduction in size.
Concepts tested

Question 768
A nurse is assessing a client who is 4 hours postpartum. Which finding should the nurse report to
the healthcare provider?
A Vaginal blood clots that are dime-size
B Blood pressure of 105/68 mmHg with a heart rate of 101 beats/min
C A saturated perineal pad every 15 minutes
D Urinary output of 35 ml/hr

Question Explanation
Correct Answer is C
Rationale: Postpartum complications include hemorrhage, anemia, and hypovolemic shock due
to blood loss. The nurse should recognize the signs and symptoms of excessive blood loss and
report them accordingly. Perineal pads that saturate every 15 mins or less are indicative of
excessive blood loss and should be reported. Vaginal blood clots less than quarter-size are
expected. Large blood clots should be reported to the healthcare provider. The heart rate is
slightly elevated. However, the blood pressure is within normal limits. The vital signs do not
indicate a complication. This urinary output is above the expected output of at least 30 ml/hr.
Concepts tested

Question 769
A nurse is caring for a client during a nonstress test (NST). At the end of a 40-min period of
observation, the nurse notes the following findings: the fetal heart rate baseline is 135 beats per
minute with minimal variability and no accelerations. There are two decelerations of 15 beats per
minute in the fetal heart rate during a period of fetal movement, each lasting 20 seconds. How
should the nurse interpret these findings?
A Fetal tachycardia
B Fetal bradycardia
C A reactive pattern
D A nonreactive pattern

Question Explanation
Correct Answer is D
Rationale: Prenatal non-stress testing (NST) is a non-invasive method used to test fetal well-
being before the onset of labor. An NST functions as a part of the biophysical profile. NST can
be used from 32 weeks gestation to term to detect the presence of fetal movements and assess
fetal heart rate acceleration. The test is used to determine if a fetus is at risk for intrauterine death
or neonatal complications, usually secondary to high-risk pregnancies or suspected fetal
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hypoxemia. A normal, reactive NST indicates fetal activity as evidenced by two or more
accelerations peaking at 15 bpm or more above baseline, each lasting 15 seconds or more, and all
occurring within 20 minutes of beginning the test. If a test is not reactive, FHR should be
monitored for at least 40 minutes to account for the fetus's sleep cycle. Most term fetuses have
many of these accelerations in each 20 to 30 minute period of active sleep, and the term fetus
seldom goes more than 60 minutes, and certainly not more than 100 minutes, without meeting
these criteria.
Concepts tested

Question 770
The nurse is educating a client who is 34 weeks pregnant and has a history of hypertension about
prenatal complications. Which finding should the nurse instruct the client to report immediately
to the healthcare provider?
A Headache that does not go away
B Pedal edema: 1+, bilaterally
C Shortness of breath on exertion
D Occasional mild contractions

Question Explanation
Correct Answer is A
Rationale: Preventing complications related to preeclampsia requires the use of assessment,
advocacy, and counseling skills. Client’s with gestational hypertension should be instructed to
perform self-monitoring and be educated on the signs of worsening preeclampsia including
visual changes, severe headaches, bleeding or bruising, and epigastric pain. All other options are
expected findings in the third trimester of pregnancy.
Concepts tested

Question 771
The nurse is providing discharge teaching to a client who had a cesarean section. Which of the
following findings should the client be instructed to report to her healthcare provider as a
possible sign of infection?
A Gradual decrease in lochia
B Mild pain at the incision site
C Wound edges that are well approximated
D Purulent drainage at the incision site

Question Explanation
Correct Answer is D
Rationale: Signs and symptoms of infection may include purulent drainage, severe pain, wound
edges not approximated, erythema, localized edema, increased body temperature, increased heart
rate, etc. These findings should be reported to the provider. It is expected that lochia will
gradually decrease over time.
Concepts tested

Question 772

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The nurse is educating a female adolescent client about the physical changes that occur during
puberty. Which statement by the client indicates an expected body image change?
A “My hips are much wider than they were a year ago.”
B “Wearing a bra is so uncomfortable.”
C “I feel like I need to hide my awkward body.”
D “I wish all this acne would just go away.”

Question Explanation
Correct Answer is A
Rationale: In puberty, the female develops breasts and wider hips. The client stating that her hips
have gotten wider is expected and does not indicate any problem coping with the physical
change. The other responses may be changes that occur in puberty (acne) but also indicate that
the client has not adjusted to the physical change effectively.
Concepts tested

Question 773
The nurse is assessing a client who is the primary caregiver for a family member after a recent
cerebral vascular accident. Which question by the nurse is appropriate to evaluate the impact that
this change has had on the family system?
A “How have things changed since you became responsible for your family member’s care?”
B “Have you considered placing your family member into a skilled nursing facility?”
C “Has anyone provided you with a list of community resources?”
D “Is your family member able to complete tasks without your assistance?”

Question Explanation
Correct Answer is A
Rationale: Asking the client to talk about how the family system has changed after becoming a
primary caregiver is appropriate to evaluate how the transition to being a primary caregiver has
affected them. All of the other responses do not assess the impact on the client.
Concepts tested

Question 774
The nurse is providing teaching to the parents of a healthy 24-month-old client about age-related
changes. Which of the following statements by the nurse is appropriate?
A “Your child will start wanting to sleep more during the day.”
B “A rounded abdomen indicates that the child is eating too much.”
C “The child should be interested in playing with toys.”
D “Temper tantrums at this age may indicate cognitive issues.”

Question Explanation
Correct Answer is C
Rationale: Toys that require interaction are desirable to toddlers and provide them with a sense
of accomplishment when they see a change based on their action. The abdomen in the toddler

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stage is expected to be round due to the immaturity of the abdominal muscles. Daytime sleeping
should decrease in the toddler stage. Temper tantrums are normal and occur because toddlers
cannot adequately express their needs.
Concepts tested

Question 775
The nurse is planning a health education class for a community health fair about secondary
prevention in health promotion. Which of the following topics should the nurse include in the
education?
A Exercise and nutrition
B Seatbelts
C Mammograms and prostate exams
D Immunizations

Question Explanation
Correct Answer is C
Rationale: Secondary prevention focuses on preventing the spread of disease, illness, or infection
once it occurs. Activities are directed at diagnosis and prompt intervention to reduce severity and
enable the client to return to a normal level of health as quickly as possible. Mammograms and
prostate exams are screening tests that can lead to early intervention. Primary prevention focuses
on preventing disease and illness, like exercise and nutrition, immunizations, and seatbelts.
Concepts tested

Question 776
The nurse is interviewing a client to obtain a health history. Which statement by the client
indicates an increased risk for developing colorectal cancer?
A “I take a vitamin D supplement every day.”
B “I have been a vegetarian for 6 months.”
C “I was diagnosed with Crohn’s disease last year.”
D “I stopped drinking alcohol about 10 years ago.”

Question Explanation
Correct Answer is C
Rationale: Inflammatory bowel disease (Crohn’s, ulcerative colitis, etc.) increases the risk of
colorectal cancers. Diets high in fruits and vegetables and little to no alcohol intake decrease the
risk of colorectal cancers. Low levels of vitamin D increase the risk, but if the client takes a
supplement every day, they will likely not have a vitamin D deficiency.
Concepts tested

Question 777
A client with newly diagnosed diabetes type 2 is receiving information on follow-up care. The
client states, “There is so much I have to learn about this illness.” What is an appropriate
response by the nurse?
A “Be sure to write down all the questions you have about diabetes before your next visit.”
B “You will be referred to a diabetes educator for further management.”

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C “Make sure to take all of your scheduled medications to prevent complications from diabetes.”
D “It is important for you to research information about diabetes thoroughly.”

Question Explanation
Correct Answer is B
Rationale: Diabetes is a complex illness. Clients with newly diagnosed diabetes will benefit from
a referral to a diabetes educator for comprehensive education on the illness. The client’s
concerns should be addressed as soon as possible to prevent complications. Medications are only
one factor to help manage the complex disease process. Newly diagnosed clients require
structured guidance for managing their disease process.
Concepts tested

Question 778
The school nurse is teaching a class on safe sex practices to high school students. Which
statement made by a student indicates further teaching is required?
A “Abstinence is the best way to prevent sexually transmitted infections.”
B “I should be careful when having anal sex so that I don’t get HIV.”
C “I should still use a condom during sex even though I am on birth control.”
D “I should always ensure the other person consents before having sex.”

Question Explanation
Correct Answer is B
Rationale: The human immune deficiency virus (HIV) can be transmitted via any mucous
membrane. Anal sex is the riskiest type of transmission. However, unprotected sex of any kind
puts clients at risk for transmission. Abstinence (not having sex) eliminates any risk of sexually
transmitted infections (STIs). Birth control does not provide protection against STIs. Mutual
consent is a necessary concept to discuss with adolescent clients.
Concepts tested

Question 779
The nurse is obtaining a health history from a male client for risk factors of prostate cancer.
Which of the following client statements about diet would increase the client’s risk?
A “I maintain a strict vegetarian diet.”
B “My favorite proteins are steak and ice cream.”
C “My family says all I eat is carbohydrates.”
D “I like to eat pizza and carbonated beverages.”

Question Explanation
Correct Answer is B
Rationale: Diet can increase the risk of prostate cancer in men. Excessive amounts of red meat or
dairy products that are high in fat increase the risk. Vegetarian diets, carbohydrates, pizza, and
carbonated beverages do not increase the risk for prostate cancer.
Concepts tested

Question 780

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The nurse is interviewing a client to determine if the client has an increased risk of skin cancer.
Which of the following questions by the nurse is appropriate?
A “How much time do you spend in the sun each day?”
B “Do you use a moisturizing lotion on your skin?”
C “What are your current skin hygiene practices?”
D “Do you regularly wear cosmetics?”

Question Explanation
Correct Answer is A
Rationale: Spending excessive time in the sun increases the risk of skin cancer; therefore, the
nurse should ask the client about their typical sun exposure. Moisturizing lotions and cosmetics
do not increase the risk of skin cancers, and while hygiene is important for infection prevention,
it does not directly affect the client’s risk of cancer.
Concepts tested

Question 781
The nurse is assessing a client who has recently been admitted to the acute care facility. Which
of the following questions by the nurse is appropriate to assess the client’s lifestyle choices?
A “Don’t you know that cigarettes are bad for you?”
B "Does anyone in your family have a problem with alcohol?”
C “Do you currently use any illegal substances?”
D “Have you ever attended a substance rehabilitation program?”

Question Explanation
Correct Answer C
Rationale: The nurse should ask the client questions about activity, substance use, diet, sexual
health, alcohol use, etc. to assess the client’s lifestyle choices. All other responses do not address
current lifestyle practices.
Concepts tested

Question 782
The nurse is assessing a client who wishes to refill a prescription for intramuscular depot
medroxyprogesterone acetate (Depo-Provera). Which statement by the client indicates that
refilling this prescription would be contraindicated?
A “I want to start a family in the next five years.”
B “I have been taking the Depo shots for three years.”
C “My period typically lasts six days.”
D “My last pregnancy was four years ago.”

Question Explanation
Correct Answer is B

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Rationale: Long term use (more than 2 years) of Depo-Provera is contraindicated due to the
medication’s ability to decrease bone mineral density. The client stating that she has been taking
this medication for three years indicates that they should not be prescribed this method any
longer. All other responses are not contraindications.
Concepts tested

Question 783
A nurse is caring for a 48-year-old client who is experiencing irregular menstrual periods and has
started having hot flashes. The nurse should expect the client to report which finding associated
with perimenopause?
A Weight loss
B Sleeping for prolonged periods without dreaming
C Chills at night
D Vaginal dryness during sexual intercourse

Question Explanation
Correct Answer is D
Rationale: During the perimenopausal years (2 to 8 years prior to menopause), women may
experience physical changes associated with decreasing estrogen levels, which may include
vasomotor symptoms of hot flashes, irregular menstrual cycles, sleep disruptions, forgetfulness,
irritability, mood disturbances, weight gain and bloating, irregular menses, headaches, decreased
vaginal lubrication, night sweats, fatigue, vaginal atrophy, and depression.
Concepts tested

Question 784
A nurse is establishing health promotion goals for a client who smokes cigarettes, has
hypertension, and has a BMI of 26. Which of the following long-term outcomes should the nurse
include in the plan of care?
A The client will be provided with smoking cessation options during the initial counseling
session.
B The client will have a decrease in BMI by the three-month follow-up appointment.
C The client will stop smoking within one week of the initial counseling session.
D The client will select an approved nutrition plan during the initial teaching session.

Question Explanation
Correct Answer is B
Rationale: Goals, outcomes, and objectives are all terms used interchangeably during the
planning process to develop outcomes that can be measured during the evaluation phase of the
nursing process. Nurses develop patient goals/outcomes that are specific, measurable, attainable,
realistic, and time-bound in collaboration with a client. Short-term goals may be achieved during
a teaching session, but long-term goals may require weekly or monthly visits.
Concepts tested

Question 785
The nurse is preparing to complete a physical assessment of an older adult client with limited
mobility. Which of the following techniques would be appropriate for this client’s assessment?
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A Completing the assessment the same way as they would for a young adult client
B Asking the client’s family member to be present during the assessment
C Organizing the assessment so that the client does not change positions frequently
D Avoiding questions that would require the client to discuss their mobility impairment

Question Explanation
Correct Answer is C
Rationale: Age, developmental status, and physical limitations always need to be considered
when performing assessments. Since this client has mobility limitations, the nurse should
sequence the assessments so that the client does not have to change positions often. All parts of
the assessment need to be completed, but the nurse should be strategic about when each aspect of
the assessment is performed. Asking the client’s family member to be present is not necessary.
Concepts tested

Question 786
The nurse is assessing a female adolescent client for her reaction to expected body-image
changes during a wellness visit. Which of the following client statements may indicate the client
is having difficulty accepting the changes?
A “I want to start shaving my legs because I hear it is hard to keep up with it once you do it.”
B “I am glad I started wearing a bra already since the boys like to snap the bra straps and I think
one of them likes me.”
C “I really want my best friend to get her period soon, so we can talk about it together.”
D “I am so much taller than all the boys in our class that I doubt anyone will ask me to go to the
end-of-year dance.”

Question Explanation
Correct Answer is D
Rationale: The adolescent developmental stage is identity versus role confusion, and to achieve
this development, it is important that the nurse assesses if the client is accepting her changed
body image as it occurs. The client indicates negative feelings about being taller than all the boys
and possibly being left out of an activity because of it. Admitting feelings about shaving legs,
attention received from wearing a bra, and having something in common with a best friend are
indications that the client is accepting of expected changes that are occurring or will occur.
Concepts tested

Question 787
The clinic nurse is preparing a female adult client for a Papanicolaou (Pap) smear. The client
states “I have never had this done before.” Which statement should the nurse make?
A “A Pap smear can detect early cervical cell changes.”
B “Every female client should always have a yearly Pap smear.”
C “A Pap smear provides more information about your sexual practices.”
D “We can confirm the presence of cancer with a Pap smear.”

Question Explanation
Correct Answer is A

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Rationale: A Pap smear is a recommended screening tool during a pelvic exam to detect cervical
cell changes. The frequency of Pap smears is determined by the pathology results. Yearly Pap
smears are not indicated for all females. Information about sexual practices can be obtained
through a patient interview. Further studies are needed to confirm the presence of cancer. A Pap
smear is a first line screening tool.
Concepts tested

Question 788
The nurse is assessing a client who is 6 hours postpartum. The client’s heart rate is 112
beats/min, and she has pale mucous membranes. The nurse notes bogginess of the uterus upon
palpation. Which complication should the nurse suspect the client is experiencing?
A Uterine atony
B Pulmonary embolism
C Disseminated intravascular coagulation (DIC)
D Inversion of the uterus

Question Explanation
Correct Answer is A
Rationale: Uterine atony is a postpartum complication resulting from the inability of the uterine
muscle to contract after giving birth. This can lead to increased vaginal bleeding, a boggy uterus,
and tachycardia. A pulmonary embolism results from a dislodged deep vein thrombosis.
Although tachycardia is a sign, a boggy uterus is not expected. Disseminated intravascular
coagulation (DIC) results in uncontrolled clotting and bleeding. Tachycardia and pallor are
common; however, a boggy uterus is not consistent with this complication. Inversion of the
uterus occurs when the uterus is turned inside out and visible through the introitus.
Concepts tested

Question 789
A nurse is caring for a client who is pregnant and is having a nonstress test performed. The fetal
heart rate (FHR) is between 130 and 150 beats/min, and there has been no fetal movement for 15
minutes. Which of the following actions should the nurse perform?
A Prepare to provide a report to the hospital nursing staff
B Continue to monitor the client with no intervention
C Offer the client a snack of orange juice and crackers
D Place the patient into supine position

Question Explanation
Correct Answer is C
Rationale: The NST involves 20 minutes of monitoring the FHR while assessing the number,
amplitude, and duration of accelerations that usually correlate with fetal movement. A normal,
reactive NST indicates fetal activity as evidenced by two or more accelerations peaking at 15
bpm or more above baseline, each lasting 15 seconds or more, and all occurring within 20
minutes of beginning the test. It is important to note that an abnormal stress test is not always
ominous and can occur with a sleeping fetus. The patient should tilt to the left to supine
hypotensive syndrome. If a test is not reactive, FHR should be monitored for at least 40 minutes
to account for the fetus sleep cycle.
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Concepts tested

Question 790
The nurse is caring for a client who is in active labor who has ruptured amniotic membranes.
Which action by the nurse is the priority?
A Start oxygen by face mask
B Prepare the woman for immediate delivery
C Check the fetal heart rate (FHR)
D Place the woman in the knee-chest position

Question Explanation
Correct Answer is C
Rationale: When membranes rupture, the priority focus is on assessing fetal heart rate to identify
a deceleration, which might indicate cord compression secondary to cord prolapse. A vaginal
exam may be done later to evaluate for continued progression of labor. Oxygen and positioning
are the interventions for cord compression and prolapse. Delivery may not be imminent
depending on cervical dilation and effacement.
Concepts tested

Question 791
The nurse is providing discharge instructions to a client about formula feeding a 2-day-old baby.
Which of the following statements should be included in the teaching?
A “The baby should drink about 50 ounces of milk a day.”
B “Save any leftover formula for the next feeding.”
C “Feed your baby at least every 4 hours.”
D “You can prop the bottle up with a blanket or a pillow.”

Question Explanation
Correct Answer is C
Rationale: Bottle-fed infants should be fed at least every four hours for the first two weeks of
life. Fifty ounces (1500 mL) is excessive intake. On average, a week-old infant drinks 3-5 ounces
(90-150 mL) per day. Any leftover formula should be discarded after a feeding, and propping up
a bottle for feeding is a dangerous technique that increases the newborn’s risk of aspiration.
Concepts tested

Question 792
The nurse is caring for an older adult client. Which of the following body image changes should
the nurse identify as an expected finding for this population?
A Feeling guilty about wrinkling skin
B Feeling socially accepted with gray hair
C Feeling isolated due to mobility changes
D Feeling happy about increased sensory perception

Question Explanation
Correct Answer is B

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Rationale: The aging adult goes through many physical changes, including the thinning and
graying of hair. The client feeling that this change is socially accepted is a positive indication of
appropriate body image. Feelings of guilt and isolation are not normal, and older adults
experience a decrease in sensory perception rather than an increase.
Concepts tested

Question 793
A nurse is planning care for a female client who identifies with traditional Islamic culture. Which
of the following individuals should be included in the decision-making process for the client’s
care?
A Client’s partner only
B All members of the family
C Designated religious leader
D Community faith healer

Question Explanation
Correct Answer is B
Rationale: Families who follow traditional Islamic culture value the family’s opinion as a unit.
When making decisions, these clients often prefer input from the family rather than deciding
independently. When possible, include all family members in healthcare decisions.
Concepts tested

Question 794
The nurse is educating clients in a retirement community about physical changes that occur with
aging. Which of the following information should be included in the teaching?
A Saliva production increases with age.
B Cardiac output increases with age.
C Subcutaneous tissue increases with age.
D Skin dryness increases with age.

Question Explanation
Correct Answer is D
Rationale: Skin dryness is a common condition in older adults. Subcutaneous tissue, cardiac
output, and saliva production all decrease with age.
Concepts tested

Question 795
The nurse is planning to provide community health education. Which of the following actions
should be the priority when planning the education session?
A Creating relationships with the population being educated
B Understanding the health needs of the population being educated
C Evaluating the health services already available in the population being educated
D Determining the average education level of the population being educated

Question Explanation

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Correct Answer is B
Rationale: Assessment of health care needs of individuals, families, and communities is the first
component in achieving healthy populations and communities. The nurse needs to understand the
needs of the specific population being educated. Once the needs are understood, then the nurse
can create relationships and build rapport by demonstrating that the nurse is aware of the needs
of the community. The nurse will also build relationships while interviewing the population to
assess the needs. Evaluating the services available and issues related to the services and
determining learning needs and barriers are also important but not a priority over the needs of the
population.
Concepts tested

Question 796
The nurse is educating clients in a community center about childhood obesity. Which of the
following statements should be included in the teaching?
A “Children who are overweight often end up with eating disorders in adolescence.”
B “Lower household income increases the risk of childhood obesity.”
C “Protein intake should be limited to lower the risk of childhood obesity.”
D “Children gain and lose weight much quicker than adults.”

Question Explanation
Correct Answer is B
Rationale: Children who come from a lower socioeconomic background often have nutritional
deficits due to the high cost of healthy foods. Low-cost food is often calorie dense; therefore,
obesity is more common. Protein should be increased in childhood, and the incidence of eating
disorders is not directly affected by eating disorders.
Concepts tested

Question 797
A nurse is performing a health history on a 59-year-old client. The client tells the nurse they have
been experiencing increasing back pain and have noticed a decrease in height. How will the
nurse educate the client on the prevention of further problems?
A “Take a daily multivitamin with your meals.”
B “Perform weightbearing activities at least 3 to 5 times a week.”
C “Be sure to consume plenty of legumes in your diet.”
D “Avoid sun exposure as much as possible.”

Question Explanation
Correct Answer is B
Rationale: The client’s physical manifestations are consistent with the development of
osteoporosis. To increase bone strength and muscular support, weight bearing exercises are
recommended at least 3 to 5 times a week. Most multivitamins do not provide the necessary
amount of recommended daily calcium to support bone health. Calcium-rich foods are
recommended to increase bone density. Legumes are rich in iron. Vitamin D supports bone
health. Sun exposure supplies a non-food source of Vitamin D.
Concepts tested

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Question 798
A community health nurse is teaching a class on proper nutrition to a group of adolescent clients.
The nurse asks a client to explain the recommended daily servings. Which statement made by the
client indicates an understanding of the recommendations?
A “I should consume 5 ounces of grains in one day.”
B “One small banana is equal to a serving of 1 cup of fruit.”
C “One egg is equal to 2 ounces of protein”
D “It is recommended I eat 2 cups of dairy daily.”
Question Explanation
Correct Answer is A
Rationale: MyPlate recommendations for adolescents include consuming 5 to 6 ounces of grains
per day. One small banana is equal to 0.5 cups servings of fruit. One egg accounts for 1 ounce of
protein. Adolescents should consume 3 cups of dairy daily.
Concepts tested

Question 799
A nurse is assessing a patient’s risk of contracting a sexually transmitted infection (STI). Which
of the following questions would be an appropriate screening question?
A “What is your current relationship status?”
B “Do you use a condom when you have sexual intercourse?”
C “Do you currently have a sexually transmitted infection?”
D "How many children do you have?"

Question Explanation
Correct Answer B
Rationale: In order to assess the risk of STI contact, the nurse needs to gather information on
current sexual health practices, such as contraceptive use or the number of sexual partners.
Asking the client if they currently have an STI is an important assessment question but does not
evaluate risk of future STIs. The client’s relationship status and number of children they have
does not directly affect the risk of STIs.
Concepts tested
Question 800
A nurse is caring for a client who has a body mass index of 29. Which of the following questions
by the nurse is appropriate to assess for the possibility of unhealthy lifestyle practices?
A “How long have you been overweight?”
B “Do you have a family history of obesity?”
C “Can you complete range of motion (ROM) exercises?”
D “How often do you take part in physical activity?”

Question Explanation
Correct Answer is D
Rationale: Asking a client about the frequency of their physical activity allows the nurse to gain
insight into their exercise patterns. Asking questions that assess the length of time or family
history may be a part of the assessment, but do not assess for the presence of unhealthy lifestyle
practices. The ability to complete ROM exercises does not provide information on lifestyle.

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Concepts tested

Question 801
The nurse is caring for a client who states, “I know that I don’t eat a healthy diet.” Which of the
following questions by the nurse is appropriate to gain further information about the client’s
nutritional choices?
A “How much do you weigh currently?”
B “Do you follow a 2,000 calorie diet?”
C “What is your favorite kind of food?”
D “What foods have you eaten in the last 24 hours?”

Question Explanation
Correct Answer is D
Rationale: Asking the client to provide examples of what foods they have eaten in the last 24
hours provides insight into the client’s dietary choices. Asking about the client’s favorite foods
or their current weight does not assess the client’s lifestyle practices. While asking the client if
they follow a 2,000 calorie diet does address intake, it does not adequately assess the types of
food that they eat.
Concepts tested

Question 802
The nurse is planning care for a client who is prescribed oral contraceptives. Which of the
following outcomes should be included in the client’s plan of care?
A Client consistently takes the pill every day.
B Client will experience a decrease in sexual desire.
C Client will discontinue barrier methods of contraception.
D Client denies contact with sexually transmitted infections.

Question Explanation
Correct Answer is A
Rationale: Expected outcomes for contraception not only include the method’s effectiveness but
also correct use of the method and satisfaction with the method. In this case, taking the oral
contraceptive daily is an expected outcome. A decrease in sexual desire is an undesirable side
effect and should not be listed as an expected outcome. If the client participates in sexual
interactions with multiple partners, they should continue to use barrier methods to prevent STI
transmission.
Concepts tested

Question 803
The nurse is caring for a client with cancer who is receiving healing touch alternative therapy.
Which finding would indicate to the nurse that the treatment is effective?
A The client routinely asks for the prescribed oxycontin every 4 hours.
B The client takes several naps during the day.
C The client reports feeling less anxious today.
D The client denies chills or shivering.

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Question Explanation
Correct Answer is C
Rationale: Clients who receive Healing Touch (HT) may sleep better, have their pain and anxiety
are reduced, have their medications work longer and better, and may not need as many pain
medications. HT does not reduce the risk of infection and would promote daytime wakefulness
due to increased rest at night.
Concepts tested

Question 804
The nurse is counseling an older adult who has total care of the spouse and suffers from a
debilitating condition. The couple voices concern over the effect that caregiver burden has on the
physical and emotional health of the caregiver. What type of care might the nurse include in the
counseling?
A Palliative care
B Bereavement care
C Respite care
D Hospice care

Question Explanation
Correct Answer is C
Rationale: The main purpose of respite care is to give the primary caregiver some time away
from the responsibilities of day-to-day care. This can occur in an adult day care center or in the
patient’s home. Nurses provide information about how to access respite care and may make
referrals. Hospice is a program providing physical, psychological, social, and spiritual care for
dying people, their families, and other loved ones. Palliative care exists within and outside of
hospice programs. It is not restricted to the end of life and can be used from the point of initial
diagnosis. Palliative care, which may be given in conjunction with medical treatment and in all
types of health care settings, is patient- and family-centered care that optimizes the quality of life
by anticipating, preventing, and treating suffering. Bereavement care is provided to families
following the death of a family member.
Concepts tested

Question 805
The nurse is planning the sequence of a comprehensive assessment of a 16-month-old child.
Which of the following assessments should be performed last?
A Otoscope examination
B Inspection of the abdomen
C Palpation of pulses
D Pupillary light reflex

Question Explanation
Correct Answer is A
Rationale: In young children, it is important to sequence an assessment from least invasive to
most invasive. Performing an invasive assessment (such as an otoscope exam) in the beginning
of the assessment may skew the remainder of the findings if the child becomes upset.
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Concepts tested

Question 806
The nurse is teaching the parents of an infant about expected growth and development. Which of
the following information should the nurse include in the teaching?
A “You can expect the infant to double birth weight by one year of age.”
B “You should see your infant’s first tooth start to erupt around three months of age.”
C “Around eight months of age, your infant should be able to sit up securely without any
support.”
D “Around six months of age, your infant should start to roll from back to front and front to
back.”

Question Explanation
Correct Answer is C
Rationale: Infants who develop as expected should be able to sit upright and securely without
any support around eight months of age. Around four months of age, infants will turn front to
back and back to front. By six months of age, infants should double their birth weight, and by
one year, infants should triple their birth weight. The first tooth typically erupts around six
months of age.
Concepts tested

Question 807
A community health nurse is providing education for a group of assigned clients about the use of
tobacco. Which statement should the nurse include in the teaching?
A “Smoking is more common among white-collar workers than blue-collar workers.”
B “Second-hand smoke affects the older adult population.”
C “Smokers use nicotine for the calming effect it produces.”
D “The amount of smoke inhaled determines the risk of heart disease.”

Question Explanation
Correct Answer is D
Rationale: Cigarette smokers have an increased risk of heart disease and is proportional to the
number of cigarettes smoked or smoke inhaled. Smoking is more common among blue-collar
workers and those that work in construction, factories, and jobs requiring protective equipment.
Second-hand smoke can affect people of any age. People with low socioeconomic status, blue-
collar workers, and service staff are disproportionately affected. A common misconception is
that smoking causes a calming effect. Nicotine is a stimulant. The calming effect is due to carbon
monoxide found in cigarettes.
Concepts tested

Question 808
The nurse is assessing a client who is 2 hours postpartum. The nurse suspects the client has
subinvolution of the uterus. Which finding should the nurse expect to observe with this client?
A Vaginal bleeding and uterine protrusion through the introitus

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B Irregular vaginal bleeding and an enlarged uterus
C Purulent lochia and uterine tenderness
D Pale mucous membranes and a laterally displaced uterus

Question Explanation
Correct Answer is B
Rationale: Subinvolution of the uterus is characterized by sustained enlargement of the uterus
and continued lochia discharge. Vaginal bleeding and uterine protrusion through the introitus are
indicative of inversion of the uterus. Purulent lochia and uterine tenderness are characteristic of
endometritis, an infection that occurs several days postpartum. Pale mucous membranes and a
laterally displaced uterus are indicative of uterine atony.
Concepts tested

Question 809
The nurse is caring for a client who identifies with a culture that the nurse is not familiar with.
Which of the following questions by the nurse would be appropriate to ask the client about the
role of family in the plan of care?
A “Are you able to make your own healthcare decisions?”
B “Is there anyone that you would like us to withhold information from?”
C “Can your partner be here every morning to talk to the providers?”
D “Who would you like included in discussions about your health?”

Question Explanation
Correct Answer is D
Rationale: When a nurse is unsure of a client’s cultural preferences, they should ask unbiased
questions to gain understanding. Assuming the client’s partner will need to be present for
healthcare discussions is not appropriate. Asking the client if they are able to make their own
decisions may be offensive.
Concepts tested

Question 810
The nurse is assessing a client who is 40 weeks pregnant and is reporting contractions. Which
statement by the client would indicate to the nurse that the client is experiencing false labor?
A “I'm feeling contractions mostly in my back.”
B “My contractions are about 6 minutes apart and regular.”
C “I feel contractions that alternate between strong and weak.”
D If I try to talk with my partner during a contraction, I can't.”

Question Explanation
Correct Answer is C
Rationale: False labor is characterized by contractions that are irregular and weak, often slowing
down or decreasing in intensity with walking or a position change. True labor contractions begin
in the back and radiate around toward the front of the abdomen. They are regular and become

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stronger over time; the woman may find it extremely difficult, if not impossible, to have a
conversation during a contraction.
Concepts tested

Question 811
The nurse is evaluating a client’s ability to care for a newborn. Which action by the client
indicates the need for education?
A Changing the baby’s diaper on the bed
B Holding the baby with one hand while feeding
C Giving the baby a pacifier while swaddled
D Putting the baby to sleep in the prone position

Question Explanation
Correct Answer is D
Rationale: A baby should be placed to sleep alone on their back in a crib or bassinet. The client
placing the baby in the prone position indicates the need for education. All other responses do
not warrant nursing action.
Concepts tested

Question 812
The nurse is assessing a 19-year-old male client at a well visit. Which of the following
statements by the client indicates an expected body image change in this age group?
A “I wish I wasn’t so tall and lanky.”
B “I am ready to settle down and start a family.”
C “I like to work out and build muscle.”
D “I am tired of having acne and this patchy beard.”

Question Explanation
Correct Answer is C
Rationale: In the late adolescent period into early adulthood, clients often build muscle more
efficiently, and the statement that the client enjoys this physical change is an expected finding.
While acne and inconsistent facial hair may still exist at 19 years of age, the client’s statement
indicates a negative outlook on these changes. Starting a family does not affect body image.
Concepts tested

Question 813
The nurse is educating a pregnant client on role transition and mental health in the postpartum
period. Which of the following statements should the nurse include in the teaching?
A “Psychosis is the most common mood disorder after delivery.”
B “Postpartum depression can be diagnosed as early as 24 hours after delivery.”
C “Postpartum mood disorders and fatigue only occur in mothers.”
D “Emotional lability is common within the first few days after delivery.”

Question Explanation
Correct Answer is D

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Rationale: Postpartum “blues” is common following childbirth and typically peaks around day 4-
5 and often resolves around day 10 after delivery. Postpartum blues include symptoms such as
emotional lability, anxiety, fatigue, and sadness. Postpartum depression symptoms are like those
of the baby “blues” but last more than two weeks. Mood disorders can also occur in partners but
are less common. Psychosis occurs only in 1-2 women per 1000 births.
Concepts tested

Question 814
The nurse is assessing a 3-month-old client’s growth and development. Which of the following
developmental milestones does the nurse expect to see for this client?
A Transfers an object from one hand to another
B Uses thumb and finger to pick up small objects
C Holds head and chest up when in the prone position
D Sits upright with support

Question Explanation
Correct Answer is C
Rationale: At three months old, an expected developmental milestone would be holding the head
and chest off the ground while prone. Sitting upright with support is expected at 6-7 months, the
pincer grasp is expected at 10 months, and transferring an object from one hand to another is
expected at 7 months.
Concepts tested

Question 815
The nurse is planning primary health prevention for a community that has had a recent increase
in sexually transmitted infections (STIs). Which of the following interventions should the nurse
include in the plan of care?
A Provide information for those who are infected about available treatments
B Educate the community about the importance of having the sexual partner treated for the
infection as well
C Screen the community about the use of condoms during sexual intercourse
D Educate the community about how the infections are transmitted from person to person

Question Explanation
Correct Answer is D
Rationale: Primary prevention includes preventing STIs in the community. This can be
accomplished through education about how infections are transmitted and could include the
importance of using condoms to prevent transmission. Screening the community about condom
use would only gather information but would not help prevent the spread of infections. Providing
treatment information and education about the importance of treating both persons would be
considered a secondary health intervention to prevent the spread of the infection.
Concepts tested

Question 816
The nurse is educating clients at a community center about diabetes mellitus. Which of the
following statements should be included in the teaching?
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A “African-American individuals have a higher risk of diabetes.”
B “You are low risk if you avoid adding salt to your food.”
C “Diabetes is more likely if you are physically active.”
D “You can lower your risk of diabetes if you move to a colder climate.”

Question Explanation
Correct Answer is A
Rationale: African American clients are at an increased risk of developing diabetes mellitus type
2. Lowering sodium intake is beneficial but does not indicate that the client is “low-risk.”
Physical activity decreases the risk of DM2, and relocating to a cooler climate does not change
the risk of DM2.
Concepts tested

Question 817
The school nurse is teaching a group of school-aged children about dental health promotion.
Which statement should the nurse include in the teaching?
A “Let me show you how to properly brush your teeth.”
B “I am going to check your teeth and gums for any problems.”
C “Any issues with your teeth will be referred to an orthodontist.”
D “Any medication you take for a tooth infection will be given at school.”

Question Explanation
Correct Answer is A
Rationale: Primary prevention strategies include assessing the knowledge base and teaching
health promotion practices such as tooth-brushing. Screening for the detection of disease is a
secondary prevention strategy. The initiation of referrals for further treatment is a secondary
prevention strategy. Medication administration in a school setting is a tertiary prevention
strategy.
Concepts tested

Question 818
A 47-year-old female client visits the clinic for an annual exam. The nurse educates the client on
the types of clinical preventative services. Which statement made by the client indicates the need
for further teaching?
A “I will follow up with a lipid panel blood test.”
B “I need to receive my influenza vaccine every year.”
C “I will schedule an appointment for a mammogram.”
D “I will ensure I visit my gynecologist for a Papanicolaou (Pap) test.”

Question Explanation
Correct Answer is C
Rationale: Breast cancer screening in women is recommended every 2 years beginning at the age
of 50. Middle-aged clients have a higher risk of cardiovascular disease. A lipid panel blood test
measures cholesterol levels and can help determine the risk of heart disease. Influenza vaccines

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are recommended yearly for the prevention of respiratory illnesses. Papanicolaou (Pap) tests are
recommended every 3 to 5 years for women ages 21 to 65.
Concepts tested

Question 819
The nurse is interviewing a client to obtain a health history. Which of the following statements
by the client indicates an increased risk for cardiovascular disease?
A “I identify as bisexual.”
B “My diet consists of a lot of vegetables.”
C “My mother died of breast cancer.”
D “I have type two diabetes.”

Question Explanation
Correct Answer is D
Rationale: Cardiac risk factors include elevated cholesterol, hypertension, consistent
hyperglycemia, diagnosed diabetes mellitus, obesity, tobacco use, sedentary lifestyle, etc. Sexual
orientation and family history of unrelated cancers do not directly affect cardiovascular health. A
diet that is high in carbohydrates and fat does increase cardiovascular risk, but a diet high in
fruits and vegetables decreases risk.
Concepts tested

Question 820
The nurse is interviewing a client about their lifestyle practices. Which of the following
statements by the client indicates that further assessment is needed?
A “I drink alcohol two to three times a month.”
B “I enjoy a large cup of coffee each morning.”
C “My weight fluctuates by a few pounds throughout the month.”
D “My job requires me to sit for about six hours each day.”

Question Explanation
Correct Answer is D
Rationale: Working in a career that requires a large amount of time seated increases the
likelihood that the client lives a sedentary lifestyle. The nurse should ask additional questions to
gather more information about activity levels to determine if the client’s health is at risk. Alcohol
and caffeine consumption in moderation will not significantly impact the client’s health.
Minimal fluctuations in body weight are normal as intake and output also fluctuate. If the client
had stated that the weight changes were significant, the nurse would need to further assess.
Concepts tested

Question 821
The nurse is interviewing a client who has recently been diagnosed with HIV. Which of the
following questions by the nurse is appropriate to assess current lifestyle choices?
A “Who did you get HIV from?”
B “Do you use injectable substances?”
C “How many children do you have?”

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D “Do you identify as male or female?”

Question Explanation
Correct Answer is B
Rationale: To assess lifestyle choices, the nurse should ask questions about substance use, sexual
practices, diet, activity level, etc. In this case, the client has a new diagnosis of HIV; therefore,
the nurse should ask questions about sexual health, use of injectable drugs, needle sharing, or
anything else that could transmit the virus to another person.
Concepts tested

Question 822
The nurse is caring for a client who uses condoms for family planning. Which of the following
would be considered an expected outcome for this client’s plan of care?
A The client will not have a herpes outbreak within the next year.
B The client will not become pregnant within the next year.
C The client will have fewer sexual partners over the next year.
D The client will experience no hormonal side effects over the next year.

Question Explanation
Correct Answer is B
Rationale: Expected outcomes for contraception not only include the method’s effectiveness but
also correct use of the method and satisfaction with the method. In this case, not becoming
pregnant is an expected outcome. Condoms do not directly affect the other outcomes listed.
Concepts tested

Question 823
A nurse working in an oncology clinic recommends ginger to certain clients receiving
chemotherapy. What findings would indicate that the herb is having the intended effect?
A The client says they can sleep through the night without interruption.
B The client feels like they have more energy now than just a few weeks ago.
C The client reports less nausea and vomiting after this round of chemotherapy.
D The client says they are less forgetful since they started taking the herb.

Question Explanation
Correct Answer is C
Rationale: Clinical trials indicate that ginger can effectively reduce nausea and vomiting
associated with chemotherapy, motion sickness, pregnancy, and surgery. Research does not
support the other options.
Concepts tested

Question 824
An oncology nurse is reinforcing coping strategies with the family caregiver of an adult client
who has cancer. What response by the client indicates additional teaching is required?
A “I need to take more walks to reduce my stress.”
B “Joining one of the cancer support groups will give me a place to share my experiences.”

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C “I think we qualify for some of the community resources you mentioned.”
D “Respite care will be a good option for us if the treatments do not work.”

Question Explanation
Correct Answer is D
Rationale: Respite care provides short-term relief for primary caregivers. It can be arranged for
just an afternoon or for several days or weeks. Care can be provided at home, in a healthcare
facility, or at an adult day center. It is usually not paid for by insurance, so it can be used at any
time a caregiver sees the need. Respite care is designed. Providing care to seriously ill family
members is commonly perceived as a chronic stressor, and caregivers often experience negative
psychological, behavioral, and physiological effects on their daily lives and health. Nurses have
the opportunity to intervene by providing clients with interventions to manage stress.
Concepts tested

Question 825
The nurse is assessing a client’s cardiovascular system. Which of the following actions by the
nurse is appropriate?
A Palpating both carotid arteries at the same time
B Auscultating heart sounds at the ninth intercostal space
C Inspecting the chest wall for heaves or lifts
D Percussing for a resonant sound over the sternum

Question Explanation
Correct Answer is C
Rationale: Inspecting the anterior chest wall heaves or lifts is an important part of a cardiac
assessment. Carotid arteries should be palpated one at a time. The ninth intercostal space is not
an appropriate location to auscultate heart sounds. Percussion over the sternum will create a flat
sound rather than a resonant sound.
Concepts tested

Question 826
The nurse is teaching the parent of a 3-month-old infant, who has Tetralogy of Fallot, what to do
if the infant experiences a hyper cyanotic spell. Which of the following information should the
nurse include in the teaching?
A “Call for emergency response immediately.”
B “Begin chest compressions.”
C “Place the infant in a knee-to-chest position.”
D “Protect the infant from injury.”

Question Explanation
Correct Answer is C
Rationale: A hypercyanotic spell occurs when a greater than usual amount of blood shunts from
right to left across the ventricular septal defect, and the infant becomes more deoxygenated. The
knee-to-chest position will increase systemic vascular resistance, causing increased pressure on

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the left side of the heart to force blood back through the pulmonic valve, thereby oxygenating
more blood. Chest compressions and calling emergency response are not necessary because the
infant’s heart is still pumping, and the infant is still breathing. The infant may become distressed
and irritable during a spell but is not in danger of injury.
Concepts tested

Question 827
The nurse is teaching a 20-year-old client about sexually transmitted infections (STIs). Which
statement made by the client to the nurse indicates the teaching was effective?
A “Gonorrhea is detected by the presence of a chancre on the genitals.”
B “The human papilloma virus (HPV) can lead to cervical cell changes.”
C “Untreated chlamydia can lead to secondary and late stages of the disease.”
D “Bacterial vaginosis can cause infertility and urethral scarring.”

Question Explanation
Correct Answer is B
Rationale: HPV is a sexually transmitted infection and one of the leading causes of cervical
dysplasia. Pap smears, treatment of abnormal cells, and sexual partner examinations are
important topics of discussion. A chancre is a sore associated with syphilis. Gonorrhea is
characterized by a yellow discharge from the genitals. Secondary and late stages are
complications of syphilis, not chlamydia. Infertility and urethral scarring can occur with an
untreated chlamydia infection. Bacterial vaginosis is often asymptomatic and can occur despite
sexual transmission.
Concepts tested

Question 828
A nurse is caring for a client who is 4 days postpartum. Upon assessment, the nurse notes dark,
purulent lochia on the perineal pad. The nurse suspects which postpartum complication?
A Mastitis
B Endometritis
C Urinary tract infection (UTI)
D Retained placenta

Question Explanation
Correct Answer is B
Rationale: Endometritis is the most common type of postpartum uterine infection. Endometritis
is an infection of the uterine lining. Physical findings include dark, profuse, purulent, or
malodorous lochia, fever, and uterine tenderness. Mastitis is an enlargement of the axillary
lymph nodes. Physical findings include tender, swollen, and painful breasts. UTIs are common
postpartum infections. However, the physical findings include urgency and frequency of
urination, fever, and pelvic discomfort. A retained placenta prevents the uterus from contracting
and can result in uterine atony. Physical findings include lochia rubra and excessive bleeding.
Concepts tested

Question 829

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The nurse is teaching parents of a newborn about umbilical cord care. Which statement should
the nurse include in the teaching?
A “Begin tub baths as soon as you get home to help cleanse the cord stump.”
B "The cord stump should change from brown to yellow in a day or two."
C “Cover the cord stump with sterile gauze until if falls off.”
D “Call your healthcare provider if you see any redness or drainage or notice a foul smell.”

Question Explanation
Correct Answer is D
Rationale: Frequent assessments of the umbilical cord stump are necessary to detect any bleeding
or signs of infection. Any cord drainage is abnormal and is generally caused by infection.
Teaching should include the following tasks. Observe for bleeding, redness, drainage, or foul
odor from the cord stump and report it to your newborn’s primary care provider
immediately. Avoid tub baths until the cord has fallen off and the area has healed. Expose the
cord stump to the air as much as possible throughout the day. Fold diapers below the level of the
cord to prevent contamination of the site and to promote air-drying of the cord. Observe the cord
stump, which will change color from yellow to brown to black by the 2nd or 3rd day. This is
normal. In 7-10 days, it sloughs off and the umbilicus heals. Never pull the cord or attempt to
loosen it; it will fall off naturally.
Concepts tested

Question 830
The nurse is assessing a client who is primigravida who is reporting contractions every 2-3
minutes. The nurse notes the presence of bloody show, intact membranes, and a cervix that is
70% effaced and 6 centimeters dilated. The nurse should understand that the client is in which
phase of labor?
A latent
B active
C transitional
D accelerated

Question Explanation
Correct Answer is B
Rationale: The first stage is the longest: it begins with the first true contraction and ends with full
dilation (opening) of the cervix. Because this stage lasts so long, it is divided into three phases:
latent, active, and transition. The active phase of labor is the time from the end of the latent
phase of labor until the completion of cervical dilation. Cervical dilation becomes more rapid
during the active phase. The cervix usually dilates from 4 to 7 cm, with 40% to 80% effacement
taking place. This phase can last up to 6 hours for the nulliparous woman and 4.5 hours for the
multiparous woman. The fetus descends farther in the pelvis and contractions become more
frequent (every 2 to 5 minutes) and increase in duration (45 to 60 seconds).
Concepts tested

Question 831

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The nurse is preparing a postpartum client for discharge with a 2-day-old baby. Which of the
following statements by the client would cause the nurse concern about the client’s ability to care
for the infant?
A “I am going to switch to bottle feeding when I get home.”
B “I am so tired that I am beginning to hallucinate.”
C “I can’t wait to be discharged, so I can have a cigarette.”
D “I want to take a shower before I am discharged.”

Question Explanation
Correct Answer is B
Rationale: Any indications that the client is experiencing psychosis warrant immediate
assessment. Signs and symptoms of psychosis may include auditory or visual hallucinations,
disorganized behavior, flight of ideas, and psychomotor agitation. All other statements do not
indicate that the client cannot care for the newborn.
Concepts tested

Question 832
The nurse is caring for a pediatric client who states, “My parents got divorced. I live with my
mom sometimes, and I live with my dad other times.” How should the nurse document this
family structure in the medical record?
A Nuclear family
B Binuclear family
C Cohabitating family
D Dyadic family

Question Explanation
Correct Answer is B
Rationale: Separated parents who assume joint custody of children are considered binuclear
families. Nuclear families are structures in which the parents and children live together.
Cohabitating families live in one home but are not married or legally bound together. Dyadic
families have no children.
Concepts tested

Question 833
The nurse is caring for a client who has refused to make any healthcare decisions without the
grandparent’s consent. Which statement by the nurse is most appropriate at this time?
A "You shouldn’t need to ask permission to take a simple medication.”
B “This procedure is necessary to save your life.”
C “Let me know once you have come to a decision.”
D “I am concerned that this is an abusive family relationship.”

Question Explanation
Correct Answer is C
Rationale: Culture and religion may affect who makes health care decisions. Asking for advice
from a matriarchal or patriarchal leader, such as a grandparent, is common in some cultures and

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should be respected by the healthcare staff. This practice alone does not indicate abuse. The
nurse should avoid making statements that scrutinize the client’s desire to seek family advice.
Concepts tested

Question 834
The nurse is assessing the growth and development of a 24-month-old client. Which of the
following actions by the client indicates age-appropriate development?
A Uses simple two-word sentences
B Pulls up from sitting to standing
C Crawls up stairs using hands and feet
D Babbles vowel sounds

Question Explanation
Correct Answer is A
Rationale: At 24 months old, an expected developmental milestone would be the use of two-
word sentences, often a noun and a verb. Pulling up from sitting is expected at 10 months,
creeping/crawling up stairs is expected at 15 months, and babbling vowel sounds is expected at 6
months.
Concepts tested

Question 835
The nurse is participating in providing tertiary health prevention in a community that has had a
recent increase in teenage pregnancy and births. Which of the following actions should the nurse
take?
A Assist the teenagers with finding affordable childcare while the teenager is in school
B Assess females in the community who are sexually active with the use of birth control
C Provide information about abortion and adoption for the teenagers who are already pregnant
D Screen the teenagers who are pregnant for participation in prenatal care

Question Explanation
Correct Answer is A
Rationale: Tertiary health prevention occurs when a defect or disability is permanent and
irreversible and involves minimizing the effects of long-term disease or disability through
interventions directed at preventing complications and deterioration. Assisting the teenagers who
have already delivered and want to keep their child with finding childcare in order for them to
finish school can assist with both the teenager and baby having a healthier and safer future.
Assessing for the use of birth control, participating in prenatal care, and providing information
about abortion and adoption would be secondary prevention. Abortion may not be an option for
some clients depending on their beliefs, culture, and laws. This information would also not be
helpful for the teenagers who have already given birth.
Concepts tested

Question 836
The nurse is educating a 17-year-old client on health risks within the adolescent population.
Which of the following statements should be included in the teaching?

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A “Cut back on your salt intake to avoid anxiety.”
B “Don’t ride with anyone who has been drinking.”
C “Your current body mass index (BMI) can predict your risk of adult cancers.”
D “Urinating after sexual intercourse reduces the risk of sexually transmitted infections.”

Question Explanation
Correct Answer is B
Rationale: In the adolescent population, alcohol and substance use is a common practice, and it is
important that clients understand not to drive while intoxicated or ride with someone who is
intoxicated. Sodium does not affect anxiety. BMI can change drastically in the adolescent period;
therefore, it is not a reliable indicator of future disease. Urinating after sex reduces the risk of
urinary tract infections, not sexually transmitted infections.
Concepts tested

Question 837
A nurse is providing care to a middle-aged client during a clinic visit. The client is reading a
pamphlet on hypertension and asks the nurse for more information on the disease process. Which
statement made by the nurse is a tertiary prevention strategy?
A “High blood pressure can affect your eyesight in the future if not controlled.”
B “Let’s take your blood pressure to verify if it is under control.”
C “Medication can help control your blood pressure.”
D “It is important to exercise at least three times a week to control your high blood pressure.”

Question Explanation
Correct Answer is D
Rationale: Physical activity recommendations to prevent complications of an illness is a tertiary
prevention strategy. Educating clients on the complications of an illness is a primary prevention
strategy. Taking blood pressure is a screening tool used as a secondary prevention strategy to
detect an illness. Medication helps to treat a medical condition and is part of secondary
prevention strategies.
Concepts tested

Question 838
The nurse is teaching a client about nutrition and maintaining a healthy weight to prevent health
problems. Which of the following client statements would indicate a correct understanding of the
teaching?
A “I will begin a healthy diet if my body mass index (BMI) goes over 30.”
B “I will maintain my body mass index (BMI) between 20 and 25.”
C “My body mass index (BMI) should be between 15 and 20.”
D “A healthy body mass index (BMI) is between 25 and 30.”

Question Explanation
Correct Answer is B

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Rationale: The client should maintain a BMI between 20 and 25 to help prevent health problems.
A BMI between 25 and 30 is considered overweight and over 30 would be obese. A healthy diet
should be maintained at all times but should definitely be started before a BMI of 30 is reached.
A BMI under 18 is considered underweight and places the client at a higher risk of nutritional
problems.
Concepts tested

Question 839
The nurse is assessing the vision of a client at a well visit. Which of the following actions by the
nurse would be appropriate?
A Instructing the client to blink rapidly
B Shining a light into both of the client’s pupils
C Asking the client to identify letters on a chart
D Palpating the client’s orbital structures

Question Explanation
Correct Answer is C
Rationale: In order to assess a client’s vision, the nurse should ask the client to identify letters,
numbers, or symbols on a chart, such as the Snellen chart or Jaeger card. While shining a light
into the client’s pupil is a common part of an eye assessment, this does not directly test vision.
Asking the client to blink rapidly and palpating the orbital structures do not assess vision.
Concepts tested

Question 840
The nurse is interviewing a client about self-care practices. Which of the following statements by
the client indicates an understanding of unhealthy behaviors?
A “I smoke tobacco, but I am trying to quit.”
B “I can’t help that my family has a history of obesity.”
C “I eat lots of red meat to make sure I get enough protein.”
D “I drink a couple of beers each day, but I’m not an alcoholic.”

Question Explanation
Correct Answer is A
Rationale: The statement that the client currently smokes tobacco but is trying to quit indicates
that the client recognizes that this habit is unhealthy. Drinking more than one alcoholic drink per
day is considered at-risk drinking, and while red meat does have a significant protein content, it
also has a high-fat content, and this meat should be consumed on a limited basis. Family history
does not affect current unhealthy behaviors.
Concepts tested

Question 841
The nurse is educating an adolescent client about sexual health. Which of the following
statements by the client indicates the need for further education?
A “Only gay men can get HIV or AIDS.”
B “I should be cautious with who I have sex with.”

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C “Sexually transmitted infections (STIs) can be transmitted through any sexual contact.”
D "Having multiple partners can be risky.”

Question Explanation
Correct Answer is A
HIV and AIDS can be transmitted to anyone regardless of race, age, or sexual preference. Being
cautious about sexual contact and knowing that multiple partners increase risk are appropriate.
STIs can be transmitted through any sexual contact, so this does not indicate the need for further
education, as this is a true statement.
Concepts tested

Question 842
The nurse is caring for a client who has a subdermal hormone implanted in the upper arm for
family planning. Which of the following is an expected outcome for this method of
contraception?
A The client expresses a desire to remove the implant.
B The client experiences an increase in libido.
C The client experiences no signs or symptoms of sexually transmitted infections.
D The client voices satisfaction with this method of family planning.

Question Explanation
Correct Answer is D
Rationale: Expected outcomes for contraception not only include the method’s effectiveness but
also correct use of the method and satisfaction with the method. An increase in libido should not
be listed as an expected outcome, as hormonal contraceptives often decrease libido. The
subdermal implant provides no protection from STIs, and the client asking to remove the implant
indicates that they are dissatisfied with the method.
Concepts tested

Question 843
The nurse is conducting a presentation on complimentary health approaches. Which statement by
an attendee indicates an understanding of the teaching?
A "As long as an herbal preparation has been tested in the clinical setting, it is safe."
B "Herbal preparations are safe as long as I carefully read the label."
C "Herbal preparations are actually drugs; I will be careful with them."
D "Herbal preparations are safer to use than my prescriptions."

Question Explanation
Correct Answer is C
Rationale: Herbal supplements may contain entire plants or plant parts. Many prescription drugs
and over-the-counter medicines are also made from plant products, but these products are
regulated by the Food and Drug Administration (FDA). The FDA considers herbal supplements
foods, not drugs. Therefore, they are not subject to the same testing, manufacturing, labeling
standards, and regulations as drugs. Many Americans take both dietary supplements and

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prescription or over-the-counter drugs. Herbal treatments may potentiate or counteract the action
of prescribed medication.
Concepts tested

Question 844
The homecare nurse is conducting a complete assessment during the first visit with a new client
and the primary caregiver. Which of the following statements by the caregiver should the nurse
identify as the priority concern?
A "We eat two meals each day."
B "It is difficult to get to all of our appointments."
C "We buy the prescriptions we can afford."
D "We have both been feeling a little down lately."

Question Explanation
Correct Answer is C
Rationale: Caregivers with higher financial burdens are at higher risk of role strain and reduced
quality of life. The financial costs of caregiving may include healthcare costs of the care
recipient and caregiver, adaptations and devices in the home, hired assistance for activities of
daily living (e.g., driving, house cleaning), and prescriptions. Cost-related medication
nonadherence may occur in both the client and the family, as family members may give up
employment to provide care.
Concepts tested

Question 845
The nurse is performing an abdominal assessment on a healthy client. Which of the following
assessments should be completed first?
A Auscultating bowel sounds
B Percussing the abdominal cavity
C Palpating for the abdominal aortic pulse
D Assessing for rebound tenderness

Question Explanation
Correct Answer is A
Rationale: The sequence of assessing the abdomen should be inspect, auscultate, percuss, and
finally palpate. The nurse should not percuss or palpate the abdomen prior to auscultating bowel
sounds, as this may increase peristalsis and create additional bowel sounds.
Concepts tested

Question 846
The nurse is caring for a toddler who was admitted with vomiting and diarrhea but has not had
any episodes for the last 4 hours. The toddler reports being thirsty and hungry. Which of the
following actions should the nurse take?
A Provide small sips of an electrolyte drink
B Provide a small amount of food and drink that the toddler would like
C Explain that the toddler will have to wait longer before eating and drinking

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D Administer a prescribed intravenous antiemetic

Question Explanation
Correct Answer is A
Rationale: Sips of an electrolyte drink would be appropriate to help the client stay hydrated.
Food should not be started until sips of liquid are tolerated. There is no need for an antiemetic if
the client is not vomiting. Explaining that the toddler will have to wait to eat or drink is not
appropriate since the vomiting stopped 4 hours ago; it would be okay to start sips.
Concepts tested

Question 847
A home health nurse is assessing the home environment of an older adult client for safety
concerns. Which action should the nurse take?
A Remove chairs in the living room
B Ensure extension cords are secured against the wall
C Close the curtains in areas not being occupied
D Rearrange all the furniture in the client’s bedroom

Question Explanation
Correct Answer is B
Rationale: Home safety should be assessed by home health nurses to prevent injuries due to falls.
Loose extension cords and wires should be secured and away from walking areas to avoid
tripping. Removal of functional furniture is not necessary. The nurse should instruct the client
never to climb on chairs to reach objects. Living areas should have good lighting. The older adult
is at risk for decreased visual acuity. Rearranging the furniture in the client’s room can disorient
the client. The only furniture that should be rearranged or removed is one that may cause
obstruction or possible injury.
Concepts tested

Question 848
The nurse is planning care for a client who is African American and is in active labor. The nurse
should understand that the client may request which cultural practice?
A The client may request the use of herbs during labor.
B The client may refuse to have the partner present during the delivery.
C The client may request female family members for support.
D The client may request to squat during the delivery.

Question Explanation
Correct Answer is C
Rationale: Culturally competent care includes respecting practices that are compatible with the
client’s culture. The nurse should be aware of commonalities with each culture. African
Americans might prefer female family members for support during labor. The use of herbs
during labor and a squatting position for birth are common practices for Native Americans.
Refusal of the partner’s presence during labor is common in the Asian American culture.
Concepts tested

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Question 849
A breastfeeding client would like to increase her milk production. What should the nurse
recommend?
A Increase the frequency of feedings or breast pump uses
B Add foods high in unsaturated fats
C Reduce the frequency of feedings or breast pump uses
D Use supplemental formula feedings

Question Explanation
Correct Answer is A
Rationale: Milk production is driven by supply and demand. The more milk that is expressed
from the breast, the more milk is produced. Reducing the number of feedings or supplementing
with formula will reduce the production of milk. Increasing dietary fat will have no effect on
milk production.
Concepts tested

Question 850
The nurse is educating a client who is pregnant about a scheduled amniocentesis. Which
statement should the nurse include in the teaching?
A “You will need to shower with the antiseptic scrub provided on the morning of the
procedure.”
B “You will receive a sedative by mouth when you arrive for the test.”
C “You will be asked to use the restroom prior to the start of the test.
D “You will be asked to turn on your left side during the procedure.”

Question Explanation
Correct Answer is C
Rationale: Amniocentesis involves a transabdominal puncture of the amniotic sac to obtain a
sample of amniotic fluid for analysis. The fluid contains fetal cells that are examined to detect
chromosomal abnormalities and several hereditary metabolic defects in the fetus before birth.
Before an amniocentesis, the woman should empty her bladder to reduce the risk of bladder
puncture during the procedure. Showering with an antiseptic scrub and preprocedural sedation
are not necessary. The woman is positioned in a way that provides an adequate pocket of
amniotic fluid on ultrasound.
Concepts tested

Question 851
The nurse is preparing to discharge a client from the neonatal intensive care unit who will require
the use of medical equipment at home. Which of the following statements by the client’s parent
indicates the need for intervention?
A “Who do I call if I need help with the baby’s equipment?”
B “What happens if I don’t remember to feed the baby?”
C “Is it alright to take the baby to the grocery store with me?"
D “Can I take some of the monitors off to bathe the baby?”

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Question Explanation
Correct Answer is B
Rationale: Discharging an infant with medical equipment can be very overwhelming for the
parent and they have many questions about the plan of care. A question such as, “What if I forget
to feed the baby?” is concerning because this is a fundamental need for the baby’s survival. The
other questions do not indicate that the parent is unsafe to care for the newborn.
Concepts tested

Question 852
The nurse is performing a home visit of a client who lives within a blended family. Which of the
following questions by the nurse is appropriate to assess roles within the family unit?
A “How many family members own a vehicle?”
B “Which of the children is the oldest?”
C “Does anyone in the home use tobacco?”
D “Who is responsible for taking the children to school?”

Question Explanation
Correct Answer is D
Rationale: Taking the children to school and other activities is a large responsibility within a
family. The nurse should ask this question and other similar questions to determine which family
member is responsible for certain tasks. While the number of vehicles and tobacco use are
important to assess, they do not affect the roles within family. The ages of the children do not
directly affect the family function.
Concepts tested

Question 853
The nurse is caring for an adolescent client who has repeatedly made comments about how they
are unhappy with the way the body changes in puberty. Which action is most appropriate by the
nurse?
A Obtain a referral for a mental health counselor
B Provide the client with educational pamphlets
C Remove any object from the room that could be used for self-harm
D Ask the client to further explain feelings about body image

Question Explanation
Correct Answer is D
Rationale: During puberty, there are significant body changes that occur, and some adolescents
struggle with body image during this time. It is important to support and explain that these
physical changes happen to everyone during adolescence. Ignoring or distraction techniques do
not address the client’s concerns. Removing objects from the client’s room is only necessary if
there is concern that the client will attempt self-harm. Feelings on body image alone do not
warrant this action.
Concepts tested

Question 854
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The nurse is assessing a 3-year-old client’s growth and development. Which of the following
actions is an expected finding for the child’s developmental level?
A Ties shoelaces
B Buttons up a shirt
C Reads time from a clock
D Stacks a tower of blocks

Question Explanation
Correct Answer is D
Rationale: At 3 years old, an expected developmental milestone would be the ability to stack
multiple blocks vertically. Tying shoelaces is expected at 5 years old, simple buttoning is
expected at 4 years old, and reading a clock is not expected until 7 years old.
Concepts tested

Question 855
The nurse is teaching a client about preventing cardiovascular disease. Which of the following
information should the nurse include in the teaching?
A “Avoid starting habits like smoking cigarettes.”
B “Maintain a body mass index (BMI) of 30 to 35.”
C “A healthy systolic blood pressure should be between 120 and 129 mm/Hg.”
D “Resistive isometric exercises are the best type of exercise to improve circulatory function.”

Question Explanation
Correct Answer is A
Rationale: Smoking is a modifiable behavioral risk factor that should be taught to clients to help
prevent illnesses like cardiovascular disease. Systolic blood pressure for an adult should be under
120 mm/Hg; 120 to 129 mm/Hg is considered elevated. A BMI of 25 to 30 is considered
overweight, and over 30 is considered obese, which places a client at higher medical risk of
coronary heart disease. Resistive isometric exercises are those in which an individual contracts
the muscle while pushing against a stationary object or resisting the movement of an object. This
promotes muscle strength and provides sufficient stress against bone to promote osteoblastic
activity. The best exercise program is a combination of isotonic, isometric, and resistive
exercises.
Concepts tested

Question 856
The nurse is performing a home safety assessment for an older adult client with limited mobility.
Which of the following findings should the nurse identify as a safety risk?
A A night light plug-in located in each room
B Several rugs present throughout the home
B Grab bars located next to the toilet
D Multiple locks on the exterior doors

Question Explanation
Correct Answer is B

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Rationale: Older adults are at a higher risk of falling and identification of items that increase the
risk of falls is important. Items that increase the risk of falls include uneven floor surfaces (rugs,
steps, etc.), poor lighting, or cluttered walkways. Having a nightlight in each room helps to
increase visibility and therefore reduces the risk of falls. Grab bars in the shower or next to the
toilet reduce the risk of falling in the bathroom, and the number of locks on the exterior doors do
not pose a safety risk for the client.
Concepts tested

Question 857
A community nurse is delivering an environmental safety presentation to construction workers
within the community. Which statement made by a client tells the nurse more education is
needed?
A “I should change my clothes and shower after working with lead-based products.”
B “I should wear gloves as my personal protective equipment (PPE) when working with lead.”
C “A blood test can reveal the amount of lead in my system.”
D “A well-ventilated area can prevent lead from triggering an exacerbation of my asthma.”

Question Explanation
Correct Answer is B
Rationale: Lead dust particles can be inhaled and affect multiple body systems. While gloves are
part of the personal protective equipment (PPE), a mask and other protective equipment are
required. Changing clothes and showering after working with lead is recommended practice to
reduce lead exposure. A lead blood test can reveal the amount of lead in the system. Lead dust is
a pollutant and may exacerbate asthma. Good ventilation is necessary when working with lead.
Concepts tested

Question 858
The nurse is screening an 80-year-old female client for causes of hypertension. Which of the
following should the nurse identify as a possible cause?
A The client’s age
B The client’s gender
C The client has obstructive sleep apnea
D The client has a history of asthma

Question Explanation
Correct Answer is C
Rationale: Obstructive sleep apnea can cause hypertension. A sympathetic response is triggered
by the frequent apneic events that cause hypoxia and hypercapnia. These clients also have a high
risk for myocardial infarction and stroke. The client’s age and gender are not risk factors for
hypertension. The disease process of asthma does not cause hypertension. It is possible for the
client’s blood pressure to increase from medications used to treat asthma, but that would not be
diagnosed as hypertension, rather just an increased blood pressure as a side effect of the
medications.
Concepts tested

Question 859
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The nurse is screening clients at a community center for nutritional deficits. Which of the
following questions by the nurse is most appropriate?
A “Can you list the food items that you have eaten for the past day?”
B “When was the last time you visited a primary care provider?”
C “How old were you when you started struggling with your weight?"
D “Does anyone in your family experience gastrointestinal issues?”

Question Explanation
Correct Answer is A
Rationale: A 24-hour diet recall is an easy way to obtain information about a client’s dietary
intake. Asking questions about family history or patterns of medical treatment may be helpful in
a client’s nutritional assessment but do not provide the nurse with information directly related to
dietary practices.
Concepts tested

Question 860
The nurse is educating a client about the importance of maintaining healthy lifestyle practices.
Which statement by the client indicates an understanding of behaviors that may negatively
impact health?
A “A sedentary lifestyle increases the risk of lung disease.”
B “Increased consumption of sugary beverages increases the risk of diabetes.”
C “Excessive sun exposure increases the risk of hypertension.”
D “Obesity increases the risk of cardiovascular disease.”

Question Explanation
Correct Answer is D
Rationale: Risk factors for cardiovascular disease include obesity, sedentary lifestyle, poor diet,
smoking, etc. Drinking sugary beverages does not increase the risk for diabetes. Excessive sun
exposure increases the risk for skin cancers.
Concepts tested

Question 861
The nurse is caring for a client who states, “I don’t enjoy sex anymore.” Which question by the
nurse is appropriate to assess the client’s perception of sexual intercourse?
A “How old were you when you became sexually active?”
B “Are you currently in a romantic relationship?”
C “What makes a sexual experience enjoyable to you?”
D “Do you have any children?”

Question Explanation
Correct Answer is C
Rationale: When a client presents a sexual concern, the nurse should ask questions to gather an
understanding of the client’s expectations of sexuality. While questions that address relationship
status, family dynamics, and sexual history may be included in the conversation, only the correct
response is approp

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riate to assess the client’s feelings.
Concepts tested
Question 862
The nurse is caring for an older adult client in the acute care setting. Which of the following
statements by the client indicates that they may be experiencing social isolation?
A “I hate that I have gotten so old.”
B “I don’t want people to see me in this condition.”
C “I wish I could walk up the stairs without getting out of breath.”
D “I depend on my family members for so much.”

Question Explanation
Correct Answer is B
Rationale: In order to identify a client at risk for social isolation, the nurse needs to assess the
client’s social network, access to transportation, and desire to interact with people. In this case,
the client is stating that they do not want people to see them, thus indicating that they want to
avoid interaction.
Concepts tested

Question 863
The homecare nurse is caring for an older adult following knee replacement surgery one week
ago. The client has multiple long-standing prescriptions for chronic conditions and has been
having episodes of dizziness occasionally for several years. Which of the following interventions
is the nurse’s priority?
A Recommend the client sleep in the downstairs bedroom
B Perform medication reconciliation to ensure the client is not experiencing an adverse drug
event
C Educate the client on disease management
D Observe the client perform the prescribed physical therapy exercises

Question Explanation
Correct Answer is A
Rationale: Polypharmacy and loss of balance are major contributors to falls. Climbing stairs may
prove challenging for the client who is experiencing pain and weakness. Throw rugs pose a risk
of tripping. The client’s acute risk for falls takes priority over the management of chronic
conditions at this time. Observing the client perform the exercises is important but not the
priority.
Concepts tested

Question 864
The nurse is concerned about the risk of paralytic ileus in a post-operative client. Which
technique is essential for the nurse to employ when assessing the client’s abdomen?
A Palpate any tender areas first
B Auscultate for bruits over abdominal arteries after palpation
C Auscultate before palpating the abdomen

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D Start auscultating at the right lower quadrant of the abdomen

Question Explanation
Correct Answer is C
Rationale: The order of assessment of the abdomen is different from other body systems.
Inspection is followed by auscultation for bowel sounds before percussion and palpation. Failure
to adhere to this order may result in the alteration of bowel sounds from either percussion or
palpation. Auscultate all four quadrants for vascular sounds after bowel sounds are assessed. It is
recommended to start at the point of the ileocecal valve, slightly right and below the umbilicus,
and proceed clockwise. Listen in each quadrant for a full minute. If no sounds are audible, listen
for up to 5 minutes. Tender areas should be palpated and percussed last.
Concepts tested

Question 865
The nurse is assessing a client who has aortic stenosis. Where should the nurse place the
stethoscope to auscultate for this abnormal heart sound?
A The third intercostal space at the mid-axillary line
B The fourth intercostal space at the mid-clavicular line
C The sixth intercostal space at the left sternal border
D The second intercostal space at the right sternal border

Question Explanation
Correct Answer is D
Rationale: The aortic valve is best auscultated at the second intercostal space at the right sternal
border.
Concepts tested

Question 866
The nurse is teaching the parent of an infant how to monitor the infant’s temperature at home.
Which of the following information should the nurse include in the teaching?
A “When using a tympanic thermometer, pull your infant’s earlobe down, and insert the tip of
the thermometer into the ear canal."
B “When using a rectal thermometer, insert the thermometer 0.25 inches past the tip into the
rectum, and hold in place for one minute.”
C “A temporal artery thermometer should be slid back and forth across the infant’s forehead
with the sensor part flat against the skin for 3 minutes.”
D “An axillary temperature can be obtained by placing the tip of the thermometer even with the
infant’s nipple line and under the arm.”

Question Explanation
Correct Answer is A
Rationale: The correct technique is described for using the tympanic thermometer. A rectal
thermometer should not be inserted any further past the tip and should be held in place for 5
minutes. The temporal artery thermometer should be slid, with the sensor part flat against the
skin, across the forehead and down the hairline to where the hairline stops near the neck. An

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axillary temperature is obtained by placing the tip of the thermometer securely into the infant’s
armpit/axillary area and holding the arm in place over the top of it until the thermometer
registers.
Concepts tested

Question 867
A nurse is taking care of an older adult client who will be discharged to an assisted living
facility. The client asks the nurse why they are being placed into assisted living. Which is an
appropriate response by the nurse?
A “You are being placed into an assisted living facility because you require assistance with
transfers from bed to chair.”
B “You are fully incontinent, and an assisted living facility will provide staff to assist you with
toileting.”
C “You are disoriented to time, place, and person and will benefit from being around other
clients at the assisted living facility.”
D “You often forget to bathe and perform hygiene, so the staff at the assisted living facility can
help remind you.”

Question Explanation
Correct Answer is D
Rationale: Assisted living can provide services to older adults who have impaired functionality
and require protective oversight. An older adult client who is able to provide their own hygiene
but requires reminders or structure can benefit from an assisted living facility. Options A, B, and
C require a nursing facility. Nursing facilities provide a living arrangement in which clients
require 24-hour nursing supervision. A client who is unable to transfer from bed to chair is at
high risk for falls. A client who is fully incontinent and requires assistance with toileting is at
high risk for skin breakdown. A client who is disoriented to person, place, and time is at risk for
falls, poor judgment, and injury.
Concepts tested

Question 868
A nurse is caring for a postpartum client who experienced a home birth. The client asks the nurse
if she can have the placenta so that she may bury it at a later time. How does the nurse respond to
this request?
A “Who is going to help you bury the placenta?”
B “Why do you feel like this practice is necessary?”
C “The placenta needs to be disposed of properly, as it is biological waste.”
D “Tell me more about what this practice means to you.”

Question Explanation
Correct Answer is D
Rationale: Nurses should be aware of cultural norms regarding placenta care. Burying the
placenta is a practice that holds meaning for various cultures. Nurses should explore how this
practice impacts the client. Asking who will help bury the placenta does not assess cultural

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meaning. “Why” questions are barriers to communication and do not promote culturally
competent care. The nurse must first explore the value of the client’s request.
Concepts tested

Question 869
A nurse is providing care to a breastfeeding client who is 3 days postpartum. The newborn had a
birth weight of 7 lbs 6 oz and now weighs 7 lbs 1 oz. The mother expresses concern about the
amount of weight the newborn has lost since birth. What intervention should the nurse
implement first to minimize further weight loss?
A Monitor the number of wet diapers to assess for dehydration
B Encourage the client to offer feedings more frequently
C Offer formula supplements between breast feedings
D Continue to monitor the weight, as this is an expected finding

Question Explanation
Correct Answer is B
Rationale: Newborns usually lose up to 6% of their birth weight within the first few days of life
but regain it in approximately 10 days. Encouraging more frequent feedings will promote milk
production. Supplementation with formula may occur when a newborn has lost >10% of birth
weight. Monitoring wet diapers is important to assess for dehydration but not to minimize weight
loss.
Concepts tested

Question 870
The nurse is assessing a client who is 4 hours postpartum from a normal spontaneous vaginal
delivery with a midline episiotomy. The nurse notes the fundus is firm and midline and at the
level of the umbilicus, perineal sutures are well approximated with slight edema, and moderate
lochia is present. Which action should the nurse take?
A Assist the client to void
B Prepare to type and crossmatch the client
C Gently massage client’s fundus
D Document the findings

Question Explanation
Correct Answer is D
Rationale: Assessments during the fourth stage center on frequent monitoring of the woman’s
vital signs, the status of the uterine fundus and perineal area, comfort level, lochia amount, and
bladder status. Assess fundal height, position, and firmness. The fundus needs to remain firm to
prevent excessive postpartum bleeding. The fundus should be firm (feel like the size and
consistency of a grapefruit) and be located in the midline. If it is not firm (boggy), gently
massage it until it is firm. Once firmness is obtained, stop massaging. This client has expected
assessment findings for the postpartum stage and, therefore, requires no intervention other than
documentation.
Concepts tested

Question 871
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The nurse is interviewing the parent of a 3-day-old client at an outpatient well visit. Which of the
following statements by the parent creates concern for the wellbeing of the infant?
A “There is no one to watch the baby while I work.”
B “My family has to share one car.”
C “There is a history of drug addiction in my family.”
D “The baby only sleeps for three hours at a time.”

Question Explanation
Correct Answer is A
Rationale: The statement that the parent has no one to watch the infant while they work is
concerning because the parent must choose between leaving the baby alone or losing their job.
While this lack of support doesn’t directly harm the infant, it can lead to an unsafe situation.
Sharing one car and newborn sleep cycles are not safety concerns. Having a family history of
substance abuse warrants further assessment, but this statement does not indicate that someone
who is abusing substances is in contact with the infant.
Concepts tested

Question 872
The nurse is caring for a client who states, “My partner got remarried, and now I have to take
care of the kids without any help.” What kind of family structure should the nurse record in the
client’s chart?
A Single-parent family
B Nuclear family
C Blended family
D Contemporary family

Question Explanation
Correct Answer is A
Rationale: A single-parent family is a home in which one member of the family is responsible for
100% of the adult responsibilities within that family unit. Nuclear families are structures in
which the parents and children live together. Contemporary families/contemporary nuclear
families may include same-sex marriage. Blended families are those who have children from
previous relationships within the same family unit.
Concepts tested

Question 873
The nurse is caring for an older adult client who has expressed feelings of guilt about the need to
move in with one of their children. Which of the following statements would be appropriate for
the nurse to make?
A “Did you have to care for your parents when they got older?”
B “What concerns you most about living with your children?”
C “How long do you expect to live with your children?”
D “Are you fearful of your children?”

Question Explanation

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Correct Answer is B
Rationale: The need for an older adult to move in with a child can create significant role strain in
the parent-child relationship. The reversal of roles can make the parent feel guilty and emotional.
The nurse should listen to the client and family’s concerns about this transition and encourage
them to express their feelings. The nurse should offer support and assist in finding solutions to
their needs. The other options do not encourage the client to discuss their concerns in a
supportive way.
Concepts tested

Question 874
The nurse is interviewing the parent of a 12-month-old infant at a well visit. Which statement by
the parent indicates the need for further assessment of the child’s development?
A “The baby just recently started crawling.”
B “The baby is starting to say a few different words.”
C “The baby loves to play with cups, pots, and pans.”
D “The baby can pick up small objects with the first finger and thumb.”

Question Explanation
Correct Answer is A
Rationale: Crawling is an expected developmental milestone for a 9-month-old child. It is
concerning that at 12 months old the baby just started to crawl, and this requires additional
assessment. At 12 months old, a child is expected to say at least two words, play with pots/pans,
and stack toys. The pincer grasp should be well developed by 12 months of age.
Concepts tested

Question 875
The nurse is teaching a male client who is 22 years old about modifiable risk factors for disease
prevention. Which of the following information should the nurse include?
A “Once you turn 65-years-old, you will need to have some screening tests more often.”
B “You should ask your parents and grandparents about their health history.”
C “You should be aware of which diseases you are more at risk for than women are.”
D “Once you turn 25-years-old, you will have a lower risk of unintentional injuries.”

Question Explanation
Correct Answer is D
Rationale: Modifiable risk factors that contribute to chronic illnesses include unhealthy diet,
physical inactivity, tobacco use, alcohol abuse, poor control of hypertension, and elevated lipid
and glucose levels. Modifiable risk factors for people who are 10 to 24 years of age include
behaviors that lead to unintentional injuries. Nonmodifiable risk factors, such as age, gender,
genetics, and family history, cannot be changed.
Concepts tested

Question 876
The nurse is caring for a client with a new colostomy. Which of the following behaviors by the
client indicates readiness to learn about ostomy care?

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A Stating that they are ready to be discharged
B Asking questions about the supplies needed for appliance change
C Requesting that the client’s partner complete their ostomy care
D Discussing the need to hire a home health nurse with their partner

Question Explanation
Correct Answer is B
Rationale: One of the most important steps in providing successful client education is assessing
the client’s readiness to learn. Clients indicate they are ready to learn when they show an interest
and acknowledge the need to learn the new information or skills. If a client is in denial, not
interested, distraught, and/or preoccupied with other concerns, they will not be receptive to any
teaching.
Concepts tested

Question 877
The nurse is assessing a client with a history of smoking. The client participated in a smoking
cessation program after receiving counseling. How will the nurse evaluate the effectiveness of
the program?
A “How many cigarettes are you smoking daily?”
B “Do you feel like this program has helped you reach your goal?”
C “Can you tell me what sort of activities were taught in this program?”
D “Do you still have the urge to smoke?”

Question Explanation
Correct Answer is A
Rationale: Follow-up care for a smoking cessation program should involve an objective
evaluation. The number of cigarettes smoked daily provides a guideline for the client’s progress.
The client’s perception of the health program and understanding of its purpose is important but
does not provide an objective evaluation for smoking cessation. The client’s urge to smoke may
remain even after a smoking cessation program. This does not objectively evaluate whether
cessation of smoking has occurred.
Concepts tested

Question 878
The nurse is caring for a client diagnosed with ascites. The nurse should screen the client for
signs or symptoms of which of the following possible causes?
A Jaundice
B Portal hypertension
C Encephalopathy
D Esophageal varices

Question Explanation
Correct Answer is B
Rationale: Ascites is an accumulation of fluid in the peritoneal cavity commonly caused by liver
damage, so the nurse should screen the client for signs and symptoms of portal hypertension.

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Ascites can also occur from cancer, kidney disease, and heart failure. Jaundice, esophageal
varices, and encephalopathy are manifestations of liver disease, and they do not cause ascites.
Concepts tested

Question 879
The nurse is caring for an adult client who is being treated for multiple traumatic injuries. Which
of the following questions by the nurse would be appropriate to assess the client for the
possibility of intimate partner violence?
A “Are you ever afraid of your partner?”
B “How many times has your partner hit you?”
C “Do you use illegal substances?”
D “Do you have any children with your intimate partner?”

Question Explanation
Correct Answer is A
Rationale: When a client has obtained multiple traumatic injuries, the nurse should be concerned
about the possibility of abuse and should screen the client accordingly. Asking the client if they
are fearful of their partner allows the nurse to have an open conversation about the relationship
dynamics. Asking how many times the partner has hit the client is assuming that abuse is
occurring. Illegal substance use and the number of children do not address the nurse’s concern of
abuse.
Concepts tested

Question 880
The nurse is educating a client about sexual health practices. Which of the following questions
by the nurse is most appropriate to assist the client with identifying unsafe sexual practices?
A “Do you know how many unplanned pregnancies occur each year?”
B “Did you know that unprotected sex increases the risk of STIs?”
C “Do you always use a contraceptive when you have sex?”
D “How common do you think HIV is in the community?”

Question Explanation
Correct Answer is B
Rationale: Asking the client about their knowledge of the risk of unprotected sex allows the
nurse to identify knowledge gaps in the client’s sexual education and have conversations about
their own personal practices. Unplanned pregnancy and contraceptive use are important
conversations to have but are not the best answer to address risky behaviors. HIV prevalence can
be included in the conversation but is not the best response to this question.
Concepts tested

Question 881
The nurse is interviewing a client who shares that they were sexually assaulted approximately
five years ago. Which question by the nurse is appropriate to assess the client’s attitude about
sexuality?
A “Would you like to be screened for sexually transmitted infections?”

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B “Was your mental health negatively impacted by the assault?”
C “Can you describe the sexual assault that occurred?”
D “How do you feel when someone makes sexual advances towards you?”

Question Explanation
Correct Answer is D
Rationale: To assess the client’s attitude about sexuality, the nurse should ask an unbiased
question that addresses the client’s feelings about sex. Describing the assault is invasive and does
not address the client’s feelings. Asking about screening for STIs may be appropriate but does
not address the client’s feelings.
Concepts tested

Question 882
The nurse is performing a client’s weekly home health visit. Which of the following statements
by the client indicates that they may be experiencing social isolation?
A “I haven’t seen anyone since the nurse came last week.”
B “I only have a few more days of medicine left.”
C “I don’t have any children of my own.”
D “Everything is more difficult now that my mobility is limited.”

Question Explanation
Correct Answer is A
Rationale: In order to identify social isolation, the nurse should assess the client’s social network,
access to transportation, and desire to interact with people. In this case, the client is stating that
they have not seen any other people since the last home health visit a week ago. This is cause for
concern and follow-up questions should be asked by the nurse.
Concepts tested

Question 883
A homecare nurse is caring for a 75-year-old client who has dementia. The spouse is the primary
caregiver. Which of the following statements indicates that the spouse is at risk for caregiver role
strain?
A The spouse has hired a weekly cleaning service because they “just can’t keep up.”
B The spouse states that they “have no idea how to take care of someone with dementia!”
C The spouse states that “our children often help with doctor’s appointments.”
D The spouse has moved the door locks to the tops of the doors because the client “goes outside
if I’m not looking.”

Question Explanation
Correct Answer is B
Rationale: Many older adults help care for aging family members and have concerns about their
own health and ability to continue to be a caregiver. This often makes them “secondary patients.”
Caregivers often face 24-hour care responsibilities for extended periods of time, which creates
physical and emotional problems for the caregiver. Signs of role strain include verbal

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expressions of apprehension about providing care, concerns that support systems are inadequate,
changes in their own health status, signs of ineffective coping, depersonalization, and neglect of
the patient. Moving the locks is a safety strategy for dementia patients. Seeking help from family
and household services are additional strategies to prevent role strain.
Concepts tested

Question 884
The nurse is assessing a client’s pulse who has an irregular heart rate. Which of the following
actions by the nurse demonstrates correct technique?
A Counting the client’s radial pulse for 60 seconds
B Counting the client's carotid pulse for 30 seconds and multiplying by two
C Counting the client’s apical pulse for 45 seconds
D Counting the client's brachial pulse for 10 seconds and multiplying by six

Question Explanation
Correct Answer is A
Rationale: If the client’s heart rate has a regular rhythm, the nurse can count the pulse for 30
seconds and multiply; however, in this case, the client has an irregular heart rate. This means that
the nurse should count the client’s pulse for a full minute to obtain an accurate pulse rate.
Concepts tested

Question 885
The nurse is performing an initial assessment of a client in the emergency department. The client
states, “I feel like I can’t breathe.” Which of the following assessments should the nurse
complete first?
A Obtaining the client’s oxygen saturation
B Auscultating the client’s breath sounds
C Palpating the client’s carotid pulse
D Inspecting the client’s extremities

Question Explanation
Correct Answer is A
Rationale: When a client is seeking care for a significant respiratory concern, the nurse should
prioritize assessments to determine the acuity of the client’s concern. Breath sounds, extremities,
and pulses should be assessed, but if the client’s oxygen saturation is very low, other
interventions may take priority.
Concepts tested

Question 886
The nurse is providing care to a 5-year-old client who has bacterial pneumonia and requires
intravenous medication. Which of the following actions should the nurse take?
A Explain what the intravenous medication is and what it is for to both the client and parent(s) at
the same time
B Describe any sensations the client may experience and use a doll or stuffed animal to
demonstrate how the equipment will be connected

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C Ask another nurse or unlicensed assistive personnel (UAP) to assist with restraining the client
when starting the medication to prevent any injury
D Allow the client to push the buttons on the infusion pump to start the infusion

Question Explanation
Correct Answer is B
Rationale: Preschool-aged children should be given short explanations of what to expect close to
the time of the procedure to reduce the amount of time the child has to worry. Using a doll or
stuffed animal in a play session to demonstrate and introduce what will happen with new
equipment allows the child to see that the doll is not injured during the procedure. This also
allows the child to handle the equipment. The parents should receive an explanation away from
the child in appropriate language for their developmental level and would also need to consent to
the procedure prior to explaining it to the child. There is no need to restrain the child without
assessing if the child would be cooperative with the procedure first. Restraining is the last resort
and should only be used if the parent is comfortable with intervention. Allowing the child to play
with equipment at this age would be appropriate but not when the equipment is actually in use.
The nurse should allow the client to touch equipment attached to a doll or stuffed animal and not
the client themselves because it could cause injury.
Concepts tested

Question 887
A nurse assesses the vision of a 65-year-old client. The nurse notes that the client’s pupils
constrict sluggishly and are 2 mm bilaterally. The client asks the nurse what the results mean.
What should the nurse tell the client?
A “This is an expected result.”
B “This is probably due to medications.”
C “You will likely be referred to a specialist for further treatment.”
D “Tell me when you noticed these changes.”

Question Explanation
Correct Answer is A
Rationale: A decrease in sensory perception is an expected finding. Visual acuity diminishes,
pupil size and constriction ability decrease, and peripheral vision is reduced due to structural
changes of the eye. Medications can cause changes in pupillary responses. However, there is no
indication that the client is taking medications. The assessment findings are consistent with
aging. There is no indication of a disease process requiring further referrals. There is no
indication that the client is having trouble with their vision.
Concepts tested

Question 888
The nurse is planning care for a postpartum client who identifies as Roman Catholic. The nurse
notes that the client’s newborn is critically ill. Which spiritual practice should the nurse expect
the client to request?
A All family members in the room to pray together
B A priest to perform an infant baptism

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C Time alone to recite the Call for Prayer
D A Mohel to perform circumcision of the infant
Question Explanation
Correct Answer is B

Question 889
The nurse is providing teaching to the parent of a newborn during the first bottle feeding of
formula. Which of the following statements by the parent indicates the need for further teaching?
A “I will keep the baby’s head up during the feeding.”
B "I will take several breaks to burp the baby during the feeding.”
C “I will make sure that some air remains in the nipple at all times during the feeding.”
D “I will expect yellow-brown stools that are pasty."

Question Explanation
Correct Answer is C
Rationale: Keeping the baby’s head in a semi-upright position helps to prevent aspiration. The
nipple should be held so it fills only with formula. The infant should not be permitted to suck air
as this leads to reflux. Burping will help any air that was swallowed to escape. A newborn who is
bottle-fed typically has soft, formed yellow stools, and they can occur with each feeding. The
frequency of stools will decline as the newborn adapts to feeding.
Concepts tested

Question 890
The nurse is preparing to discharge a postpartum client who has a history of postpartum
depression after the birth of the first child. Which follow-up care should the nurse include in the
plan for this client?
A An appointment with a mental health counselor, scheduled prior to discharge
B An appointment with the obstetrician in 6 weeks, scheduled prior to discharge
C One visit from a homecare nurse to take place in 2 days, scheduled prior to discharge
D Two visits from a lactation consultant over the next month

Question Explanation
Correct Answer is A
Rationale: Postpartum depression (PPD) is a form of clinical depression that can affect women
after childbirth. Unlike the postpartum blues, women with postpartum depression feel worse over
time, and changes in mood and behavior do not go away on their own. Different from baby
blues, the symptoms of PPD last longer, are more severe, and require treatment. Based on the
woman’s history of prior depression, prophylactic antidepressant therapy may be needed during
the third trimester or immediately after giving birth. Management mirrors that of any major
depression: a combination of antidepressant medication, antianxiety medication, adequate sleep
and rest, and psychotherapy in an outpatient or inpatient setting.
Concepts tested

Question 891

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The nurse is assessing an 18-month-old client at a well visit. Which of the following findings
indicates that the client is experiencing growth or developmental delays?
A The client has a total of eight teeth.
B The client cannot state their full name.
C The client mimics household chores.
D The client cannot stack two blocks.

Question Explanation
Correct Answer is D
Rationale: A toddler should be able to stack two blocks at 15 months old; not having the motor
control to complete this action indicates a developmental delay. At 18-months-old, a toddler can
say 7-20 simple words, but asking the child to state their full name is not expected. At 18 months
old, 8-10 teeth are expected, and imitation of chores is a typical play activity at this age.
Concepts tested

Question 892
The nurse is assessing a 4-year-old client at a well-child visit. Which of the following findings
indicate that the child’s development is delayed?
A Inability to tie shoe laces
B Plays games with letters or numbers
C Unable to tell time on a clock
D Speaks in two-word sentences

Question Explanation
Correct Answer is D
Rationale: At 4 years of age, the child should have a vocabulary of approximately 1,500 words
and should be able to construct complete sentences. Simple two-word sentences (typically a noun
and an action word) are an expected developmental milestone of the 2-year-old child. Tying
shoelaces is not expected until 5 years of age, and playing games with numbers or letters is a
normal finding of the 5-year-old but may begin earlier. The ability to tell time on a clock is not
expected until 7-years-old.
Concepts tested

Question 893
The nurse is preparing an 8-year-old client to have a computed tomography (CT) scan of the
abdomen with contrast. Which of the following statements by the nurse is appropriate to explain
the procedure?
A “The machine doesn’t hurt you if you stay still.”
B “When you get the IV contrast, it will make you feel like you have to urinate.”
C “The scanner is scary, but it goes very fast.”
D “The machine takes pictures of what is inside of you.”

Question Explanation
Correct Answer is D

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Rationale: Diagnostic procedures can be extremely stressful for pediatric patients. Preparing a
child for the procedure by using calm communication and explaining the process at an age-
appropriate level of understanding helps to reduce stress associated with the procedure.
Concepts tested

Question 894
The nurse is caring for an adolescent client who is seeking care for new onset facial acne. Which
question by the nurse is appropriate to evaluate the client’s feelings on body image?
A “How long has this acne been occurring?”
B “Does acne affect how you feel about yourself?”
C “Does anything make your acne worse?”
D “Have you had any thoughts of harming yourself?”

Question Explanation
Correct Answer is B
Rationale: Body image can be negatively impacted by physical changes in puberty, like acne.
Asking the client how it makes them feel about themselves is an appropriate way to begin
discussing body image. All of the other responses do not address the topic of body image or self-
esteem.
Concepts tested

Question 895
The nurse is teaching a client about primary health prevention. Which of the following actions
should the nurse take?
A Ask the client to complete a screening survey
B Perform a review of body systems
C Provide sex education about preventing sexually transmitted infections
D Assist the client with returning to the highest level of health by providing education

Question Explanation
Correct Answer is C
Rationale: Primary health prevention actions include providing health education about marriage,
sex, and genetic screening. Secondary prevention focuses on preventing the spread of disease,
illness, or infection once it occurs. Screening surveys and focused examinations to prevent
complications are helpful for early diagnosis and prompt treatment. Education and retraining are
part of tertiary prevention for restoration and rehabilitation to minimize the effects of long-term
disease or disability.
Concepts tested

Question 896
The clinic nurse is preparing to administer prescribed vaccines to a 4-month-old client. The
client’s parent asks if the influenza vaccine will be administered during the visit. Which is an
appropriate response by the nurse?
A “The influenza vaccine is not recommended until adulthood.”

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B “I will administer the influenza vaccine with this series of vaccines.”
C “The influenza vaccine is recommended starting at the age of one-year-old.”
D “The influenza vaccine can be administered in two months.”

Question Explanation
Correct Answer is D
Rationale: The Centers for Disease Control and Prevention (CDC) recommends administering
the influenza vaccine starting at the age of 6 months and yearly after the initial dose.
Concepts tested

Question 897
The nurse is following up with a primipara client who enrolled in a maternal-infant health
program. Which statement made by the client demonstrates the program was effective?
A “I place my baby forward-facing in the back seat of the car.”
B “I throw away my excess breast milk since I can also give my baby formula.”
C “I lay my baby on their side every night before bed.”
D “I will take my baby to get several vaccines when they turn 2 months old.”

Question Explanation
Correct Answer is D
Rationale: Maternal, infant, and child health programs focus on infant care and postpartum
health. Immunizations are part of health promotion. At 2 months, infants will receive between 5
and 6 scheduled vaccines. Infants should be placed rear-facing in a car seat until the age of 2 to
4. Breast milk provides natural antibodies and should be encouraged over formula if the client is
able to breastfeed or produce breastmilk. Babies should be laid on their backs to prevent
accidental suffocation.
Concepts tested

Question 898
The nurse is screening a client who had surgery for diabetes mellitus, type 2, and the client asks,
“Why would you think I have diabetes? I feel fine and no one in my family has diabetes.” Which
of the following responses would explain the reason for the nurse to screen the client?
A "When I tested your arterial blood gases, your pH level was decreased.”
B “Your urine test showed that your BUN and creatinine levels were severely decreased."
C “When I tested your urine, I noticed there were ketones present.”
D “Your laboratory results show an increase in serum osmolality and glucose levels.”

Question Explanation
Correct Answer is D
Rationale: Diabetes mellitus (DM), type 2, can result in hyperglycemic hyperosmolar syndrome
(HHS) when the client is unaware that they have diabetes. HHS is a metabolic disorder of type 2
DM resulting from a relative insulin deficiency initiated by an illness that raises the demand for

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insulin. Laboratory results would show an increase in serum osmolality and blood glucose levels
over 600 mg/dL. BUN and creatinine levels would be elevated. Ketones and a decreased arterial
pH level would be present in DKA, which is a complication of DM, type 1.
Concepts tested

Question 899
The nurse is caring for a client who asks the nurse to repeat themselves several times during
normal conversation. Which of the following actions by the nurse would be appropriate to screen
the client for hearing loss?
A Provide the client with a written plan of care
B Eliminate background noise during conversations with the client
C Ask the client to repeat whispered numbers or letters
D Inspect the client’s middle ear using an otoscope

Question Explanation
Correct Answer is C
Rationale: If hearing loss is suspected, the nurse should perform the whispered voice test to
screen the client for hearing difficulty. This test involves the examiner whispering three numbers
or letters to the client and having the client repeat them. If the client has normal hearing acuity,
they should be able to correctly repeat the whispered characters. While eliminating background
noise and inspecting the client’s middle ear may be done as a part of a hearing exam, they do not
screen for hearing loss. Providing a written plan of care can be helpful but does not address the
client’s inability to hear.
Concepts tested

Question 900
The nurse is educating older adult clients at a health fair. Which of the following statements
should be included in the teaching?
A “Exercise is important to keep your bones healthy.”
B “Most older adults would benefit from weight loss diets.”
C “Depression is a normal part of the aging process.”
D “Group activities increase the risk of falling.”

Question Explanation
Correct Answer is A
Rationale: Regular exercise is an important part of musculoskeletal health in the older adult
population, and this should be included in the client education. Weight-loss diets are not
recommended in most cases. Depression is an abnormal finding for any age group. Group
activities are beneficial to prevent social isolation; they do not increase the risk of falls.
Concepts tested

Question 901
The nurse is caring for a client who is being treated for a sexually transmitted infection (STI).
Which of the following questions by the nurse is appropriate to assess the client’s need for
contraceptives?

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A “Have you been sexually active within the last month?”
B “What method do you use to prevent pregnancy?”
C “Does your partner know that you have an STI?”
D “What is your sexual orientation?”

Question Explanation
Correct Answer is B
Rationale: To assess the client’s need for contraception, the nurse should ask an unbiased
question that addresses the client’s current sexual practices. A timeline of sexual activity and
their partner’s STI status should be investigated but do not directly affect the client’s need for
contraception.
Concepts tested

Question 902
The nurse is preparing to discharge a client home. Which statement by the client should cause
the nurse to be concerned about the possibility of environmental isolation?
A “My dog will be so excited to see me when I finally get back home.”
B “My children have offered to come over to help me with cooking.”
C “I am going to need to use a walker to get around the house.”
D “I will have to call my neighbor to help me get up the front steps of the house.”

Question Explanation
Correct Answer is D
Rationale: The client stating that they will have to call a neighbor to help them get up and/or
down the steps leading to the house should cause the nurse to be concerned about environmental
isolation because the client is unable to independently enter/exit the home. This is cause for
concern and follow-up questions should be asked by the nurse.
Concepts tested

Question 903
The home health nurse is assessing the ability of a client who has chronic obstructive pulmonary
disease (COPD) to manage prescribed medications. The nurse notes that the client often skips
months refilling the prescriptions. Which action should the nurse take?
A Determine if the client has difficulty paying for the medications
B Identify accessible public transportation to the client’s pharmacy
C Request prescriptions for generic medications from the provider
D Use the manufacturers’ websites to obtain coupons for one free 30-day supply for each
medication

Question Explanation
Correct Answer is A
Rationale: Cost-related medication nonadherence is a major barrier to chronic disease
management. Nonadherence may include skipped or reduced doses and delaying to fill and/or

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not filling prescriptions. Older adults may forgo medications because of inadequate prescription
coverage by insurance programs and high out-of-pocket costs. Patient pharmaceutical assistance
programs provide eligible applicants with their medications at a reduced cost. Medications for
more severe forms of COPD are not available in generic versions, so this is not an appropriate
solution. There is no indication that the client has a barrier to accessing care, only affording care.
A 30-day coupon does not address the long-term goal of medication adherence.
Concepts tested

Question 904
The nurse is caring for a client who has a prescription for daily weight measurements. Which of
the following actions by the nurse is appropriate?
A Removing the client’s clothing prior to measuring weight
B Weighing the client at the same time each day
C Measuring the client’s weight while taking vital signs
D Alternating the scale from the previous day

Question Explanation
Correct Answer is B
Rationale: To ensure accuracy, the nurse should weigh the client at the same time each day and
use the same scale as previous weight measurements. The client does not need to remove
clothing unless a particular item of clothing is bulky or heavy. The client should be wearing
clothing that is similar to the items worn during previous weight measurements. The nurse
should not perform any additional assessments while the weight is being measured.
Concepts tested

Question 905
The nurse is gathering a health history for a client who is being seen for a well visit. The client
states, “I am just so tired all the time. I don’t understand it.” Which question by the nurse would
be appropriate to further assess the client’s concern?
A “Do you take any medications that make you sleepy?”
B “Does anyone else in your household experience sleep issues?”
C “How many hours on average are you sleeping each night?”
D “Can you tell me more about the fatigue you’re experiencing?”

Question Explanation
Correct Answer is D
Rationale: When interviewing a client about a concern, it is best to use open-ended questions that
allow the client to provide more details about the issue. All other responses are closed or direct
questions that prompt the client to give very short (often one-word) answers.
Concepts tested

Question 906
The nurse is providing discharge teaching for the parent of a 3-year-old client who has a long-leg
hip spica cast. Which of the following information should the nurse include in the teaching?
A “Assist with feeding your child to encourage oral intake.”

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B “Provide puzzles or small building blocks to play with to help develop your child’s fine motor
skills.”
C “Continue to cuddle and touch your child often on non-casted areas of the body.”
D “Avoid moving and repositioning your child too often.”

Question Explanation
Correct Answer is C
Rationale: Children at this age thrive on being touched. The parent of a child in a large body cast
may need a demonstration of how to cuddle or move the child in this type of cast. Remind the
parent that the child can and should be touched often on areas that are not covered by the cast.
The child at age three wants to be independent and feed themself. Encouraging independence
and offering finger foods that the child can handle themselves would encourage oral intake more
than the child being fed; the cast should be protected from dropped or spilled food. The parents
should be taught how to easily move and reposition the child. Carrying the child or using a toy
wagon can be easily taught to the parents to avoid the child feeling isolated in one place of the
home. Small toys should be avoided with this type of cast because they can fall into the cast and
cause skin integrity issues.
Concepts tested

Question 907
An older adult client is prescribed a daily calcium supplement. The client asks the nurse why this
is necessary. What education does the nurse provide to the client?
A “Consuming enough calcium will prevent injuries to your bones.”
B “A calcium supplement is necessary to maintain bone density.”
C “Most older adults do not consume enough calcium in their diets.”
D “Older adults require supplementation of all vitamins and minerals.”

Question Explanation
Correct Answer is B
Rationale: Osteoporosis is a disease caused by bone density loss. Calcium shifts from the bone
into the bloodstream and causes bones to become weak and brittle. Older adults are at a higher
risk for fractures due to osteoporosis. A calcium supplement is recommended to maintain bone
density. Calcium consumption will not prevent injuries. Calcium can promote bone density but
will not prevent trauma. Older adults require a calcium supplement in addition to an adequate
diet. Calcium loss is greater among older adults. Supplementation of vitamins and minerals does
not address the specific need for calcium.
Concepts tested

Question 908
A pregnant client asks the nurse when her expected delivery date will be. The client tells the
nurse her last menstrual period was January 28th. What date will the nurse tell the client is the
expected delivery?
A November 4th r
B October 28th
C December 4th

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D November 11th

Question Explanation
Correct Answer is A
Rationale: The expected delivery date is calculated using Nagele’s rule. Three months are
subtracted from the last known menstrual cycle. Seven days are added to the result. For this
scenario, the calculation is as follows: (January 28 – 3 months = October 28) > (October 28 + 7
days = November 4).
Concepts tested

Question 909
The nurse is observing a 6-year-old client at a well visit. Which of the following findings
indicate that the client is experiencing developmental delays?
A Writing words with spelling errors
B Expressing interest in reading
C Asking the provider for more toys
D Fixating on a brightly colored object

Question Explanation
Correct Answer is D
Rationale: A 6-year-old client should demonstrate the ability to write words but may reverse
letters or misspell words. They also find enjoyment in reading quietly. Toys are still an important
part of play at 6-years-old and often hold more importance than imaginative play. Brightly
colored objects are attractive to children but a fixation on objects is a concern. Fixation on bright
objects or lights is normal for infants and toddlers, but this behavior typically disappears in the
school-aged child.
Concepts tested

Question 910
The home health nurse is educating a client who was discharged 2 days ago about the symptoms
of postpartum metritis. Which finding should the nurse include in the teaching?
A Lower abdominal tenderness
B Urinary frequency
C Mild reddish lochia
D Perineal soreness and edema

Question Explanation
Correct Answer is A
Rationale: Metritis is an infectious condition that involves the endometrium, decidua, and
adjacent myometrium of the uterus. It occurs within the first two days postpartum or as late as
two to six weeks postpartum. Symptoms of metritis are lower abdominal pain and uterine
tenderness, followed by fever, most commonly within the first 24 to 72 hours postpartum. Chills,
headaches, malaise, and anorexia are common. Sometimes the only symptom is a low-grade
fever.
Concepts tested

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Question 911
The nurse is assessing a 16-month-old client at a well visit. Which of the following findings is
expected for the client’s developmental level?
A Opening a door by turning a doorknob
B Speaking in three-word sentences
C Scribbling with a crayon
D Walking upstairs unassisted

Question Explanation
Correct Answer is C
Rationale: At 15 months of age, a toddler can scribble with a pencil or crayon; therefore, this
would be an expected finding for a 16-month-old. At this age, the child will only have 4-20
words in their vocabulary and cannot put together simple sentences. The motor control to turn a
doorknob or walk upstairs alone is not expected until 24 months old.
Concepts tested

Question 912
The nurse is assessing a 9-year-old client who is having abdominal pain. Which of the following
statements by the client would indicate that the client’s cognitive ability is below the expected
development?
A “I am hurt so bad.”
B “My stomach started hurting yesterday.”
C “Please don’t touch my belly.”
D “Make the pain stop soon.”

Question Explanation
Correct Answer is A
Rationale: According to Piaget, children between the ages of 7-12 years old are in the “Concrete
Operational” thinking stage. This mode of thinking is logical and systematic. They are also
aware of the concept of time (past, present, future, and reversibility). Asking the examiner not to
touch their belly does not indicate a cognitive delay but fear of additional pain. The response that
does indicate a lower cognitive level than expected is the response “I am hurt so bad.” This
statement falls into the pre-operational thought process of Piaget’s stages (egocentric, present
tense only, and simplistic).
Concepts tested

Question 913
The nurse is preparing to perform a physical assessment of a preschool-aged child. Which of the
following actions by the nurse is appropriate?
A Allow the child to play with certain tools before use
B Direct all interview questions to the child
C Separate the child from the parent during the assessment
D Perform the most invasive part of the assessment first

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Question Explanation
Correct Answer is A
Rationale: Allowing the child to touch assessment tools, such as a stethoscope, before placing it
on their chest helps to relieve the child’s anxiety of the unknown. The child may be able to
answer simple interview questions, but the caregiver will provide most of the subjective data.
Removing the parent from the exam room may create separation anxiety, and the most invasive
aspects of an assessment should be performed last to ensure that objective data collected is not
skewed by pain or anxiety.
Concepts tested

Question 914
The nurse is teaching a client newly diagnosed with diabetes mellitus, type 1, who requires
insulin administration. Which of the following actions should the nurse take first?
A Assess the client’s level of motivation to learn
B Evaluate the client’s developmental level for learning
C Ask the client if they prefer that information is provided in writing
D <span style="font-weight: 400;">Identify if the client would like a family member to be
present</span>
Identify if the client would like a family member to be present

Question Explanation
Correct Answer is A
Rationale: Achievement of desired learning outcomes depends on a client’s motivation to learn,
readiness and ability to learn, and the environment where learning will take place. Motivation to
learn is influenced by the client’s belief in the need to know something. Without motivation, the
client’s style of learning, need for support, and ability to learn do not matter.
Concepts tested

Question 915
The nurse is teaching a client who has a high risk for diabetes mellitus (DM), type 2, about
prevention. Which of the following information should the nurse include in the teaching?
A “It is important for you to keep your body mass index below 30.”
B “Including daily exercise with dietary recommendations will give you the best results when
trying to lose weight.”
C “Avoid eating foods that have more than 10 grams of sugar per serving.”
D “The number of grams of fiber that you consume should be counted as calories when you are
trying to maintain or lose weight.”

Question Explanation
Correct Answer is B
Rationale: Dietary recommendations combined with daily exercise is the best way to lose and or
maintain body weight and decrease the risk of DM, type 2. Sugar consumption should be limited
to maintain a healthy diet and prevent type 2 DM. However, the recommendation is to limit
added sugar or sweeteners so that less than 10% of calories come from added sugars. The
recommended daily calories can vary from person to person and can depend on the amount of
exercise the person includes in their daily routine. BMI should be maintained under 24, not 30.
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Fiber is a polysaccharide that cannot be broken down by the digestive system, which means it
does not contribute to the number of calories consumed in the diet.
Concepts tested

Question 916
The clinic nurse is collecting the health history of an 11-year old client during a wellness visit.
The parent asks, “When can my child get the human papillomavirus (HPV) vaccine?” Which
response would be appropriate for the nurse to make?
A “The HPV vaccine is recommended when your child goes through menarche.”
B “We can administer the HPV vaccine now.”
C “The HPV vaccine should be administered after the age of 15.”
D “The HPV vaccine is not administered until your child is sexually active.”

Question Explanation
Correct Answer is B
Rationale: The Centers for Disease Control and Prevention recommend that 11–12-year-olds
receive a 2-shot series of the HPV vaccine despite not being sexually active. The HPV vaccine
can be administered through adulthood if not received at the age of 11–12. After the age of 15, a
3-dose series is recommended.
Concepts tested

Question 917
A client with high risk for metabolic syndrome was referred to a registered dietician for
nutritional counseling. The nurse is evaluating the client’s progress. Which finding demonstrates
the counseling was effective?
A Systolic blood pressure of 135 mmHg
B Triglyceride level of 147 mg/dL
C Fasting blood glucose level of 102 mg/dL
D High density lipoprotein (HDL) level of 39 mg/dL

Question Explanation
Correct Answer is B
Rationale: Metabolic syndrome is characterized by abdominal obesity, high triglyceride levels,
low high-density lipoprotein (HDL) levels, increased blood pressure, and increased fasting blood
glucose. The expected finding after dietary changes is a triglyceride level below 150 mg/dL. The
systolic blood pressure should be less than 130 mmHg. The fasting blood glucose level should be
below 100 mg/dL. The HDL level for males should be greater than 40 mg/dL and greater than 50
mg/dL for females.
Concepts tested

Question 918
The nurse is screening clients at a local clinic for chronic obstructive pulmonary disease
(COPD). The nurse should monitor for which of the following results?
A Spirometry did not improve after receiving an inhaled bronchodilator.
B Computed tomography (CT) scan shows bronchial dilation.

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C Alpha1-antitrypsin levels are elevated.
D Serum IgE levels are elevated.

Question Explanation
Correct Answer is A
Rationale: Spirometry is when a client is asked to empty the lungs completely with force and a
measurement is obtained. This evaluates airflow obstruction by determining the ratio of FEV1 to
forced vital capacity (FVC). Genetic risk for COPD is Alpha1-antitrypsin deficiency. A CT scan
showing bronchial dilation can indicate bronchiectasis. During an asthma attack caused by
allergies, the client’s serum IgE levels will be elevated.
Concepts tested

Question 919
The nurse is interviewing a client and notices that the client is having a difficult time answering
questions. Which action by the nurse would be an appropriate environmental adjustment to
make?
A Reducing the background noise in the room
B Turning off the overhead room lights
C Moving to stand at the entrance of the room
D Attempting the interview at a later time

Question Explanation
Correct Answer is A
Rationale: When a client is having a hard time answering questions, it may be due to hearing
difficulties, confusion, or processing disorders. Reducing the background noise ensures that the
client can hear the questions without other noise distractions. Turning off the lights and moving
further away from the client may create further difficulty for the client. Attempting the interview
at a later time is not appropriate if an environmental change can allow for a successful
assessment.
Concepts tested

Question 920
The nurse is providing discharge teaching to a client who regularly smokes tobacco. Which of
the following statements by the nurse would be appropriate to include in the education?
A “It takes a few years to see the benefits of quitting smoking.”
B “Switching to vapor-based tobacco use is better for your lungs.”
C “Smoking cessation is important to reduce your risk of cancers.”
D <span style="font-weight: 400;">&ldquo;The best way to quit smoking is to stop
abruptly.&rdquo;</span>
“The best way to quit smoking is to stop abruptly.”

Question Explanation
Correct Answer is C
Rationale: Smoking tobacco is a preventable risk factor for heart disease, lung disease, stroke,
and cancer. Educating the client on the importance of quitting and the relation to these diseases is

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appropriate teaching. Preliminary benefits of smoking cessation occur within days of quitting
smoking. There is no “best way” to quit; this is individualized based on the client’s situation.
Vapor-based tobacco products have not been proven to be better than cigarette smoking.
Concepts tested

Question 921
The nurse is interviewing an adolescent client who states, “I am sexually active, but I don’t want
my parents to know.” Which question by the nurse is appropriate to assess the client’s health
promotion practices?
A “Do you use condoms or birth control when you have sex?”
B “Are you afraid to tell your parents that you are sexually active?”
C “Have you had contact with any sexually transmitted infections?”
D “How old were you when you had sex for the first time?”

Question Explanation
Correct Answer is A
Rationale: To assess the client’s need for contraception, the nurse should ask a non-biased
question that addresses the client’s current sexual practices. Sexual history questions should be
included in the assessment but do not directly affect the client’s need for contraception.
Concepts tested

Question 922
The nurse is caring for clients in a rural heart failure clinic. Which of the following clients is
experiencing a disparity in accessibility to healthcare?
A A 67-year-old retired client who needs a cardiac magnetic resonance imaging (MRI) to
determine the cause of heart disease and has to be sent to another facility for radiology services
B A 70-year-old retired client who cares for his chronically ill spouse, who states, “It is difficult
to come to all of these appointments when the drive to get here is over an hour”
C A 60-year-old client who is self-employed and being followed after a myocardial infarction
and is worried about how they will pay since they “haven’t been able to work”
D A 60-year-old client with a pacemaker, who appears modest and prefers to be seen by a
healthcare provider of the same gender.

Question Explanation
Correct Answer is B
Rationale: Nurses providing community-based care must know about the five "As" of access to
care: affordability, availability, accessibility, accommodation, and acceptability. Affordability is
the client's ability and willingness to pay for services. Availability is the extent to which the
provider has the resources, such as personnel and technology, to meet the client’s
needs. Accessibility refers to geographic accessibility, determined by how easily the client can
physically reach the provider's location. Accommodation is how the provider's operation is
organized in ways that meet the preferences of the patient. Acceptability is the extent that the
client is comfortable with the more immutable characteristics of the provider and vice versa.
These characteristics include the age, sex, social class, and ethnicity of the healthcare provider
(and of the client).
Concepts tested
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Question 923
The nurse is caring for a client who has a fractured clavicle and is being discharged home from
the emergency department (ED). The client received morphine during this ED admission and is
visibly drowsy. When providing discharge teaching, what would be the most appropriate nursing
action?
A Give verbal and written instructions for when to call the provider to both the client and a
family member
B Plan for a follow-up telephone call the next day to provide the discharge teaching to the client
C Demonstrate to the client's family the application and removal of the sling
D Give written instructions to the client so they can read when they get home

Question Explanation
Correct Answer is A
Rationale: Before discharge, verbal and written instructions in the client’s preferred language are
given to the client. The nurse should assess client readiness and include caregivers as learners if
a barrier to learning is identified. Discharge teaching is completed prior to the client leaving the
ED, so phoning the client the next day to provide initial teaching is not acceptable.
Concepts tested

Question 924
The clinic health nurse is reviewing the medical records of a group of female clients. The nurse
would include a recommendation for hormonal emergency contraception in which of the
following situations?
A The client who reports consistently taking oral contraceptives who had unprotected
intercourse with a new partner yesterday
B The client with an intrauterine device who reports having a condom break during intercourse
two days ago
C The client who reports on Thursday that she missed two doses of her oral contraceptive pills
after having intercourse on Saturday
D The client who reports missing her daily dose of oral contraceptive the same day she had
unprotected intercourse

Question Explanation
Correct Answer is D
Rationale: Emergency contraception (EC) reduces the risk of pregnancy after unprotected
intercourse or contraceptive failure, such as condom breakage. It is used within 72 hours of
unprotected intercourse to prevent pregnancy. The sooner ECs are taken, the more effective they
are. They reduce the risk of pregnancy for a single act of unprotected sex by almost 80%. The
client who reports missing her daily dose of oral contraceptive (yesterday or the day before) and
had unprotected sex (same day) would require education on EC.
Concepts tested

Question 925

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The nurse is observing a client’s interactions with a newborn in the immediate postpartum
period. Which of the following statements by the client indicates appropriate attachment to the
new infant?
A “I’m nervous about changing the baby’s diaper.”
B “I need a pacifier, so the baby won’t cry.”
C “The baby looks a lot like my grandmother.”
D “Please take the baby out of the room, so I can sleep.”

Question Explanation
Correct Answer is C
Rationale: Identifying likenesses to family members is a part of something called the “claiming
process” and indicates appropriate interest in the newborn. The client’s nervousness about
changing a diaper and asking for a pacifier may be normal but do not indicate appropriate
attachment. The client asking for the baby to be removed is concerning because it may indicate
poor attachment to the infant.
Concepts tested

Question 926
The nurse is teaching an adolescent client and the parent about implementing peritoneal dialysis
(PD) at home. Which of the following information should the nurse include in the teaching?
A “It is a good idea to prepare a snack for your child to eat while receiving the treatment because
children typically feel hungry.”
B “Allow your child to perform a pretend procedure on a doll while receiving the treatment to
prevent boredom.”
C “Try to avoid using humor with your child while performing the treatment because your child
may feel made fun of.”
D “Allow your child to independently perform as much of the procedure as safely as possible.”

Question Explanation
Correct Answer is D
Rationale: The developmental stage of the adolescent is to achieve a sense of identity. Allowing
the child to perform as much of the procedure as possible and make decisions or order supplies
will help the child achieve self-identity. Children often feel full when receiving PD and will not
want to eat while receiving the treatment; it is best to offer liquids. The adolescent would not be
an appropriate age to offer a doll to, but rather have games, electronic devices, or peers to
talk/text with during the treatment to prevent boredom. Effective communication techniques to
use with the adolescent include creativity and humor, respect, appropriate medical terminology,
and nonjudgment.
Concepts tested

Question 927
A nurse is performing a psychosocial assessment on a 23-year-old female client who is
primigravida. The client states, “I am so overwhelmed thinking about having to care for this
baby.” What is an appropriate follow-up statement by the nurse?
A “You will be fine. It is normal to feel this way.”

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B “It is always overwhelming for first-time moms.”
C “How does your partner feel about the baby?”
D “Who will be helping you care for the baby?”

Question Explanation
Correct Answer is D
Rationale: The nurse should assess the client’s support systems to ensure the client has the
appropriate support during pregnancy, childbirth, and the postpartum period. Stating that the
client will be fine is false reassurance. Stating that first-time mothers are all overwhelmed does
not address the client’s individual concern. The nurse is assuming the client has a partner and
does not address the client’s concern.
Concepts tested

Question 928
A client comes to the prenatal clinic for her first visit. After identifying that September 7th was
the first day of the client’s last menstrual period, the nurse informs the client that the estimated
date of delivery is which of the following?
A June 14th
B June 7th
C July 7th
D July 1st

Question Explanation
Correct Answer is A
Rationale: Nagele’s Rule for calculating due date: Subtract three months from the first day of the
last period and add seven days. Alternatively, count 40 weeks, or 280 days, from the first day of
the last menstrual period (LMP).
This is an estimate, based on the assumption that ovulation occurred on day 14 of the menstrual
cycle.
Concepts tested

Question 929
A nurse is caring for a client in the first trimester of pregnancy whose rubella titer is negative.
Based on this result, which of the following education should the nurse provide?
A “You should expect to receive a rubella booster during the 2nd trimester.”
B “After you give birth, you will receive a booster for rubella.”
C “During your third trimester, you should get the rubella booster.”
D “We will need to give you a rubella booster today.”

Question Explanation
Correct Answer is B
Rationale: Screening for rubella occurs during the first prenatal visit to determine immunity. A
rubella antibody titer of 1:8 or greater proves evidence of immunity. Women who are not
immune should be vaccinated during the immediate postpartum period, so they will be immune
before becoming pregnant again. Nurses need to check the rubella immune status of all new

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mothers and should make sure all mothers with a titer of less than 1:8 are immunized prior to
discharge after the birth of the newborn. Advise pregnant women to avoid live virus vaccines
(MMR and varicella) and to avoid becoming pregnant within 1 month of having received one of
these vaccines because of the theoretical risk of transmission to the fetus.
Concepts tested

Question 930
The nurse is providing education to a postpartum client. Which of the following statements
should be included in the teaching?
A “Night sweats are common for the first few days postpartum.”
B “Postpartum headaches are not a cause for concern.”
C “Bedrest is recommended for the first three weeks after delivery.”
D “Separation of the abdominal muscles is permanent.”

Question Explanation
Correct Answer is A
Rationale: Significant diaphoresis occurs in the first three days postpartum and often increases at
night. Headaches warrant the need for additional assessment as they may be a sign of postpartum
preeclampsia. Bedrest is not recommended due to the increased risk of embolus formation.
Diastasis recti typically resolves over time.
Concepts tested

Question 931
The nurse is assessing a client who is 4 months old. Which of the following physical assessment
findings is expected?
A Presence of two to four teeth in the mouth
B Client weight is eight pounds above birth weight
C Ability to sit up unassisted for thirty seconds
D Head circumference is less than chest circumference

Question Explanation
Correct Answer is B
Rationale: From birth to 6-months-old, the infant should gain about two pounds per month;
therefore, at 4 months old, a weight that is 8 pounds more than the birth weight is expected.
Teeth generally erupt around 6-8 months old, and the ability to sit up unassisted occurs at 8
months of age. Head circumference is expected to be larger than chest circumference until 6
months old.
Concepts tested

Question 932
The nurse is interviewing a client who is 11 years old. Which statement by the client would
indicate the need for further developmental assessment?
A “I love to go on field trips and learn about new things.”
B “At school, we read books, and my dog is brown.”

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C “I like strawberry ice cream, but my friends like chocolate.”
D “A bowling ball is heavy, but a car is heavier.”

Question Explanation
Correct Answer is B
Rationale: Between the ages of 7-12 years old, children think logically and begin to classify
objects into categories. They are also aware of relationships, such as increasing/decreasing size
and weight. The response, “At school, we read books, and my dog is brown” demonstrates static
thinking (two unrelated thoughts within a sentence), and this likely indicates a lower cognitive
level than expected. This warrants additional assessment of the client’s developmental status.
Concepts tested

Question 933
The nurse is preparing to interview an adolescent client whose parents are also in the exam room.
Which of the following nursing statements is appropriate before the interview begins?
A “We need to separate all of you so that I can ask questions on high-risk behaviors.”
B “Do you mind if your parents stay in the room while I ask you some questions?”
C “Have you discussed sexual health with your parents prior to coming to the clinic?”
D “I am going to have your parents step out to complete this family health history questionnaire
while we talk.”

Question Explanation
Correct Answer is D
Rationale: Adolescents often take part in high-risk behaviors and may not be honest about these
practices in front of their parents. Asking the parents to step out of the room and complete a
separate task allows the nurse to obtain accurate subjective data from the client. Stating the need
to discuss high-risk behaviors may make the parents and the adolescent uncomfortable.
Concepts tested

Question 934
The nurse is caring for a client during a routine prenatal visit. Which action by the client
indicates that the client is not coping with the physical changes of pregnancy?
A “My breasts have grown so much that I need new bras.”
B “I don’t feel like getting on the scale today.”
C “My belly is so big that I can’t see my toes anymore.”
D “I exercise twice a week so that I don’t gain too much weight.”

Question Explanation
Correct Answer is B
Rationale: In pregnancy, women gain a significant amount of weight. Statements such as “I don’t
feel like getting on the scale” or “I don’t want to look at myself” may indicate that the client is
not accepting the expected body changes of pregnancy. The other statements do discuss weight
gain but do not indicate that the client’s body image has been negatively impacted.
Concepts tested

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Question 935
The nurse is screening clients for cancer risk factors at a community event. Which of the
following clients has an increased risk of cancer due to non-modifiable risk factors?
A A client who has a family history of breast malignancies
B A client who smokes cigarettes
C A client who has an elevated body mass index
D A client who has a sedentary career

Question Explanation
Correct Answer is A
Rationale: A non-modifiable risk factor is a factor that increases the risk of disease/illness that
the client cannot change (family history, race, etc.). All incorrect responses are modifiable risk
factors of cancer (things that the client has control of and can be changed).
Concepts tested

Question 936
During an assessment interview, a middle-age client verbalizes experiencing increasing stress at
work. The client asks the nurse what they can do to help prevent complications from stress. What
advice will the nurse give the client?
A “Inhale through your nose and exhale through your mouth as deeply as possible several times
a day.”
B “It might be helpful to reconsider your career choice at this time.”
C “Your work situation will be short-lived, so you shouldn’t experience complications.”
D “Incorporate kava into your diet to help with the anxiety.”

Question Explanation
Correct Answer is A
Rationale: Relaxation techniques help develop awareness and can help prevent the negative
effects of stress. The nurse should suggest mini-relaxation techniques throughout the day.
Advising the client to reconsider their career choice is not within a nurse’s scope of practice.
Telling the client their work situation will be short-lived is an assumption and does not address
the client’s concern. Kava is an herbal treatment not approved by the Food and Drug
Administration and can cause liver damage if not monitored properly.
Concepts tested

Question 937
The nurse is assessing a client who recently had a below-the-knee amputation (BKA). The client
lives alone and has recently lost their job. Which intervention should the nurse perform to ensure
the client’s physiological needs are met?
A Provide the client with a list of support groups
B Assist the client with researching job opportunities
C Collaborate with the client’s case manager for respite care
D Obtain a referral for home health care

Question Explanation

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Correct Answer is D
Rationale: Physiological needs refer to basic needs, such as food, sleep, and water. The client
lives alone so the nurse should ensure the client has access to basic needs. Home health nurses
can assess a client’s living situation. Providing the client with support groups meets the social
need in Maslow’s Hierarchy of Needs. Assisting the client with job opportunities meets safety,
not physiological needs. Respite care is used to assist caregivers with the client’s needs. The
client in this scenario lives alone.
Concepts tested

Question 938
The nurse is assessing clients for risk factors for cancer. Which of the following ethnicities
would have the highest risk?
A American Indian
B Hispanic
C Asian
D African American

Question Explanation
Correct Answer is D
Rationale: The nurse should identify that African American men have the highest risk for cancer.
The risk is two times higher than Hispanic male clients. American Indian and Asian clients have
a lower risk for cancer.
Concepts tested

Question 939
The nurse is interviewing a client to obtain the client’s medical history. Which action by the
nurse is appropriate to ensure effective communication?
A Document the client’s history during the interview
B Sit at the client’s eye level during the interview
C Maintain a distance of two to three feet away from the client
D Invite other healthcare providers to witness the interview

Question Explanation
Correct Answer is B
Rationale: Sitting at the client’s eye level is an effective technique to establish trust and show
equal authority status. Interviews should be conducted at a distance of 4-5 feet, and documenting
while the client is speaking may indicate to the client that the examiner is not actively listening.
In most cases, interviews should occur with one client and one examiner; having multiple
providers in the room may intimidate the client.
Concepts tested

Question 940
The nurse is caring for a client who uses illegal injectable substances. Which statement by the
nurse is appropriate to educate the client on reducing the risk of infection?

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A “Getting clean needles from a needle exchange program will lower your chance of
infection.”
B “You should only inject substances into upper extremity veins to prevent infections.”
C “Using the same injection site more than once in the same day increases the likelihood of
infection.”
D “The only way to reduce your risk of infection is to stop using injectable drugs.”

Question Explanation
Correct Answer is A
Rationale: When injection needles are used by multiple people or kept in unclean conditions, the
risk of infection increases dramatically. Utilizing a Syringe Service Program (SSP) or a Needle
Exchange Program (NEP) reduces the risk of transmission of pathogens. The location of the
injections and the frequency of injections do not directly affect infection rates. Cessation of
injectable substance use is the ultimate goal, but it is not the only way to reduce the risk of
infection.
Concepts tested

Question 941
The nurse is caring for a client at a postpartum follow up visit. Which of the following questions
by the nurse is appropriate to assess the client’s desire for contraception?
A “What are your intentions for family planning?”
B “Have you used hormonal birth control before?”
C “How many uterine surgeries have you had?”
D “Do you participate in risky sexual behavior?”

Question Explanation
Correct Answer is A
Rationale: To assess the client’s desire for contraception, the nurse should ask a non-biased
question that addresses the client’s family planning intention. History questions should be
included in the assessment but do not directly affect the client’s need for contraception.
Concepts tested

Question 942
A nurse is providing contraceptive education to a 21-year-old woman. When discussing
hormonal birth control, what additional benefits would the nurse most likely include?
A Reduced risk for migraine headaches
B Decreased risk of depression
C Protection against blood clots
D Improvement in acne symptoms

Question Explanation
Correct Answer is D
Rationale: Oral contraceptives (OC) can make menstruation regular, lighter, and less painful,
reduce the risk of ovarian, uterine, and colon cancer, reduce symptoms of premenstrual

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syndrome, reduce acne, protect against pelvic inflammatory disease, and reduce the risk of
fibroids, ovarian cysts, and non-cancerous breast disease. OCs increase the risk of blood clots
and myocardial infarction and can slightly increase the risk of breast cancer.
Concepts tested

Question 943
The nurse is caring for an adult client admitted to the hospital for hyperosmolar hyperglycemia
who will now be using insulin at home. In addition to answering all the client’s questions, which
of the following interventions will be most effective in maximizing the client’s self-care
abilities?
A Verbalize step-by-step directions while drawing up the medication and administering the
injection to the client
B Demonstrate to the spouse how to draw up and administer the injection and ask if they have
any additional questions
C Provide the client with an instructional video and then watch them perform a return
demonstration
D Schedule a homecare visit for diabetic teaching and provide the client with verbal and written
instructions on insulin administration

Question Explanation
Correct Answer is A
Rationale: The plan of nursing care should include specific education to promote self-care and
independence. Psychomotor skills teaching should include a demonstration by the nurse and then
a return demonstration by the client. Teaching the caregiver does not promote self-care. The
nurse should be an active participant in client education using videos as a resource and not the
primary source of education. Teaching should begin during admission and be reinforced by
outside services.
Concepts tested

Question 944
The nurse is preparing to inspect the tympanic membrane of a 2-year-old client. Which technique
by the nurse is appropriate?
A Lifting the pinna up and back once the otoscope has been inserted
B Instructing the client to hold their breath while the otoscope is used
C Inserting the otoscope while the child is laying in the prone position
D Pulling the pinna down slightly before inserting the otoscope

Question Explanation
Correct Answer is D
Rationale: For young children, the pinna should be pulled straight down prior to inserting the
otoscope. This action allows the ear canal to straighten and allows the examiner to view the
tympanic membrane more easily. Holding breath is not necessary, and the client should be
upright during this exam.
Concepts tested

Question 945
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The nurse is assessing a school-aged child. Which of the following actions by the nurse is
appropriate?
A Explaining each part of the assessment to the child
B Using an adult sized blood pressure cuff on the child’s leg
C Avoiding the abdominal assessment for privacy
D Addressing the child’s parent for all interview questions

Question Explanation
Correct Answer is A
Rationale: The school-aged child is often curious and may be intimidated by medical equipment;
therefore, explaining all actions in simple terms helps to avoid anxiety and allows the child to see
the interaction as a learning experience. A pediatric blood pressure cuff should be used unless the
child is measured and requires adult size. All systems should be assessed, and the child should be
addressed for most questions.
Concepts tested

Question 946
A school nurse is performing a vision screening on a 7-year-old child. The child tells the nurse
they have trouble reading the blackboard in class. How does the nurse respond?
A “Your vision does not reach full capacity until the age of 8.”
B “You may have a condition known as myopia.”
C “It seems like you have hyperopia and may need glasses.”
D “This will correct itself in a couple of years.”

Question Explanation
Correct Answer is B
Rationale: Myopia (nearsightedness) is an inherited condition that causes the child to have
difficulty seeing distant objects. Visual capacity should be optimally functional by age 6 or 7.
Hyperopia (farsightedness) is common in school-age children. Glasses are usually not needed
due to the eyes adjusting their lenses. The school-age child should have a visual acuity of 20/30
or better in each eye. Children with vision less than 20/30 should be referred for further testing.
Concepts tested

Question 947
A nurse is assessing a female client who is 13-weeks pregnant. Which statement made by the
client indicates a need for prenatal counseling?
A “I sing to my baby every night before bed.”
B “I should perform abstinence to ensure I don’t hurt the baby.”
C “I find myself crying at simple comments more often.”
D “I look at my body in the mirror multiple times a day.”

Question Explanation
Correct Answer is B
Rationale: Sexual intercourse is safe during pregnancy unless there are complications or
discomfort. The client should be informed of safe sex practices. Talking with and about the fetus

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is an expected response during the second trimester of pregnancy. Mood swings are an expected
response throughout the pregnancy due to hormonal changes. Introversion and focusing on the
changes in body image is an expected response throughout pregnancy.
Concepts tested

Question 948
During the first prenatal visit at 7 weeks, the client asks when the baby will be born. The nurse
responds that after identifying the first day of the client’s last menstrual period, the healthcare
provider will include which of the following assessments to accurately assign an estimated due
date?
A Auscultating fetal heart sounds
B Performing a transvaginal ultrasound
C Performing a pelvic exam
D Utilizing the quickening method

Question Explanation
Correct Answer is B
Rationale: Ultrasound measurement of the embryo or fetus in the first trimester (up to and
including 13 6/7 weeks of gestation) is the most accurate method to establish or confirm
gestational age. As soon as data from the last menstrual period (LMP), the first accurate
ultrasound examination, or both, are obtained, the gestational age and the estimated date of
delivery (EDD) should be determined, discussed with the patient, and documented clearly in the
medical record.
Concepts tested

Question 949
The nurse is reviewing the laboratory data for a client who is 10 weeks gestation. The nurse
notes the following results: hemoglobin level of 9.8 g/dL, rubella titer positive, urine glucose
level of 0 mmol/dL, and nontreponemal tests (venereal disease research laboratory [VDRL])
negative. Based on the results, which education should the nurse provide to the client?
A Side effects of iron supplements and food sources of iron
B Scheduling for the rubella vaccine
C Necessity of completing the entire prescription for penicillin
D Steps for completing the oral glucose tolerance test (GTT)

Question Explanation
Correct Answer is A
Rationale: Iron deficiency is the most common pathologic cause of anemia in pregnancy.
Increased risk during pregnancy is due to increased maternal iron needs and demands from the
growing fetus, and, in the third trimester, expanded maternal blood volume. The consequences of
iron-deficiency anemia include preterm delivery, perinatal mortality, and postpartum depression.
Neonatal consequences include low birth weight and poor mental and psychomotor performance.
Nursing management of the woman with iron-deficiency anemia focuses on encouraging
adherence to iron therapy and providing dietary instruction about the intake of iron-rich foods.
The client has a positive rubella titer, indicating immunity. Therefore, a booster is not required.
The nontreponemal tests were negative, indicating the client has no antibodies to syphilis and
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does not require antibiotics. There is no glucose in the urine and, therefore, no indication of
diabetes. The GTT will be administered in the first part of the third trimester to screen for
gestational diabetes.
Concepts tested

Question 950
The nurse is providing discharge teaching to a postpartum client about signs of postpartum
complications. Which of the following information should be included in the education?
A “Come to the emergency department if you are still bleeding in one week.”
B “Call your healthcare provider if you get a fever higher than 100.4°F.”
C “Return to the hospital if you are experiencing urinary frequency.”
D “Notify your healthcare provider if you begin producing more than six ounces of breast milk.”

Question Explanation
Correct Answer is B
Rationale: Maternal body temperature above 38°C (100.4°F) indicates infection, and the client
should notify the provider of this finding. Bleeding (lochia) can occur for several weeks after
delivery, and urinary frequency is common in the first few days after delivery. Breast milk
production varies greatly from one person to another; therefore, the amount of milk produced is
not a cause for concern.
Concepts tested

Question 951
The nurse is caring for a female client who is 10-years-old. Which of the following findings
would be expected during a physical assessment?
A Presence of breast buds
B Pubic hair over mons pubis
C Lateral curvature of the spine
D Absence of the two central teeth

Question Explanation
Correct Answer is A
Rationale: Between ages 9-10 years old, a female will develop breast buds, so this would be a
normal finding for a healthy 10-year-old. Pubic hair begins to grow between 11-12 years of age
but does not cover the mons until 12-13 years old. The two permanent central incisors should
have grown in between the ages of 6-8 years old. Lateral curvature of the spine is an abnormal
finding for any age group.
Concepts tested

Question 952
The nurse is caring for a school-aged child who states, “My parents got a divorce.” Which
question by the nurse would be appropriate to assess the psychological impact of this family
system change?
A “Why did your parents get a divorce?”

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B “Has your parent’s divorce changed the way you feel?”
C “How old were you when your parents got divorced?”
D “Who do you live with now that your parents are divorced?”

Question Explanation
Correct Answer is B
Rationale: Asking a child to talk about their feelings related to a family system change, such as a
divorce, is appropriate to evaluate the psychological impact the event has had on them. All the
other responses do not assess the impact on the client.
Concepts tested

Question 953
The nurse is assessing a 3-year-old client who is crying and touching the abdomen stating, “It
hurts really bad.” Which action by the nurse is appropriate to further assess this child’s pain?
A Ask the child to rate pain using the Wong-Baker Faces Pain Rating Scale
B Tell the child to describe the quality of their pain
C Perform deep palpation over the location that is most sensitive
D Wait until the child stops crying to continue the assessment

Question Explanation
Correct Answer is A
Rationale: The Wong-Baker Faces Scale is easily understood by most young children and is an
accurate way to assess the severity of the child’s pain. When assessing a 3-year-old client, it is
important to choose words that are developmentally appropriate. This client most likely will not
understand how to answer the question of "Describe the quality of your pain" but may be able to
answer a question like “What does the hurt feel like?” Performing deep palpation over a painful
area is not recommended. Waiting until the child is calm may take a significant amount of time.
The nurse should comfort and reassure the child while asking the child simple questions to
gather more information at this time.
Concepts tested

Question 954
The nurse is caring for a pregnant client who states, “I don’t feel attractive anymore.” Which
statement by the nurse is most appropriate to evaluate the client’s concerns about her body
image?
A “Pregnancy doesn’t make a woman unattractive.”
B “You’ll look like you did before you gave birth after you give birth.”
C “Is there something specific that makes you feel that way?”
D “What does your partner think about your looks?”

Question Explanation
Correct Answer is C
Rationale: Significant body changes in pregnancy, such as weight gain or integumentary system
changes, may affect the client’s body image. Asking the client to provide further details about

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why they feel unattractive gives the nurse more information about how to address body image
concerns. Asking for insight into the partner’s opinion is not necessary.
Concepts tested

Question 955
The nurse is caring for a client who has recently undergone an above the knee amputation.
Which question by the nurse is appropriate to evaluate the client’s feelings about their body
image?
A “Are you worried about losing your mobility?”
B “Has your family come to visit you since you had the surgery?”
C “Do you plan to utilize a prosthetic leg after you have healed?”
D “Does the loss of your leg change how you feel about yourself?”

Question Explanation
Correct Answer is D
Rationale: Significant physical changes, such as an amputation, may affect the client’s body
image. Asking the client to share their feelings about self-esteem or perceived body image
provides insight into how the change has impacted the client. While mobility and prosthetic use
may be important questions to ask, they do not address body image concerns. Family visitation
does help to support the client throughout a stressful event but does not directly affect the client’s
body image.
Concepts tested

Question 956
A 12-month-old child is receiving a hepatitis A vaccine. The child’s parent verbalizes to the
nurse, “I am so glad my child won’t be receiving vaccines for a while.” What is the nurse’s
response to this statement?
A “Bring your child in when you feel ready for their next dose.”
B “A second dose is required within the next three months.”
C “You will have to bring your child in within a year to receive another dose.
D “I agree. Children receive so many vaccines at once.”

Question Explanation
Correct Answer is C
Rationale: The hepatitis A vaccine is a 2-dose vaccine administered initially at the age of 12
months. The second dose should have a minimum interval of 6 months and be completed by the
age of 23 months. The nurse should be objective in educating the child’s mother regarding
immunizations.
Concepts tested

Question 957
The nurse is taking care of a client diagnosed with major depressive disorder. The client states,
“It feels so tough to perform everyday activities.” Which response by the nurse helps the client
achieve optimal health?
A “Let’s discuss what everyday activities mean to you.”

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B “Let’s come up with a plan to help you accomplish your everyday activities.”
C “Tell me what your everyday activities consist of.”
D “It is important to have someone help you with your everyday activities.”

Question Explanation
Correct Answer is B
Rationale: The nurse should assess the client’s ability to maintain a healthy lifestyle while
promoting independence. Assisting the client with a plan is a strategy for improving mental
health. Discussing what everyday activities consist of and what they mean to the client
establishes a therapeutic alliance but does not promote optimal health. Telling the client they
require help with everyday activities does not promote independence.
Concepts tested

Question 958
The nurse at a local community center is screening males who have sex with other males for risk
factors for human immunodeficiency virus (HIV). Which of the following ethnicities would have
the highest risk?
A African American
B White American
C Hispanic
D Asian

Question Explanation
Correct Answer is A
Rationale: Evidence shows that young black/African American males who have sex with other
males (MSM) have the highest risk for HIV.
Concepts tested

Question 959
The nurse is interviewing a client to obtain a health history. Which of the following statements
by the nurse should be included in the interview?
A “May I listen to your breath sounds?”
B “What medications do you take at home?”
C “Which arm should I use to take your pulse?”
D “Can you lift your shirt to expose your abdomen?”

Question Explanation
Correct Answer is
Rationale: The components of a health history include biographic data, history of present illness,
medical history, medication reconciliation, family history, subjective data review of systems, and
a functional assessment of activities of daily living (ADLs). Listening to breath sounds, taking a
pulse, or inspecting the abdomen are all a part of objective data collection that occurs during the
physical assessment, not the health history.
Concepts tested

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Question 960
The nurse is educating adolescent clients about safe sex practices. Which of the following
statements should be included in the teaching?
A “You should wear a condom every time you have sexual intercourse.”
B “Abstinence is the only way to reduce your risk of pregnancy.”
C “Oral contraceptives are the most effective way to prevent sexually transmitted infections
(STIs).”
D “You can tell if someone has an STI because they will have genital lesions.”

Question Explanation
Correct Answer is A
Rationale: A barrier method of contraception (such as a condom) is the only way to reduce the
risk of STI transmission; therefore, education about the importance of condom use is important
to include in the education. Abstinence is the only way to completely prevent pregnancy, but
there are other forms of contraception that reduce the risk of pregnancy. Oral contraceptives do
not reduce the risk of STIs, and there are many STIs that do not have visual clinical
manifestations.
Concepts tested

Question 961
The nurse is discussing contraceptive methods with a client. Which of the following statements
by the client would contraindicate the use of a cervical cap?
A “My menstrual cycle is irregular.”
B “I have sex at least 3 times per week.”
C “I had toxic shock syndrome about 2 years ago.”
D “My partner is allergic to latex.”

Question Explanation
Correct Answer is C
Rationale: Diaphragms and cervical caps are contraindicated for clients who have a history of
toxic shock syndrome. Sexual activity and irregular menstrual cycles are not contraindicated for
cervical cap use. If the client or client’s partner is allergic to latex, a silicone cervical cap can be
used.
Concepts tested

Question 962
The parent of an infant who is 4 weeks old asks, “When will my baby start rolling over?” Which
of the following is an appropriate nursing response?
A “I wouldn’t worry about rolling over just yet because your baby is just a month old.”
B “Rolling from back to front as well as front to back should happen between 4-5 months old.”
C “Rolling over is a developmental milestone that doesn’t occur until 7 months of age.”
D “I am surprised that your baby is not starting to turn from front to back already.”

Question Explanation
Correct Answer is B

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Rationale: Gross and smooth motor development occur gradually over the first year of life. The
task of rolling from back to front occurs at 4 months and by 5 months old, the infant should be
able to roll from front to back as well. Expecting an infant to complete this task at 4 weeks old is
not appropriate, and if the child is not able to roll over by 7 months old, this may indicate
developmental delays. It is not appropriate to avoid answering the parent’s question due to the
baby’s age.
Concepts tested

Question 963
A nurse is counseling a client who has a new diagnosis of rotator cuff tendinitis in the left
shoulder. Which of the following self-care strategies should the nurse recommend for reducing
discomfort?
A Perform active range of motion exercises
B Intermittently apply ice to the shoulder
C Exercise with weights to strengthen the shoulder
D Sleep with the affected shoulder down

Question Explanation
Correct Answer is B
Rationale: Inflammation is present in rotator cuff injuries, so application of ice may help
improve discomfort. Repetitive overhead motions can exacerbate shoulder injuries and lead to
increased pain. The client should support the affected arm on pillows while sleeping to keep
from turning onto the shoulder.
Concepts tested

Question 964
The nurse is caring for a client who states that they have recently become a single parent. Which
question by the nurse is appropriate to assess how this family structure change has affected the
client?
A “Are tasks more difficult now that you don’t have help?”
B “When did you and your partner separate?”
C “How many children live with you currently?”
D “Where did your partner go after you separated?”

Question Explanation
Correct Answer is A
Rationale: Asking the client to talk about hardships related to a family system change such as a
divorce/separation is appropriate to evaluate how the transition to being a single parent has
affected them. All the other responses do not assess the impact on the client.
Concepts tested

Question 965
The nurse is assessing a female client in an outpatient clinic. Which of the following questions
should the nurse ask to screen for an increased risk of breast cancer?
A “Do you take any hormonal birth control?”

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B “Have you ever had breast surgery?”
C “How long does your menstrual cycle last?”
D “What geographic location are you from?”

Question Explanation
Correct Answer is A
Rationale: The presence of hormones, in particular estrogen and progesterone, throughout a
woman’s life cycle and lifestyle choices have an influence on the risk of developing breast
cancer. Breast surgery, menstrual cycle, and geographical location do not affect the likelihood of
breast cancer.
Concepts tested

Question 966
The nurse is planning care for several clients in the labor and delivery unit. Which mother-baby
pair would the nurse identify as needing a Coombs test?
A Rh-positive mother with Rh-positive baby
B Rh-negative mother with Rh-positive baby
C Rh-positive mother with Rh-negative baby
D Rh-negative mother with Rh-negative baby

Question Explanation
Correct Answer is B
Rationale: An Rh-negative mother who delivers an Rh-positive baby may develop antibodies to
the fetal red blood cells. The mother may have been exposed during pregnancy or placental
separation. Rh-positive mothers do not require this test or treatment with RhIG (RhoGAM).
RhIG is indicated for intramuscular injection to Rh-negative women with a negative Coombs
test. The administration of RhIg at 26 to 28 weeks of gestation further reduces the risk of Rh
incompatibility (isoimmunization).
Concepts tested

Question 967
The nurse is evaluating a toddler's readiness for toilet training. Which milestones should the
nurse assess to determine the readiness of the child? Select all that apply.
A Recognition of the urge to defecate or urinate
B Parents willing to invest the time needed to teach the child
C Ability to have a dry diaper for two hours and wake from a nap with a dry diaper
D Ability to button clothing when dressing themselves
E Fine motor development enough to be able to remove clothing

Question Explanation
Correct Answer is A, B, C, E
Rationale: The nurse should provide guidance to parents concerning toilet training. This
discussion should begin at a child's routine visit to a health care provider. The parents should be
given information and supported through the potentially frustrating time of toilet training. The

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nurse should evaluate the toddler's and parents' readiness or educate the parents on signs that the
child is ready to begin toilet training. The child should wake from a nap with a dry diaper and be
able to have a clean diaper for two hours. The child should be able to begin removing clothes.
However, the clothing worn by the child should be easy to remove. The child will need to be able
to recognize the urge to defecate or urinate. The parents should understand that this could be a
time-consuming and frustrating process. The child may display the ability to remove clothing.
However, the child may not have the fine motor skills to button clothing after toileting.
Concepts tested

Question 968
The nurse is developing a plan of care for a 14-year-old adolescent with severe scoliosis who is
required to wear a thoracic-lumbosacral orthosis brace. Which issue should be the priority?
A Reliance on the family for social support
B Lacking independence in physical activities
C Looking different from their peers
D Compliance with treatment regimen

Question Explanation
Correct Answer is C
Rationale: Scoliosis is a lateral curvature of the spine. Treatment of severe scoliosis is long-term
and involves bracing either with or without surgery. Being restricted by a brace or surgery is
difficult for a child in any developmental stage. The child should be as independent as is safely
possible, and nursing care should be focused on educating the client and the family about the
benefits of the intervention and positive reinforcement. Conformity to peer influences or pressure
peaks around age 14. Because peers may tease, make fun of, or bully the client because of the
brace, the priority is to help the client learn how to deal with the reactions of others.
Concepts tested

Question 969
The nurse is caring for a male client admitted with a diagnosis of a spinal cord injury. The client
asks the nurse how the injury will affect his ability to have sex. Which is the best response by the
nurse?
A "There are drugs to help with achieving an erection."
B "Sexual intercourse may be possible."
C "Sexual functioning will not be impaired at all."
D "Normal sexual function is not possible."

Question Explanation
Correct Answer is B
Rationale: During the acute phase of a spinal cord injury (SCI), the long-term effects are not
predictable and depend on the body’s healing. Sexual function, or the ability to have sex after an
SCI, will depend on multiple factors, including the severity of the injury and the age and health
of the client. Sexual intercourse might be possible. The nurse should refrain from making
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absolute statements that are not founded on facts and considered outside of the nurse’s scope of
practice. Drugs used for erectile dysfunction are not typically effective with an SCI.
Concepts tested

Question 970
During a routine visit, the nurse is evaluating developmental milestones for a 7-month-old child.
Which of these developmental activities should the child be able to perform?
A Says several words
B Uses a neat pincer grasp
C Drinks from a cup
D Sits leaning on hands for support

Question Explanation
Correct Answer is D
Rationale: The age at which a child typically develops the ability to sit while supporting
themselves is around 7 months. Around 8 months, the child should be able to sit erect without
support. Saying several words, drinking from a cup, and using a neat pincer grasp are
developmental milestones that most children do not reach until age 11-12 months. Fine motor
behavior, such as grasping an object, develops in stages. The palmar grasp of the newborn
develops into a crude pincher grasp at 8 to 10 months of age and a neat pincher grasp around 11
months of age.
Concepts tested

Question 971
The client is in her first trimester of pregnancy. Which developmental task should the client
accomplish during this stage of pregnancy?
A Addressing fears related to giving birth
B Accepting the pregnancy
C Accepting the loss of physical intimacy
D Viewing the fetus as a separate and unique being

Question Explanation
Correct Answer is B
Rationale: During the first trimester, the developmental focus is toward accepting the pregnancy
and adjusting to pregnancy-related physical changes and discomforts. During the first and third
trimesters, the client may become introspective, focusing on herself and the health of her baby.
The client can maintain physical intimacy with her partner if she wishes, including sexual
intercourse. Looking at the fetus as a separate being and overcoming fears related to giving birth
begins in the second or third trimester.
Concepts tested

Question 972
The nurse enters a toddler's hospital room to administer oral medication. When the nurse asks the
child, "Are you ready to take your medicine?" the child's response is an immediate, "No!" Which
action would be appropriate by the nurse?

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A Notify the health care provider and request a parenteral form of the medication
B Explain to the child that the medicine must be taken now
C Ask another nurse to hold the child while giving the medication
D Leave the room and return five minutes later to try to give the medication

Question Explanation
Correct Answer is D
Rationale: During toddlerhood, a child will begin to display negativism. This negativism is an
effort to develop a sense of control and autonomy. By asking the child if they were ready to take
the medication, the nurse gave the child a choice. However, toddlers do not have an accurate
sense of time, so leaving the room and coming back later is another episode to the toddler, and
the child's response may be more positive. The other actions are not appropriate at this time.
Concepts tested

Question 973
The nurse is assessing a client during the first stage of labor. Which action is correct when
evaluating the characteristics of uterine contractions?
A Evaluate intensity by pressing fingertips into the uterine fundus
B Assess uterine contractions every 30 minutes throughout the first stage of labor
C Place a hand on the abdomen below the umbilicus and palpate uterine tone with fingertips
D Determine frequency by timing the end of one contraction until the end of the next contraction

Question Explanation
Correct Answer is A
Rationale: The characteristics of uterine contractions include frequency, duration, and intensity.
The frequency of contractions is measured from the beginning of one contraction to the
beginning of the next contraction. Duration is how long each contraction lasts from beginning to
end. Intensity refers to the strength of the contraction, which is determined by pressing down on
the fundus with the fingertips to see if the fundus can be dented. If the fundus can be indented
with fingertips at the peak of a contraction, the contraction is deemed mild. It is best practice to
time several consecutive contractions before charting frequency or duration.
Concepts tested

Question 974
The nurse in a pediatric office is speaking with the parents of a 3-year-old child. The parents ask
the nurse about normal growth and development. The nurse knows that which finding may be
indicative of abnormal childhood development?
A Use of four-word sentences
B Positive Babinski reflex
C Presence of all primary teeth
D Presence of a pincer grasp

Question Explanation
Correct Answer is B

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Rationale: The nurse must have an adequate understanding of normal physical development in
children. The Babinski reflex occurs after the sole of the foot has been firmly stroked. The big
toe moves upward or toward the top surface of the foot. The other toes fan out. This reflex is
normal in children up to two years old. It disappears as the child gets older. A positive Babinski
reflex in a 3-year-old child indicates the need for a neurological follow-up. Pincer grasp
describes the ability for a child to grasp objects between their index finger and thumb and should
be established by 10 months. By three years, children should have all of their primary teeth and
the ability to speak in 3- to 4-word sentences.
Concepts tested

Question 975
The nurse is preparing a presentation focusing on the prevention of Lyme disease. Which
statement by a participant would require further clarification by the nurse?
A "I should wear light-colored clothing and long pants when gardening."
B "Lyme disease can spread to my brain if I don't seek treatment."
C "I will call the doctor if I see a rash that looks like a bull's eye."
D "Lyme disease is caused by a virus similar to the flu."

Question Explanation
Correct Answer is D
Rationale: While the symptoms of Lyme disease are similar to influenza, Lyme disease is not
caused by a virus. Lyme disease is caused by the spirochete, Borrelia burgdorferi, which is
transmitted to humans by deer ticks. Because the ticks are so small, it is easier to see them on
light-colored clothing. Long pants and long-sleeved shirts help protect individuals from insect
bites. After being outdoors, individuals should assess their bodies for any ticks or rashes. Parents
should be instructed to check children for ticks and rashes. There may be a "bull's eye" rash at
the site of the tick bite. Without antibiotics, the disease can spread to the brain, heart, and joints
of the body.
Concepts tested

Question 976
The nurse is doing preconception counseling with a woman who is planning a pregnancy. Which
statement indicates that the client understands the connection between alcohol consumption and
fetal alcohol disorder?
A "Drinking alcohol with meals helps to reduce the effects of alcohol."
B "I understand that a glass of wine with dinner is healthy."
C "Beer is not really hard alcohol, so it is safe to drink while pregnant."
D "If I drink, my baby may be harmed before I know I am pregnant."

Question Explanation
Correct Answer is D
Rationale: The teratogenic effects of heavy maternal alcohol consumption contribute to an
increased risk of fetal alcohol spectrum disorders (FASD). The effects of FASD include brain,
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craniofacial, and cardiac defects. Children with FASD may also suffer from neurotoxicity and
immune system dysfunction. These teratogenic effects occur even in the first weeks of
pregnancy. The time between conception and the discovery of pregnancy puts the child at risk.
Therefore, women considering pregnancy should not drink any alcoholic beverages. It is
unknown how much, if any, alcohol is safe during pregnancy.
Concepts tested

Question 977
The nurse is caring for a client with moderate Alzheimer's disease who is admitted for evaluation
of a pressure ulcer. The spouse of the client appears distressed and voices concern about
continuing to care for the client at home. Which action is most appropriate at this time?
A Encourage the spouse to describe their concerns
B Offer information about the local Alzheimer's Association chapter
C Request a sedative prescription for the client
D Provide resources about respite care

Question Explanation
Correct Answer is A
Rationale: Alzheimer's disease is a progressive neurological disease leading to dependence with
most activities of daily living, incontinence, speech, and emotional lability. It is very challenging
for caregivers to take care of those clients; therefore, it is most appropriate at this time to address
the spouse's concern. This can be achieved by encouraging the spouse to talk about challenges
they are experiencing. The pressure ulcer may be evidence that the spouse can no longer care for
the client without additional resources at home. Based on the information gained, the nurse can
then decide on what action to take next.
Concepts tested

Question 978
The nurse is teaching a 9-year-old child to self-administer bronchodilators for asthma
management. Which cognitive developmental milestone should the nurse consider for a child of
this age?
A Children of this age apply concepts from one context to another.
B Abstract logic is useful for teaching concepts to children this age.
C Children of this age can think logically in the organization of facts.
D Children of this age are egocentric and highly imaginative.

Question Explanation
Correct Answer is C
Rationale: Children in the concrete operational stage (7 to 11 years old), according to Piaget, are
capable of mature thought when they are allowed to mentally or physically organize objects.
Children of this age attach concepts to concrete situations. The conceptual abilities become
increasingly flexible, and the child can articulate the process and perform the actions mentally.
However, due to the psychomotor domain of self-administration, the child should be encouraged
to demonstrate self-administration of bronchodilators. Children of the formal operational age (11
years or older) can transfer concepts learned from one context to another and may apply abstract

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logic. Children in the pre-operational stage (2 to 6 years old) are egocentric and highly
imaginative.
Concepts tested

Question 979
The nurse is caring for the neonate immediately following vaginal delivery. Which interventions
will promote temperature regulation in the neonate? Select all that apply.
A Bathe the newborn to remove contaminants from the delivery
B Encourage skin-to-skin contact with the mother
C Place the newborn under a radiant warmer
D Dry the newborn off with warm towels
E Wrap the newborn in blankets and use warmed caps on the newborn

Question Explanation
Correct Answer is B, C, D, E
Rationale: The ability to thermoregulate is not adequately developed in newborns. The nurse
plays a vital role in temperature regulation, and nurses should understand that newborns,
especially preterm newborns, are exceptionally vulnerable to both overheating and underheating.
Newborns lose heat easily after birth. The initial method for promoting temperature regulation in
stable newborns is skin-to-skin contact with the mother. The nurse should ensure that the infant
transporter (isolette) is fully charged and heated. Additionally, prewarmed blankets and hats
should be prepared in anticipation of delivery. The nurse should also avoid placing a temperature
probe over bony prominences or areas of brown fat to ensure accurate temperature measurement.
Bathing should be deferred until the newborn is medically stable and should be completed using
a radiant heating source.
Concepts tested

Question 980
The nurse is assessing a client in her third trimester of pregnancy. The recent ultrasound suggests
the baby is small for the gestational age. However, an earlier ultrasound indicated normal
growth. The nurse understands that this change is most likely associated with which problem?
A Maternal hypertension
B Sexually transmitted infection
C Exposure to teratogens
D Chromosomal abnormalities

Question Explanation
Correct Answer is A
Rationale: Maternal hypertension is a common cause of late pregnancy fetal growth restriction.
Vasoconstriction reduces the placental exchange of oxygen and nutrients. Chromosomal
abnormalities, sexually transmitted infections, and exposure to teratogens are associated with
abnormal fetal development in the first trimester.
Concepts tested

Question 981

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The parents of a 2-year-old client state they are concerned with behavior the child is exhibiting,
including temper tantrums and refusing assistance from the parents. Which response by the nurse
demonstrates comprehension of the developmental level of this child?
A "At this age, the child will use past and present experience to determine future goals. They
will reflect on their place in society."
B "This behavior is learned from their environment. Monitor the behavior of older siblings to
prevent the behavior from worsening."
C "It sounds like your child may have a developmental delay. This behavior needs to be further
evaluated by the health care provider."
D "During toddlerhood, children desire autonomy. These behaviors can be frustrating but are
considered normal."

Question Explanation
Correct Answer is D
Rationale: According to Erikson, the toddler will develop a sense of autonomy while overcoming
a sense of doubt or failure. The toddler will most likely exhibit negativism as they explore
autonomy and use terms like "no" or "me do." The characteristics of negativity, ritualism, and
swift mood swings can be exhausting to parents. Parents should be supported in dealing with
these normal behaviors constructively, which will help the child learn acceptable social
interactions. While siblings may model this behavior, the actions described by the parents are the
hallmark of toddlerhood. During adolescence, the child will begin to form their sense of identity
through reflection and experiences. Toddlers do not have the capability to engage in reflective
practices and are working toward autonomy, not finding their identity.
Concepts tested

Question 982
A local school had an increased incidence of pediculosis capitis in the past week. The school
nurse plans a screening of all children. Which manifestation observed by the nurse
would confirm the presence of pediculosis capitis?
A Whitish oval specks sticking to the hair shaft
B White flakes on the student's shoulders
C Scratching the head more than usual
D An oval pattern of occipital hair loss

Question Explanation
Correct Answer is A
Rationale: Diagnosis of pediculosis capitis, or head lice, is made by observation of the white
eggs (nits) firmly attached to the hair shafts. Treatment can include the application of a
medicated shampoo with lindane for children over two years old and meticulous combing with a
special comb for the removal of all nits. White flakes would most likely be dandruff or dried hair
product. Dandruff is easily distinguished from nits because dandruff does not attach to the hair
shaft and is easily removed. While head lice could cause head-scratching, but it can also be
attributed to other causes. An oval pattern of hair loss can be caused by many different things,
including tinea capitis (ringworm) and hair shaft trauma (child pulling out the hair). The nurse
should explain to the children that anyone can get head lice, and lice are transmitted from one
person to another by the use of personal items such as combs, hair ornaments, scarfs, or hats.
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Concepts tested

Question 983
The nurse is assessing an adolescent client who delivered a baby three weeks ago. The client tells
the nurse that she is worried about not returning to her pre-pregnancy weight.
Which initial action should the nurse take?
A Give the client several pamphlets about healthy postpartum nutrition
B Review the client's weight pattern during the past year
C Ask the client to record her dietary intake for the next few weeks
D Encourage the client to talk about her concerns and self-image

Question Explanation
Correct Answer is D
Rationale: Body image is significant to an adolescent. The nurse must acknowledge this
and initially collect more information about the client's self-image before discussing nutritional
needs, diet, or exercise. Adolescents often need more support and information about what to
expect after the birth of a child, especially since the postpartum period can be overwhelming.
Nonjudgmental and developmentally appropriate interactions are needed to care for the physical
and emotional needs of adolescent mothers.
Concepts tested

Question 984
The nurse is educating a client concerning the risk factors of osteoporosis. Which statement by
the client would indicate additional education is needed?
A “Weight-bearing exercises may help increase my bone density.”
B “My female gender puts me at higher risk for osteoporosis.”
C “A few cups of coffee a day will not increase my risk of osteoporosis.”
D “Some common medications have been linked to an increased risk of osteoporosis.”

Question Explanation
Correct Answer is C
Rationale: Osteoporosis is caused by a combination of genetics, lifestyle, and environmental
factors. Non-modifiable risk factors include advanced age, family history of osteoporosis, female
gender, and a small frame. Modifiable risk factors include lifestyle and environmental factors.
Lifestyle and environmental risk factors include a sedentary lifestyle and increased use of
caffeine, tobacco products, and alcohol. Common medications that could cause osteoporosis are
corticosteroids, aluminum-based antacids, loop diuretics, and supplemental thyroid hormones.
Concepts tested

Question 985
The nurse is interviewing a client during her first trimester of pregnancy. During the interview,
the client tells the nurse that she has several sex partners and is unsure of the identity of the
baby's father. Which nursing intervention is most appropriate at this time?
A Counsel the client to consent to testing for human immunodeficiency virus and sexually
transmitted infections

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B Discuss the risk of cervical cancer
C Ask the client for the name of each sexual partner
D Refer the client to a family planning clinic

Question Explanation
Correct Answer is A
Rationale: The client's behavior places her at high risk for human immunodeficiency virus (HIV)
and other sexually transmitted infections (STIs). While the client is voicing concern about not
knowing who the father of the child is, the nursing priority is the safety and health of the mother
and baby; therefore, the most appropriate intervention is for the nurse to provide information and
counsel the woman to consent to HIV and STI testing. After the appropriate testing has occurred,
the nurse can discuss health risks and methods to determine the paternity of the child. Referring
the client to a family planning clinic, or requesting the names of sexual partners is not
appropriate.
Concepts tested

Question 986
Which of these activities are examples of primary prevention activities? Select all that apply.
A Rehabilitation
B Cholesterol screening
C Breast self-exam
D An exercise class
E Car seat installation education
F Vaccination

Question Explanation
Correct Answer is D, E, F
Rationale: Engaging in an exercise class, correctly installing a child safety or car seat and getting
vaccinations are considered primary prevention activities. Rehabilitation falls under tertiary
prevention. Cholesterol screening and breast self-exam are secondary prevention interventions.
Concepts tested

Question 987
A woman comes to a clinic to discuss contraceptive options. Which statement by the client
indicates to the nurse a need for additional teaching? Select all that apply.
A "I will return every month for a medroxyprogesterone acetate (Depo-Provera) injection."
B "My diaphragm will work no matter how much weight I gain."
C "If my etonogestrel vaginal ring (NuvaRing) falls out, I still will be protected from a potential
pregnancy."
D "Using an intrauterine device (IUD) increases my risk for a pelvic infection."
E "I should stop smoking before starting an oral contraceptive."
F "Not having any type of sexual intercourse is the only way to be sure I won't get pregnant."

Question Explanation
Correct Answer is A, B, C

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Rationale: Women who smoke while taking oral contraceptives have an increased risk for a
myocardial infarction, stroke and hypertension, so smoking cessation should be encouraged.
Diaphragms should be refitted after pregnancy and pelvic surgery and whenever the client's
weight changes. Medroxyprogesterone acetate (Depo-Provera) injections are effective for three
months. Cervical caps, sponges and IUDs increase the risk for pelvic infections. Vaginal rings
may fall out and alternative contraceptive methods should be used. Abstinence is the only
method that provides complete protection from pregnancy.
Concepts tested

Question 988
The clinic nurse is meeting with a client who wants to talk about her and her partner's plan for a
future pregnancy. What information is important for the nurse to give to the client?
A Only the women's medical history should be considered.
B Immunizations should be avoided at this time.
C Folic acid should be started before the client has a confirmed pregnancy.
D All prescribed medications should be continued without concerns.

Question Explanation
Correct Answer is C
Rationale: Women should start to take folic acid prior to pregnancy to decrease the risk of neural
tube defects. Preconception care involves a complete review of both partners' medical history.
Medications, supplements, nutrition and psychosocial concerns should be reviewed. Risk factors
which impact pregnancy, such as alcohol, drug use, medications, infections, etc., should be
identified and avoided. Immunizations should be reviewed and encouraged before pregnancy.
Concepts tested

Question 989
The nurse is interviewing a client to verify pregnancy. What information from the client will
provide presumptive findings? Select all that apply.
A Uterine changes
B Cervical changes
C Breast sensitivity
D Amenorrhea
E Nausea
F Fatigue

Question Explanation
Correct Answer is C, D, E, F
Rationale: A newly-pregnant client will typically report subjective (presumptive) changes such
as breast sensitivity, missed period, nausea and fatigue. Uterine and/or cervical changes cannot
be subjectively reported by the client but will be findings assessed during a physical exam by the
health care provider
Concepts tested

Question 990

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The nurse is caring for a client who has just experienced a miscarriage. Which action should the
nurse implement first?
A Provide information on birth control methods.
B Monitor the client for bleeding.
C Refer the client to a grief counselor.
D Administer Rho(D) to the client.

Question Explanation
Correct Answer is B
Rationale: The nurse's priority is to address the client's physical needs (A-B-C) according to
Maslow's hierarchy of needs. The nurse must first assess and monitor bleeding and be prepared
to act if there is a complication such as a hemorrhage. The other actions are also part of the
nurse's plan/implementation but are not the initial priority.
Concepts tested

Question 991
The nurse is providing education to a client in her first trimester of pregnancy. Which statement
indicates that the client requires additional teaching?
A "I will continue to take my prenatal vitamins as directed."
B "It is normal to have some fatigue."
C "I will continue to exercise as directed."
D "I will schedule visits with my health care provider as needed."

Question Explanation
Correct Answer is D
Rationale: A pregnant client should adhere to the recommended health care visit protocol
throughout the pregnancy. The nurse should assist with setting up an appointment schedule for
the client. Adhering to the appointment schedule with the health care provider (HCP) can help
ensure a healthy pregnancy and can identify and prevent complications. Therefore, the client’s
statement about seeing their HCP "as needed" is incorrect and requires additional teaching. The
other client statements are correct and do not require additional teaching.
Concepts tested

Question 992
A client who has just given birth asks the nurse what an Apgar score means. What is
the best response by the nurse?
A “The score indicates that your newborn experienced complications during delivery."
B "The score is a general overview of how well your newborn is doing."
C "The score indicates that your newborn may have future complications."
D "The score is for the physician and not something you need to worry about."

Question Explanation
Correct Answer is B
Rationale: The Apgar score gives the health care team a general overview of how well the
newborn is acclimating and is usually done at 1 and 5 minutes after birth. It is a composite score

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of five assessments: heart rate, respiratory effort, muscle tone, reflex irritability and color. It is
not a predictor of future problems or lack thereof. Although the score is most meaningful to the
health care team, the role of the nurse is to educate and answer the client’s question directly and
honestly.
Concepts tested

Question 993
Question 8
The nurse is providing information to a pregnant client about the potential risks of an
amniocentesis. Which risk factors shall the nurse include? Select all that apply.
A Preeclampsia
B Premature rupture of membranes
C Ectopic pregnancy
D Spontaneous abortion
E Preterm labor
F Increase in blood glucose levels

Question Explanation
Correct Answer is B, D, E
Rationale: During an amniocentesis, amniotic fluid is removed from the uterus through the
insertion of a hollow needle through the abdominal wall and into the uterus. Reasons include
genetic testing, fetal lung testing, and removal of excess amniotic fluid (polyhydramnios).
Amniocentesis carries various risks, including: leaking amniotic fluid, rupture of amniotic
membrane, miscarriage or spontaneous abortion, preterm labor, needle injury to the fetus, Rh
sensitization and infection.
Concepts tested

Question 994
A hospitalized, school-age child with a spica cast says to the nurse "I am bored." Which type of
activity would be most appropriate for the nurse to implement for this child?
A Unlimited television time
B Push-pull toys
C Jump rope
D Board games

Question Explanation
Correct Answer is D
Rationale: School-age children enjoy activities which promote physical growth, intellectual
ability and fantasy. With the spica cast, vigorous physical activity will be limited. Quiet activities
include reading, arts and games. The nurse should discourage unlimited television or electronic
screen time. Push-pull toys would be more appropriate for younger children, such as toddlers.
Concepts tested

Question 995
<template>

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A <template>
B <template>
C <template>
D <template>

Question Explanation
Correct Answer is A
Concepts tested

Question 996
The nurse is collecting baseline data on a 14-month-old child during a wellness visit in the
primary care provider's office. Which of the following measurement methods are correct? Select
all that apply.
A The nurse places the tape measure around the child's head at the widest part of the frontal and
occipital bones.
B The nurse measures the child's chest circumference by placing the measurement tape around
their chest at the nipple line.
C The nurse places the child on an infant platform scale in either a sitting or supine position.
D The nurse measures the child's height while the child stands against the wall supported by the
parent.
E The nurse counts the child's pulse by placing one finger on the radial artery for a full minute.

Question Explanation
Correct Answer is A, B, C
Rationale: Data collection methods should be correct for the age of the client. Data collection
methods for children under the age of two are different than those for older children. A healthy
14-month-old child who is developing normally may prefer to sit on the scale than to be laid on
the scale but their height should still be measured while laying down. A toddler's head and chest
circumference are measured with a tape measure. The head circumference is measured at the
widest point of the frontal and occipital bones, while the chest circumference is measured at the
nipple line. An infant or toddler's pulse is counted apically, not radially.
Concepts tested

Question 997
The nurse is caring for a neonate born 12 hours ago who is exhibiting a hyperactive Moro reflex
and slight tremors. The previous nurse reported that the neonate’s mother was using methadone
during pregnancy. While developing a plan of care, which of the following actions is the
nurse’s priority?
A Assess for neonatal abstinence syndrome
B Offer fluids to prevent dehydration
C Administer loperamide to stop diarrhea
D Hold the infant at frequent intervals

Question Explanation
Correct Answer is A

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Rationale: Neonatal abstinence syndrome (NAS) is a cluster of findings that occur in a newborn
who was exposed to opiates while in the mother’s womb. Two major types of NAS is due to
addictive illegal use of opiates or opiate prescription drugs, such as methadone. Symptoms of
NAS depend on the type of drug the mother used, how often the drug was used, and how much.
Withdrawal symptoms could include tremors, irritability, high-pitched cry, hyperactive reflexes,
and/or seizures. The priority nursing action is the assess the neonate for withdrawal symptoms
and notify the health care provider immediately for further orders of treatment.
Concepts tested

Question 998
The nurse is assessing a client in early labor. While positioning the client to perform a vaginal
exam, the client reports feeling dizzy and nauseous. The client appears pale and has low blood
pressure. Which action should the nurse take initially?
A Encourage deep breathing
B Call the health care provider
C Turn her to her left side
D Elevate the foot of the bed

Question Explanation
Correct Answer is C
Rationale: While in the supine position, the weight of the uterus can put pressure on the vena
cava and aorta. The client is experiencing symptoms of hypotension and dizziness due to
constriction of blood flow. To relieve the pressure on the vena cava and aorta, the nurse should
initially turn the client to the left side to reduce pressure and relieve postural hypotension.
Concepts tested

Question 999
A new parent calls the pediatrics office to speak to the nurse. The parent reports that their 4-
week-old infant sleeps almost 16 hours a day and the parent expresses concern that there might
be something wrong with their child. How should the nurse respond?
A "Please make an appointment for the baby to be seen by the pediatrician."
B "Tell me more about other behaviors of the baby."
C "Why do you think that your baby is abnormal?"
D "That is normal for a baby that age. You do not need to worry."

Question Explanation
Correct Answer is B
Rationale: Using therapeutic communication techniques and following the nursing process, the
nurse should gather more information from the parent about their baby, in order to be able to
determine if the child should be seen in the office. Although sleeping 16 hours a day is within the
normal range for a 4-week-old infant, the nurse should encourage the parent to describe other
behaviors such a feeding and how the baby acts when awake."'Why" questions or dismissing the
parent's concern are nontherapeutic.
Concepts tested

Question 1000
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The nurse is planning to care for a preschool-aged child with a recent illness. Which nursing
intervention would be most appropriate for the nurse to implement based on the child's
developmental needs?
A Allow the child to make realistic goals
B Encourage the opportunity to make choices
C Allow the child to explore the playroom
D Encourage the use of imaginary play

Question Explanation
Correct Answer is B
Rationale: A preschool-aged child’s age ranges from 3 years to 5 years. During these years,
Erikson’s stage of development puts them in the initiative versus guilt stage. Within this stage,
the nurse should allow the child an opportunity to make their own choices and act upon those
choices. This will allow the child to have increased initiative and learn to make decisions for
themselves. If they make the wrong decision they will feel guilty and will need further guidance.
Allowing the child to make realistic goals does not occur until ages 6 to 11 while in the industry
versus inferiority stage. Imaginary play and having the child explore the playroom is at a much
younger stage, autonomy versus self-doubt, and the child should have resolved that stage.
Concepts tested

Question 1001
A 9-year-old child is taken to the emergency department with right lower quadrant pain and
vomiting. During preparation for an emergency appendectomy, what should the nurse expect to
be the child's greatest fear?
A Perceived loss of control
B An unfamiliar environment
C Change in body image
D Guilt over being hospitalized

Question Explanation
Correct Answer is A
Rationale: According to Erikson’s stage of development, this child is in the industry versus
inferiority developmental stage. The age range for this stage is 5 to 13 years. Within this stage,
children learn new skills and are influenced by their peers. They may feel competent or feel
inferior and doubt themselves. Possible problems or concerns could include isolation from peers,
inability to cope causing anger and shame, self-doubt, and perceived loss of control.
Concepts tested

Question 1002
The postpartum nurse is reviewing the medical record of a client who had a vaginal delivery two
hours ago. The record indicates that the client's amniotic membranes ruptured 36 hours before
the birth. Which potential postpartum complication is of highest concern for this client?
A Infection
B Bleeding

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C Hypoxemia
D Dehydration

Question Explanation
Correct Answer is A
Rationale: Membranes that have been ruptured for more than 24 hours prior to the birth
significantly increases the risk of infection to both the mother and the newborn. Therefore, the
nurse’s highest priority is to assess for signs and symptoms of infection including fever, chills,
abdominal pain, foul-smelling lochia, tachycardia and hypotension.
Concepts tested

Question 1003
A nurse is preparing to perform a physical examination on an 8-month-old child who is sitting
happily on the mother's lap. Which assessment should the nurse perform first?
A Measure the height and weight
B Auscultate the heart and lungs
C Elicit the deep tendon reflexes
D Examine the mouth and ears

Question Explanation
Correct Answer is B
Rationale: The nurse should auscultate the heart and lungs during the first quiet moment with the
infant so as to be able to hear sounds clearly. Other assessments may follow in any order.
Concepts tested

Question 1004
A 30-month-old child is admitted to the hospital unit. Which of these toys would
be most appropriate for this child?
A Large wooden puzzle
B Cartoon stickers
C Blunt scissors and paper
D Beach ball

Question Explanation
Correct Answer is A
Rationale: This child is 2 ½ years old, or 30 months. Appropriate toys for this child’s age include
items such as dolls and stuffed animals, toy telephone, wooden puzzles, and/or construction toys
that snap together. Child’s play between the age of 2 and 3 is more purposeful and they have the
fine motor skills needed to complete a large wooden puzzle. Children between the ages of 4 to 5
will start to use blunt scissors with art projects; this age is appropriate for safety purposes as
well. Cartoon stickers and a beach ball are toys for a younger child between the ages of 1 to 2.
Concepts tested

Question 1005

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A client who is pregnant comes to the clinic for a first visit. The nurse gathers data about the
client's obstetric history which includes 3-year-old twins and a miscarriage 10 years ago. How
should the nurse accurately document this information?
A Gravida 3 para 1
B Gravida 3 para 2
C Gravida 4 para 2
D Gravida 2 para 1

Question Explanation
Correct Answer is A
Rationale: Para is the number of deliveries (of an infant more than 20 weeks gestation).
Regardless of how many babies are delivered at one time (twins, triplets, etc.), the delivery is
still counted as 1. Gravida is the number of pregnancies. This woman had a miscarriage (at 12
weeks), so that would be gravida 1, para 0. With the twins, the count would be gravida 2, para 1.
With the current pregnancy, she is gravida 3, para 1 - 3rd pregnancy to date, but only one
previous delivery (of the twins).
Concepts tested

Question 1006
The labor and delivery nurse is caring for a client in active labor. The client has chosen natural
childbirth with assistance from a doula and family members. Which action by the nurse would
be most helpful for the client to achieve her goal of an unmedicated labor and birth?
A Closely monitor the interactions of the client with the doula
B Assess the effectiveness of the labor support team and offer suggestions as needed
C Have pain medication readily available and offer it on a regular basis
D Encourage the client to stay in bed in a side-lying position

Question Explanation
Correct Answer is B
Rationale: A doula is a woman, typically without formal obstetric training, who is employed by
clients to provide guidance and support during labor. The nurse's role involves clinical skills and
administrative responsibilities that are not part of the doula's role. The nurse is responsible for
assessing both the mother and fetus and remains an important part of the labor and birth in this
scenario. The nurse's expertise allows the nurse to make helpful suggestions to the support
persons and the client, such as encouraging the client to find comfortable positions, both in and
out of bed. It is appropriate to let the client and her support persons know all of the pain control
options, but it would be inappropriate to continually offer pain medication to someone who has
chosen natural childbirth. Doulas use techniques such as imagery, massage, acupressure and
patterned breathing to reduce a woman's pain.
Concepts tested

Question 1007
The parent of a 5-year-old child is concerned about an outbreak of measles in the community.
The nurse understands that additional education about immunizations is needed when the parent
makes which of the following statements? Select all that apply.

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A "My child should receive a second dose of the measles vaccine now."
B "We should avoid playing with children with high fevers."
C "My child is unlikely to get measles because of their first vaccine at age one."
D "My child should have passive immunity from the vaccine I had as a child."
E "If a child develops a rash, the risk of spreading measles is gone."

Question Explanation
Correct Answer is D, E
Rationale: Measles is a preventable communicable disease that was well controlled in the United
States until recently. There have been outbreaks of measles in communities where children did
not receive the vaccines. The Centers for Disease Control and Prevention (CDC) recommends
immunization at around age one, with a booster between ages four and six. The child should be
protected from the disease after the first vaccine. The period of time measles is communicable is
from 3 to 5 days before the rash appears until about four days after the rash appears. In the first
year of life, the child may have passive immunity from the mother. It is important to avoid being
in confined spaces with any individual with a high fever.
Concepts tested

Question 1008
The home health nurse is visiting an older adult client who recently moved to this community
from a much colder climate. The nurse provides the client with instructions on how to prevent a
heat stroke. Which statement by the client indicates that additional teaching is needed?
A "I will not take my diuretic on days that I exercise."
B "I will increase my fluid intake if I develop cramps when exercising."
C "I will take my daily jog early in the morning when it is cool outside."
D "I will wear loose clothing and a hat when I walk my dog."

Question Explanation
Correct Answer is A
Rationale: It is important to exercise outside when the temperature is low as exposure to high
temperature increases the likelihood of heat-induced injury. Increasing fluid intake before,
during and after exercise will decrease the likelihood of muscle cramping. Loose clothing and a
hat to provide shade will keep the body temperature down. While taking a medication such as a
diuretic is a risk factor for non-exertional heat stroke, clients should always take medications as
prescribed. If the client takes a diuretic, increasing fluid intake while exercising and being
exposed to high temperatures will aid in maintaining adequate hydration status.
Concepts tested

Question 1009
Which information in a client's history would place them at an increased risk for skin
cancer? Select all that apply.
A The client is receiving an immunosuppressant drug.
B The client's profession is fisherman.
C The client is dark-skinned.
D The client has blond hair and green eyes.

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E The client is 65-years-old.

Question Explanation
Correct Answer is A, B, D, E
Rationale: A client with fair skin tone, blond or red hair and blue or green eyes are at increased
risk for skin cancer. People who work outdoors (e.g., fishermen, farmers, bridge construction
workers) are exposed to increased sunlight and ultraviolet light. Age risk factors are adults
younger than 30 years and older than 50 years old. Risk of squamous cell skin carcinoma is
increased for individuals receiving immunosuppressant drug therapy. Other risk factors include a
previous history of sunburns, indoor tanning and family history of skin cancer.
Concepts tested

Question 1010
The nurse working in a dermatology office is reinforcing teaching with a client about skin cancer
prevention. Which statement by the client requires follow up by the nurse?
A "I will use a tanning bed to get a tan so I avoid the harmful rays from the sun."
B "I will wear a wide-brimmed hat, sunglasses and long sleeves when I'm outside."
C "I will avoid sun exposure between the hours of 11 am and 3 pm."
D "I plan to use sunless tanning creams to safely produce a tan."

Question Explanation
Correct Answer is A
Rationale: The major cause of skin cancer is overexposure to the sun's harmful ultraviolet (UV)
rays. Sunscreen should be worn at all times when outdoors. It is also recommended to wear a
wide-brimmed hat, long sleeves and sunglasses when outside. The sun's UV rays are the
strongest between 11 am and 3 pm and should be avoided if possible. Sunless tanning creams
can safely produce a tan coloring of the skin without harmful exposure to the sun. The nurse
should follow up on the statement about using a tanning bed because tanning beds emit the same
harmful UV rays as the sun and should be avoided.
Concepts tested

Question 1011
The nurse in a health clinic is educating a female student on ways to prevent sexually transmitted
infections. Which statement indicates the client understands the nurse's teaching?
A "We will always use a latex condom even if we are just having oral sex."
B "I trust my boyfriend and we have been dating for a while now."
C "We don't need to use a condom because I'm taking the birth control pill."
D "Both of us have received the HPV vaccine and we will be immune."

Question Explanation
Correct Answer is A
Rationale: Sexually transmitted infections (STIs) are infections spread from partner to partner
during vaginal, oral, or anal sex. Prevention includes education on safe sex practices. Latex
condoms provide a barrier to protect against infection and should be used during every sexual

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encounter including vaginal, oral, or anal sex. Birth control pills do not protect against STIs. The
HPV vaccine does not protect against other STIs.
Concepts tested

Question 1012
The nurse in a pediatrician's office is performing a physical assessment on a 2-year-old child.
The nurse is attempting to obtain a tympanic temperature but the child is not cooperating. Which
intervention would be most helpful in trying to obtain the temperature reading?
A Request that another nurse hold the child down.
B Allow the child to touch and inspect the thermometer.
C Document that the child was uncooperative.
D <span style="font-weight: 400;">Offer a sucker as a reward for holding still.</span>
Offer a sucker as a reward for holding still.

Question Explanation
Correct Answer is B
Rationale: A toddler is in a developmental stage where they begin to express a need for
independence and control over themselves and the world around them. Toddlers tend to resist
cooperating and like to say "no" in order to assert their autonomy. The most helpful approach is
to allow the child to touch and inspect the thermometer because it helps alleviate fears and aid in
cooperation. Physically holding a child down is not appropriate. Offering candy is not
recommended because food should not be used as a reward for good behavior or cooperation. An
accurate temperature is important in a physical assessment and every effort should be made to
obtain that data.
Concepts tested

Question 1013
The obstetric nurse is providing care to a client during a prenatal visit. The client states that she
is considering breastfeeding when the baby is born. Which action should the nurse take first?
A Teach the client about the benefits of breastfeeding.
B Assess the client's knowledge and perceptions about breastfeeding.
C Ask the client about her employer's breastfeeding policy.
D Provide information for a local breastfeeding support group.

Question Explanation
Correct Answer is B
Rationale: The first step in the nursing process is assessment. Assessment is the collection of
information obtained by the nurse in order to develop nursing problems and an education plan
unique to the client. The first action the nurse should take is to assess the client's knowledge and
perceptions about breastfeeding. Potential barriers to breastfeeding include embarrassment,
misconceptions, employment and cultural norms. The other actions are used to improve
breastfeeding success but are not implemented until after the first step of assessment has been
completed.
Concepts tested

Question 1014
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The nurse is measuring blood pressures at a community health fair. When the nurse tells a client
that his blood pressure is 160/96 mm Hg, he states, "My blood pressure is usually much lower."
Which of the following options would be the best response by the nurse?
A "Check your blood pressure again in a few months."
B "See your health care provider immediately."
C "Make an appointment to see your health care provider next year."
D "Get your blood pressure checked again within the next 1-2 weeks."

Question Explanation
Correct Answer is D
Rationale: High blood pressure is defined as blood pressure 130/80 mm Hg or higher.
Hypertension is determined by systemic vascular resistance and cardiac output. The client's
blood pressure reading is moderately high and should be rechecked. Since the client states his
blood pressure is "usually much lower" the elevated blood pressure could be a concern, but it is
not clear what the client considers to be a "much lower" blood pressure. Hypertension is
typically diagnosed after screening. After an elevated blood pressure reading is noted on
screening, the average of two or more measurements on at least two separate visits in the next
couple weeks is needed to diagnose hypertension. Although the client's blood pressure is higher
than normal, it is not considered a medical emergency. It is not necessary to seek medical
attention immediately. The client needs to have their blood pressure reevaluated in the next
couple weeks. Waiting a year, is too long.
Concepts tested

Question 1015
The nurse is assessing a 5-day-old infant brought to the pediatrician's office by the infant's
parents. During the assessment, the nurse identifies clear breath sounds with equal chest
expansion, a respiratory rate of 38 to 42 breaths per minute with occasional periods of apnea
lasting 10 seconds in length. What is the correct analysis of these findings?
A The infant should be seen immediately by the pediatrician
B The infant will require emergency lifesaving services
C The infant's breathing pattern is normal
D The infant will need a referral to a respiratory specialist

Question Explanation
Correct Answer is C
Rationale: Respiratory rates in newborns (first four weeks of life) are 30 to 60 breaths per
minute. Newborn infants breathe faster than children and adults. Periods of apnea often occur,
lasting up to 15 seconds. The nurse should reassure the infant's parents that this is an expected
finding and is known as "periodic breathing" and occurs as the newborn's lungs and brains
become more coordinated. Although the pediatrician should examine the infant, it is not
imperative that the infant be seen immediately. The infant is not in any respiratory distress. The
nurse's assessment findings for the infant are normal. At this point, there is nothing in the nurse's
assessment that would indicate that the infant will need a referral to a respiratory specialist or
require emergency lifesaving intervention.
Concepts tested

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Question 1016
<template>
A <template>
B <template>
C <template>
D <template>

Question Explanation
Correct Answer is A
Concepts tested

Question 1017
The nurse is admitting a school-age child to the pediatric unit. Which of the following concerns,
provided by the child's parents, would the nurse recognize as a finding of type 1 diabetes?
A Decreased appetite
B Dry skin
C Weight gain
D Bed-wetting

Question Explanation
Correct Answer is D
Rationale: Type 1 diabetes is a condition in which glucose in the blood becomes high due to a
lack of insulin. In school-age children, clinical signs of type 1 diabetes include fatigue, poluria
(frequent urination), polydipsia (increased thirst), polyphagia (extreme hunger), and weight loss.
Diabetics usually have dryer skin. However, dry skin is not a specific finding in this child.
Clients with type 1 diabetes, whose glucose is extremely elevated, will present with polyphagia
and not a decreased appetite. Due to the insulin deficiency, cells are unable to use glucose for
energy production. Clients with type 1 diabetes typically present with weight loss, not weight
gain. Due to the insulin deficiency, cells are unable to receive glucose for energy production. As
a result, cells are starving, and fats get converted to energy. Bed-wetting in a school-age child
who previously did not wet the bed at night, would prompt the parents to seek medical attention.
Bed-wetting could be an indication of polyuria due to excess sugar building up in the child's
bloodstream, as this pulls fluid from the tissues into the blood stream.
Concepts tested

Question 1018
The nurse in an obstetrics clinic is reviewing the medical record of a currently pregnant client
with a GTPAL history of 3-2-0-1-2. How should the nurse interpret the GTPAL score?
A The client has been pregnant a total of four times.
B The client has three living children.
C The client has had two term births.
D The client has not had any miscarriages.

Question Explanation
Correct Answer is C

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Rationale: The GTPAL system calculates the obstetric history of a woman in terms of the
number of times she has been pregnant (Gravidity), the number of Term births she has had, the
number of Premature births she has had, the number of Abortions or miscarriages she has had,
and the number of Living children she currently has. A GTPAL score of 3-2-0-1-2 indicates 3
pregnancies (including the current one), 2 term births, 0 preterm births, 1 miscarriage/abortion
and 2 living children.
Concepts tested

Question 1019
The nurse is assisting with the delivery of a newborn infant. Which intervention immediately
after delivery is the priority?
A Dry off infant with a warm blanket
B Assign one minute APGAR score
C Obtain vital signs
D Apply identification bracelets

Question Explanation
Correct Answer is A
Rationale: The priority intervention during the newborn period includes maintaining the infant's
temperature by drying and warming the infant; and removing any wet blankets or towels from
the infant to avoid dropping their body temperature. Maintaining the temperature of the newborn
is essential to decreasing the risk of respiratory distress. Normal temperature promotes normal
oxygen requirements. The cold-stressed infant may present with signs of respiratory distress and
cardiac depression. Identification bands should be placed on the infant after birth, but this
intervention wouldn't take higher priority than warming the newborn. The APGAR score is an
important part of the initial assessment and is performed at 1 and 5 minutes after birth. This
assesses the infant's overall condition at birth. The score occurs after the baby is being warmed.
Vital signs are performed along with the APGAR score.
Concepts tested

Question 1020
The nurse is admitting a client newly diagnosed with hypertension. Which of the following is
the best method for assessing the client's blood pressure?
A With legs crossed
B After exercising
C In both arms
D With arms hanging down

Question Explanation
Correct Answer is C
Rationale: Accurate blood pressure measurement is essential for diagnosis, management and
treatment of hypertension. Not only do health care providers (HCP) need to accurately measure
blood pressure, clients need to be taught the correct skill as well. Blood pressure should be taken
in both arms due to the fact that one subclavian artery may be stenosed and this results in a false
high BP in that arm. All clients should be seated in a straight-back chair with their feet flat on the
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ground; not crossed, as this could falsely elevate the client's blood pressure. The client's arm
should be supported at the mid-sternum level. Having the arm above the heart leads to an
underestimation of blood pressure, and below the heart leads to an overestimation of blood
pressure. The client should not exercise recently. In addition, they should not drink caffeine or
smoke nicotine for at least 30 minutes before their blood pressure is taken.
Concepts tested

Question 1021
The nurse works in a pediatric hospital. Which of the following actions should be planned in the
care of an 18-month-old child?
A Engage the child in games with other children
B Hold and cuddle the child frequently
C Encourage the child to feed self with finger foods
D Allow the child to walk independently on the unit

Question Explanation
Correct Answer is C
Rationale: According to Erikson, the toddler is in the stage of autonomy versus shame and doubt.
It is not until a child reaches the preschool years that they would interact and play with other
children. The nurse should encourage independent activities of daily living that allow toddlers to
assert their budding sense of control. Toddlers are gaining a sense of autonomy. The nurse would
encourage toddlers to feed themselves. Although an 18-month toddler would still need to be held
and cuddled; they would not need to be held as frequently as an infant. Although an 18-month
toddler would be walking, they should not be walking independently on the nursing unit. It
would not be safe.
Concepts tested

Question 1022
The nurse is caring for a 2-year-old toddler with a neural tube defect. The mother of the child
asks the nurse, "What can I do to decrease the chances of having another baby with a neural tube
defect?" Which of the following responses would be the most appropriate response by the
nurse to the client's mother?
A "Multivitamins are recommended during pregnancy.
B "Folic acid should be taken before and after conception."
C "A well-balanced diet promotes normal fetal development."
D "An increase in iron improves the health of the mother and fetus."

Question Explanation
Correct Answer is B
Rationale: The American Academy of Pediatrics recommends that all childbearing women
increase folic acid from dietary sources and/or supplements prior to getting pregnant and during
pregnancy. Evidence-based practice validates that increased amounts of folic acid prevents
neural tube defects such as spina bifida.
Concepts tested

Question 1023
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The nurse is caring for a client who asks the nurse to explain the basic ideas of homeopathic
medicine. Which of the following responses by the nurse would best explain the approach of
such remedies?
A Boost the immune system
B Destroy organisms causing disease
C Increase bodily energy
D Maintain fluid balance

Question Explanation
Correct Answer is A
Rationale: Homeopathic medicine treats clients with minute doses of plant, mineral or animal
substances that provide a gentle stimulus to the body's own defenses.
Concepts tested

Question 1024
The nurse is caring for a 14-month-old toddler just diagnosed with cystic fibrosis. The parents
state this is the first child in either family diagnosed with this disease, and ask about the risk to
future children. Which of the following would be the best response by the nurse?
Question 19 Answer Choices
A One in four chance for each child to carry that trait
B One in two chance that each child will have the disease
C One in two chance of avoiding the trait and disease
D One in four risk for each child to have the disease

Question Explanation
Correct Answer is D
Rationale: Cystic fibrosis (CF) is an autosomal recessive genetic condition that is inherited. A
person with a non-functional copy of the gene is a carrier. Carriers for CF have no symptoms,
but can pass the gene on to their children. An individual must inherit two non-functioning CF
genes, one from each parent, to have CF. In this situation, both parents must be carriers of the
trait for the disease because neither one of them has the disease. Therefore, for each pregnancy,
there is a 25% chance of the child having the disease, a 50% chance of carrying the trait, and a
25% chance of having neither the trait nor the disease.
Concepts tested

Question 1025
The nurse is speaking to the parents of a 4-year-old child who are concerned about the child
wetting the bed several times a month. What should the nurse's initial response be?
A "You should limit fluid intake close to bedtime"
B "These accidents can happen at this age."
C "How long has this been occurring?"
D "Have you tried waking the child to urinate?"

Question Explanation
Correct Answer is C

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Rationale: Involuntary voiding or bed-wetting may occur from infections, developmental delays
and anatomical malformations. Bed-wetting may also be related to hereditary factors. Following
the nursing process, the initial response should be one that invites the parents to provide more
details so that the nurse can gain a clearer picture of what might be happening or contributing to
the child's enuresis, i.e., involuntary urination at night. Based on the additional information
received, the nurse can decide how best to proceed.
Concepts tested

Question 1026
The nurse is admitting a 2-year-old child who has had a seizure. Which of the following
statements by the child's parents would be the most important in the determination of the
etiology of the seizure?
A "His naps have been getting longer and longer."
B "He seems to be constipated."
C "He's had an ear infection for two days."
D "Red meat has been his favorite food lately."

Question Explanation
Correct Answer is C
Rationale: Up to 10% of all children experience at least one seizure during their childhood.
Contributing factors to seizures in children, commonly in the first two years of life, include age,
infections associated with febrile seizures, fatigue, not eating properly, and excessive fluid intake
or fluid retention. Febrile seizures are the most common type of seizure. Young children who
develop otitis media can develop high temperatures. The consumption of red meat and
constipation are not considered triggers for seizure activity. Although longer naps may occur in
children who have an infection, longer naps do not routinely precede a seizure.
Concepts tested

Question 1027
A client experiences postpartum hemorrhage eight hours after the birth of twins. Following
administration of IV fluids and 500 mL of whole blood, the hemoglobin and hematocrit are
within normal limits. The client asks the nurse whether she should continue to breastfeed the
infants. Which statement by the nurse is most supported by evidence-based practice?
A "Yes, because breastfeeding will help to contract the uterus and reduce the risk of bleeding."
B "No, because breastfeeding twins will take too much energy after the hemorrhage."
C "No, because breastfeeding should be delayed until the "real milk" is secreted."
D "Yes, because the blood transfusion provides additional immunoglobulins to the infants."

Question Explanation
Correct Answer is A
Rationale: The most supported evidence-based practice would be for the client to breastfeed the
twins to help contract the uterus and reduce the risk of uterine bleeding. Stimulation of the
breasts during breastfeeding releases oxytocin, which contracts the uterus. This contraction is

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especially important to enhance the prevention of hemorrhage. The other statements are not
correct or supported by the literature.
Concepts tested

Question 1028
The nurse in a pediatric clinic is talking to the mother of a 1-month-old baby who is being
breastfed. The mother is concerned about the baby's stools and reports that the stools are a lumpy
yellow liquid. How should the nurse respond?
A “If you eat more fiber, it will pass through your milk and harden the stools.”
B “The stools should be more of a brown color and formed by now.”
C “Those stools are normal for a baby who is breastfed.”
D “You should supplement breastfeeding with formula to thicken the stools.”

Question Explanation
Correct Answer is C
Rationale: Breastfed infants who are 4 to 6 weeks old typically have stools that are frequent and
yellow to gold in color. The texture is often described as soft to a thick, seedy, or curdy liquid.
The mother is describing a normal finding for a breastfed infant. The other responses are
incorrect or inappropriate for this infant.
Concepts tested

Question 1029
The community health nurse is participating in a health policy forum. Which statement by the
nurse best describes the purpose of community health research?
A To describe the health conditions of populations
B To identify the health conditions of the environment
C To evaluate illness in the community
D To explain the health conditions of families

Question Explanation
Correct Answer is A
Rationale: Community health focuses on the maintenance, protection, and improvement of health
especially of groups, populations, and communities. The purpose of community health research
is best described as research that focuses on the health of populations in a community rather than
the health of an individual. Community health nurses focus on short and long-term care for
disease prevention, such as controlling the spread of communicable diseases, supporting self-
management of chronic diseases, and providing education to vulnerable and underserved
populations such as the homeless, elderly, and minority groups.
Concepts tested

Question 1030
The nurse in a pediatrician's office is assessing a 4-month-old infant's motor skills. Which action
by the infant should the nurse expect at this age?
A Drinking from a cup

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B Grasping a rattle
C Banging blocks
D Waving good bye

Question Explanation
Correct Answer is B
Rationale: A child between the ages of 3 to 6 months should be able to reach and grab things.
Grasping a toy, like a rattle, would be an expected finding. The other actions would be seen in
older infants. Children between the ages of 6 to 9 months will start to be weaned from the bottle
and introduced to a “sippy” cup. Children between the ages of 9 to 12 months may recognize a
few familiar sounds, say and wave goodbye, and play more with blocks and other toys.
Concepts tested

Question 1031
The nurse is teaching child preparation classes to a group of parents. One couple asks about their
rights to develop a birth plan. Which response by the nurse would be most appropriate?
A "Have you talked with your health care provider about this?"
B "What is your reason for wanting such a plan?"
C "Let us discuss your rights as a couple."
D "Write your ideal plan for the next class."

Question Explanation
Correct Answer is C
Rationale: The most appropriate response from the nurse would be to discuss their rights as a
couple. Once their question is answered, the nurse should encourage them to speak with their
health care provider about their specific plan. They can be encouraged to write their plan out and
share it with the nurse at their next class once they have all the information they need and input
from their health care provider. A simple birth plan can help ensure the couple’s wishes are
known and respected by the whole team. The plan needs to be realistic and allow for the best
approach in case any complications arise.
Concepts tested
Question 1032
While caring for a postpartum client during the first hour after a non-complicated vaginal
delivery, the nurse determines that the uterus is boggy, and there is a moderate amount of vaginal
bleeding. Which action should the nurse take first?
A Check for any abnormal vital signs
B Massage the fundus until firm
C Provide perineal care
D Document the findings

Question Explanation
Correct Answer is B
Rationale: A boggy uterus means that the uterine muscle is not contracting firmly and is more
flaccid than desired. This is also referred to as "uterine atony." A flaccid uterus can lead to

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prolonged bleeding and hemorrhage; therefore, the first action of the nurse should be to massage
the fundus to promote good uterine tone and prevent postpartum hemorrhage.
Concepts tested

Question 1033
The nurse is caring for an adolescent after an injury from a fall who has a history of hemophilia
A. While preparing to provide education, which statement should be emphasized to clients
diagnosed with this condition?
A Alternative sedentary and structured activities should be discussed
B Physical limitations must be explained to peer groups
C Implications of taking risks after acute bleeding episodes should be emphasized
D Safely exercising and taking part in sports are important

Question Explanation
Correct Answer is D
Rationale: An age-appropriate treatment goal is to establish an age-appropriate safe environment.
Adolescents diagnosed with hemophilia should be aware that contact sports may trigger bleeding
episodes. However, developmental characteristics of this age group, such as impulsivity,
inexperience, and peer pressure, place adolescents in unsafe environments.
Concepts tested

Question 1034
The nurse measures the head and chest circumference of an 18-month-old infant. When
comparing the data, the nurse notes the two measurements are the same. What action should the
nurse take next?
A Record the findings in the chart
B Palpate the anterior fontanel
C Feel the posterior fontanel
D Notify the health care provider

Question Explanation
Correct Answer is A
Rationale: These are expected findings, and the nurse will record the measurements in the client's
chart. Between 6 months and 2 years, an infant's head circumference and chest circumference
measurements are about the same. A newborn's head is usually about 2 centimeters larger than
the chest size; after age 2 years, the chest size becomes larger than the head.
Concepts tested

Question 1035
The nurse is speaking with the parents of a 2-year-old child who was just diagnosed with cystic
fibrosis. Which recommendation by the nurse is best?
A Restrict activities to inside the house
B Allow the child to continue normal activities
C Schedule frequent rest periods
D Limit exposure to other children

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Question Explanation
Correct Answer is B
Rationale: Although cystic fibrosis causes severe damage to the lungs, physical activity remains
important for the child's emotional development as well as disease management. A 2-year-old is
developing autonomy and remaining active will support chest physical therapy. Exercise tends to
mobilize mucus and help with expectoration. Therefore, the best recommendation is to allow the
child to continue their normal activities. The other recommendations are not appropriate or
necessary for this child.
Concepts tested

Question 1036
The nurse is teaching the parents of a 2-week-old infant about the prevention of sleep-related
death, such as sudden infant death syndrome (SIDS). Which intervention is the priority?
A Place the infant on their back to sleep
B Avoid placing stuffed animals near the sleeping infant
C Avoid exposing the infant to tobacco smoke
D Place the infant on a firm surface to sleep

Question Explanation
Correct Answer is A
Rationale: Sudden infant death syndrome (SIDS) is the death of a seemingly healthy infant less
than one year of age that remains unexplained after a complete postmortem examination
(autopsy) including an investigation of the death scene and a review of the case history to rule
out abuse. The cause of SIDS is unknown; however, research suggests it may have to do with the
portion of an infant’s brain that controls breathing and arousal from sleep. The highest risk for
SIDS is associated with sleeping in a prone position (on the stomach); other risk factors include
the use of soft bedding, overheating (thermal stress), and cosleeping with an adult, especially on
a sofa or noninfant bed. Since 1994, the incidence of SIDS in the United States has steadily
decreased due to the Back to Sleep campaign (supine, or on their back, sleeping). Although all
interventions listed are appropriate, placing the infant in a supine position/on their back to sleep
is the priority.
Concepts tested

Question 1037
The school nurse is counseling a sexually active teenage girl about pregnancy prevention. The
teenager reports a regular 32-day menstrual cycle. The nurse informs her she is most likely to get
pregnant during which days in her menstrual cycle?
A Days 7-10
B Days 11-13
C Days 17-19
D Days 14-16

Question Explanation
Correct Answer is C

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Rationale: Ovulation occurs 14 days before the onset of menses, thus the teenager with a 32-day
cycle is most likely to get pregnant between days 17 and 19. The follicular phase occurs from
menstruation to ovulation.
Concepts tested

Question 1038
The nurse is working in a community clinic and receives a call from the parent of a school-aged
child. The child was diagnosed with erythema infectiosum (fifth disease) the day before by the
child's pediatrician. The parent reports that the child was sent home from school due to the
presence of a rash. How should the nurse respond?
A Tell the parent to bring the child to the clinic for further evaluation
B Explain to the parent that this rash is not contagious and does not require isolation
C Send over printed materials about this viral illness to the child's school
D Instruct the parent to keep the child in isolation at home for 2 to 3 days

Question Explanation
Correct Answer is B
Rationale: Fifth disease is a viral illness. It begins with cold or flu-like symptoms, and it is at this
stage that it is contagious. Once the rash appears, the child is no longer considered contagious.
Therefore, the nurse should explain to the parent that the child is not contagious and does not
require to be isolated or seen in the clinic. The nurse could send educational materials about fifth
disease to the child's school at a later time.
Concepts tested

Question 1039
A nurse is assigned to a 12-year-old diagnosed with an acute illness. Which approach indicates
that the nurse understands common sibling reactions to hospitalization?
A Visitation is helpful for both.
B The siblings may enjoy privacy.
C Those cared for at home cope better.
D Younger siblings adapt very well.

Question Explanation
Correct Answer is A

Question 1040
A pregnant woman in the third trimester of pregnancy calls the clinic nurse and reports having
severe heartburn. Which initial intervention should the nurse recommend to the client?
A Sleep with the head elevated on pillows
B Take an antacid between meals
C Increase intake of foods high in fiber
D Drink frequent small amounts of liquids

Question Explanation

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Correct Answer is A
Rationale: Heartburn (indigestion) is a common occurrence during pregnancy especially in the
later trimesters. Progesterone slows GI motility and relaxes the cardiac sphincter; in addition, the
stomach is displaced upward and compressed by the enlarging uterus. An initial, non-invasive,
easily implemented intervention is to sleep with the head/upper body elevated. Taking antacids
between meals would be an intervention that the health care provider needs to approve and
prescribe. There is no evidence that frequent sips of water or increased fiber intake will reduce
heartburn.
Concepts tested

Question 1041
The home health nurse is talking to the spouse of a client with Parkinson's disease. The spouse
reports feeling frustrated because it takes the client over one hour to get dressed in the morning.
How should the nurse respond?
A Hire a home aide to dress the client
B Allow the client the time needed to get dressed
C Leave the client in a night gown or pajamas
D Firmly encourage the client to dress more quickly

Question Explanation
Correct Answer is B
Rationale: Parkinson’s disease (PD) is a degenerative neurological disorder resulting from nerve
cells in the brain not producing enough dopamine, which regulates movement. People with PD
experience tremors, muscle stiffness, slow movement, rigidity, poor balance, and coordination.
With careful planning and activity modification, the client can maintain their ability to safely
care for themselves. The nurse should plan for and allow enough time for the client to meet their
own needs when dressing, toileting, and bathing. Pushing the client to dress more quickly,
leaving the client in clothes meant for nighttime, and hiring someone to dress the client will work
against supporting the client's independence and dignity.
Concepts tested

Question 1042
The nurse is informed by a client that her home pregnancy test was positive. The client asks what
the pregnancy test is looking for. Which response by the nurse is appropriate?
A "The home pregnancy test is looking for the body's release of estrogen."
B "The pregnancy test is looking for the human chorionic gonadotropin hormone."
C "The test is looking for the presence of alpha-fetoprotein."
D "The pregnancy test is looking for an absence of progesterone."

Question Explanation
Correct Answer is B
Rationale: Human chorionic gonadotropin (HCG) is the biologic marker on which pregnancy
tests are based. Reliability is about 98%, but the test does not conclusively confirm pregnancy.
Progesterone is the hormone that maintains pregnancy, and when its levels drop, the woman will
go into labor. Estrogen is at its highest level during pregnancy, however, it is not tested on a
pregnancy test. Alpha-fetoprotein is part of a screening for birth defects.
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Concepts tested

Question 1043
The nurse is teaching a group of clients about glaucoma. Which of the following statements
made by a participant indicates an understanding of glaucoma?
A "I wish I didn't have to stop driving. I don't know how I'll manage."
B "I will take half of the usual dose of my daily antihistamine to maintain my blood pressure."
C "I take extra fiber and drink lots of water to avoid getting constipated."
D "I have to sit at the side of the pool with the grandchildren since I can't swim with this eye
problem."

Question Explanation
Correct Answer is C
Rationale: Any activity that involves straining increases intraocular pressure and should be
avoided in clients with glaucoma. Since antihistamines can increase pressure in the eye, they
should be avoided. Many people with glaucoma do give up driving at night, but most people do
not have to give up driving altogether. Swimming should cause no problems (as long as the
person has not had recent eye surgery), but it might be a good idea to wear goggles when in a
pool.
Concepts tested

Question 1044
The clinic nurse is evaluating an older male client who reports having trouble urinating. After the
client uses the bathroom, which method should the nurse use to check for post-void residual
(PVR)?
A Check for rebound tenderness in the lower abdomen
B Palpate for rounded swelling above the pubic bone
C Scan the bladder using a portable ultrasound scanner
D Insert an intermittent urinary catheter (straight catheterization)

Question Explanation
Correct Answer is C
Rationale: Urinary retention and incomplete bladder emptying can result from urethral
obstruction, as seen in benign prostatic hyperplasia (BPH). The nurse can palpate the area from
the umbilicus towards the symphysis pubis. An empty bladder rests behind the symphysis pubis
and should not be palpable. The nurse can also percuss this area. A urine-filled bladder produces
a dull sound, but a bladder ultrasound is the most effective technique since it will digitally
register bladder volume. Routine catheterization to check for PVR is not recommended.
Abdominal rebound tenderness will not determine urinary retention.
Concepts tested

Question 1045
A 24-year-old female calls the health clinic and informs the nurse that she has missed two
periods while using a 21-day hormone-containing contraceptive. She states that she may have
forgotten to take a pill for a few days in one cycle. What is the most appropriate response by the
nurse?
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A Take the over-the-counter emergency contraceptive levonorgestrel (Plan B)
B Continue taking the pills, take a home pregnancy test, and call the health care provider for
advice about the test results
C Immediately stop taking the birth control pills, and make an appointment to rule out a
pregnancy
D Come to the clinic, and discuss different options for contraception that do not require taking a
daily pill

Question Explanation
Correct Answer is B
Rationale: It's not unusual for women who are taking hormone pills for birth control to have light
periods or no bleeding at all. If a woman skips two periods in a row, regardless if she missed any
pills, she should take a home pregnancy test and call the health care provider (HCP) for advice
about the test results. She should not stop taking the pills and risk a pregnancy unless instructed
to do so by the HCP. Plan B is a type of emergency contraception, also known as the "morning-
after pill," and should be used within 72 hours after unprotected sex; it will not stop the
development of a fetus once someone is already pregnant. Switching to a different form of
contraception is a possibility but only after the woman confirms she is not pregnant.
Concepts tested

Question 1046
The nurse is teaching a parent about the side effects of routine immunizations. Which finding
should be immediately reported to the primary health care provider?
A Fatigue
B Seizure activity
C Localized tenderness
D Irritability

Question Explanation
Correct Answer is B
Rationale: While severe complications are rare, any seizure activity must be immediately
reported; seizures can occur up to 7 days after injection. Other reactions that should be reported
include crying for more than three hours, a temperature over 105°F (40.5°C) following DTaP
immunization, and tender, swollen, reddened areas where the shot was given.
Concepts tested

Question 1047
The nurse is teaching a smoking cessation class and notices that there are two pregnant women in
the group. Which information is a priority for these women?
A Moderate smoking is effective in weight control.
B The placenta serves as a barrier to nicotine.
C Low tar cigarettes are less harmful during pregnancy.
D There is a relationship between smoking and low birth weight.

Question Explanation

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Correct Answer is D
Rationale: Nicotine reduces placental blood flow and may contribute to fetal hypoxia or placenta
previa, which results in the decreased growth potential of the fetus. Nicotine readily crosses the
placenta, and any form of nicotine should be avoided during pregnancy.
Concepts tested

Question 1048
A mother asks the nurse if she should be concerned about her child's tendency to stutter. Which
assessment data would be the most useful in counseling the parent?
A Current family stressors
B Sibling position in family
C Age of the child
D Parental discipline strategies

Question Explanation
Correct Answer is C
Rationale: During the preschool period, children use their rapidly growing vocabulary faster than
they can produce their words. This failure to master sensorimotor integrations results in
stuttering. This dysfluency in speech patterns is a normal characteristic of language development.
Therefore, knowing the child's age is most important in determining if any true dysfunction
might be occurring with stuttering.
Concepts tested

Question 1049
A healthy 18-year-old who is entering college in the fall presents to the clinic for immunizations.
Which immunization(s) does the nurse anticipate the health care provider recommending prior to
college? Select all that apply.
A Human papillomavirus (HPV) vaccine
B Tetanus, Diphtheria, Pertussis vaccine (Tdap)
C Seasonal influenza vaccine
D Meningococcal conjugate vaccine (MCV4)
E Pneumococcal polysaccharide vaccine (PPSV23)
F Shingles vaccine

Question Explanation
Correct Answer is A, B, C, D
Rationale: Adults older than age 50 should get the shingles vaccine. The PPSV23 is given to
adults older than age 65. The pneumococcal vaccine PCV13 is routinely given to
infants/children. An 18-year-old who is going to college should receive the TDAP, MCV4, and
seasonal influenza vaccine. He or she should also receive the HPV vaccine if s/he has not already
received it.
Concepts tested

Question 1050

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During an assessment of a postpartum client, the nurse palpates a firm fundus and observes a
constant trickle of bright red blood from the vagina. The nurse identifies which condition as
the most likely cause of these findings?
A Retained placenta
B Genital lacerations
C Uterine atony
D Clotting disorder

Question Explanation
Correct Answer is B
Rationale: Continuous trickling of blood in the absence of a boggy fundus indicates undetected
genital tract lacerations. The nurse should notify the health care provider, as the client may need
surgical intervention to stop the bleeding. The nurse should begin to weigh peripads to document
blood loss. All other options would present with a boggy fundus due to impeding contractions of
the uterus or it filling with blood.
Concepts tested

Question 1051
The home health nurse is developing a plan of care for a client with osteoarthritis. What should
be the priority goal for this client?
A Exhibit healthy coping mechanisms
B Take medications as prescribed
C Maintain and preserve functional status
D Maintain a healthy weight

Question Explanation
Correct Answer is C
Rationale: Osteoarthritis (OA) is the progressive deterioration and loss of cartilage and bone in
one or more joints. The client with OA is expected to maintain or improve a level of
mobility/functional status and activity that allows him or her to function independently with or
without an assistive ambulatory device for as long as possible. Management of the client with
OA often requires an interprofessional health team effort. If needed, the nurse should consult and
collaborate with the physical therapist (PT) and occupational therapist (OT) to meet the outcome
of independent function and mobility. Major interventions include therapeutic exercise and the
promotion of ADLs and ambulation by teaching about health and the use of assistive devices.
Concepts tested

Question 1052
A postpartum mother is unwilling to allow the father to participate in the newborn's care even
though he is interested in doing so. She states, "I am afraid the baby will be confused about who
the mother is. Baby raising is for mothers, not fathers." The nurse's initial intervention should
include which focus?
A Talk with the father and help him accept the wife's decision
B Arrange for the parents to attend infant care classes
C Encourage the mother to express her feelings and concerns

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D Discuss sharing parenting responsibilities with the mother

Question Explanation
Corect Answer is C
Rationale: Encouraging the mother to express her feelings may lead to the resolution of
competitive feelings in a new family. Cultural influences may also be clarified at this time.
Concepts tested

Question 1053
The nurse is beginning nutritional counseling with a pregnant client. Which step should the nurse
take first?
A Question her understanding and use of the food pyramid
B Teach her the risks of pica during pregnancy
C Explain diet changes that are necessary for pregnant women
D Conduct a diet history to determine her normal eating routines

Question Explanation
Correct Answer is D
Rationale: Assessment is always the first step in planning teaching for any client. A thorough and
accurate history is essential for gathering the needed information. The results of this information
provide the basis of the planned educational needs.
Concepts tested

Question 1054
The nurse is providing anticipatory guidance to the parents of a 6-month-old infant. Which
intervention should the nurse recommend to support the development of trust?
A Provide warm blankets to facilitate sleep
B Offer feedings on a strict, set schedule
C Do not allow the child to be held for too long
D Tend to the child quickly when it begins to cry

Question Explanation
Correct Answer is D
Contyrato Rationale: Social and emotional development is based on trust, love, and security. The
best way to develop trust is to consistently and promptly meet the infant's needs. When an infant
cries, it is a way for the infant to communicate a need such as being hungry, wet, in pain, or
scared. By attending to a crying infant quickly, it will help to establish trust. The other
interventions will not help to promote the development of trust in the child.
Concepts tested

Question 1055
A 72-year-old client is admitted for possible dehydration. The nurse knows that older adults are
particularly at risk for dehydration due to which physiologic change?
A A decreased metabolic rate
B A decreased sensation of thirst

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C An increased need for extravascular fluid
D An increase in diaphoresis

Question Explanation
Correct Answer is B
Rationale: Older adults have a reduction in thirst sensation, and this causes them to consume
fewer fluids. Other risk factors may include fear of incontinence, inability to drink fluids
independently, increased frequency to void with increased fluid intake, and lack of motivation.
Concepts tested

Question 1056
A 23-year-old single client in the 33rd week of her first pregnancy tells the nurse that she has
everything ready for the baby and has made plans for the first weeks together at home. Which
normal emotional reaction does the nurse recognize?
A Focus on fetal development
B Ambivalence about pregnancy
C Acceptance of the pregnancy
D Anticipation of the birth

Question Explanation
Correct Answer is D
Rationale: Directing activities toward preparation for the newborn's needs and personal
adjustment are indicators of an appropriate emotional response in the third trimester and a part of
"nesting," according to Rubin. Ambivalence about pregnancy is an expected emotion during the
first trimester. Acceptance of the pregnancy with a focus on fetal development is important in the
second trimester.
Concepts tested

Question 1057
The parent of a 2-year-old child reports to the nurse feelings of frustration and anger due to the
child constantly saying "no" and refusing to follow directions. The nurse should explain that the
child's behavior is an attempt to meet which developmental goal?
A Self-esteem
B Autonomy
C Initiative
D Trust

Question Explanation
Correct Answer is B
Rationale: Developing a sense of autonomy is the goal of development during toddlerhood,
according to Erikson. Several characteristics, especially negativism and ritualism, are typical of
toddlers in their quest for autonomy. As toddlers attempt to express their will, they often act with
negativism, or giving a negative response to requests. The words “no” or “me do” can be the sole
vocabulary. Emotions become strongly expressed, usually in rapid mood swings. Understanding
and coping with these swift changes are often difficult for parents. Many parents find the

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negativism exasperating and, instead of dealing constructively with it, give in to it, which further
threatens the child's search for acceptable methods of interacting with others.
Concepts tested

Question 1058
The nurse is planning to give a 3-year-old child oral digoxin. Which action is the best approach
by the nurse?
A "You will feel better if you take your medicine."
B "Do you want to take this pretty red medicine?"
C "Would you like to take your medicine from a spoon or a cup?"
D "This is your medicine, and you must take it all right now."

Question Explanation
Correct Answer is C
Rationale: At 3 years of age, a child often feels a loss of control when hospitalized. Giving a
choice about how to take the medicine allows the child to express an opinion and have some
control.
Concepts tested

Question 1059
The parent of a 2-year-old hospitalized child asks the nurse why the child starts screaming every
time the parent gets ready to leave the hospital room. How should the nurse respond?
A "At this age, this is a normal response to the fear of being separated from you."
B "Don't worry; that behavior will stop in a few days with patience from you."
C "I think it would be best not to stay with the child while in the hospital."
D "You might want to "sneak out" of the room once the child falls asleep."

Question Explanation
Correct Answer is A
Rationale: The protest phase of separation anxiety is a normal response for a child this age. In
toddlers ages 1 to 3, separation anxiety is at its peak. After three years of age, it begins to
diminish until the adolescent years when the behavior is minimal. In addition, the stress of being
hospitalized is most likely adding to the child's separation anxiety. The other responses are
incorrect and nontherapeutic.
Concepts tested

Question 1060
The nurse is caring for a client who has active tuberculosis and a history of noncompliance.
Which action by the nurse would represent appropriate care for this client?
A Ask the health care provider to change the regimen to fewer medications
B Ask a family member to supervise daily compliance
C Instruct the client to wear a high efficiency particulate air mask in public places
D Schedule weekly clinic visits for the client

Question Explanation

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Correct Answer is B
Rationale: Direct-observed therapy (DOT) is a recognized method for ensuring clients'
compliance with drug regimens. A program can be set up to directly observe the client taking the
medication in the clinic, home, workplace, or other convenient location.
Concepts tested

Question 1061
The nurse is assessing the growth and development of a 9-year-old child. Which finding
indicates that the child has attained the development stage of concrete operations, according to
Piaget?
A The child thinks in mental images or word pictures.
B The child reasons that homework is time-consuming but necessary.
C The child explores the environment with the use of sight and movement.
D The child verbalizes understanding that stealing is wrong.

Question Explanation
Correct Answer is D
Rationale: According to Piaget's theory of cognitive development in children, the stage of
concrete operations is characterized by logical thinking and moral judgments. This stage is
associated with school-aged children from about age 7 to 11. Exploring the environment is seen
in the sensorimotor stage (birth to 24 months). Mental symbolization is seen in the
preoperational stage (2 to 4 years). Formal operational thought is seen with adolescents, who
might reason that homework is time-consuming but necessary.
Concepts tested

Question 1062
The parents of a child recovering from varicella would like the child to return to school as soon
as possible. Which finding would support the nurse's assessment that the child is no longer
contagious?
A Presence of vesicles
B Elevated temperature
C All lesions crusted
D Rhinorrhea

Question Explanation
Correct Answer is C
Rationale: Chickenpox, or varicella, consists of a rash that begins with macules which then
progresses to vesicles that break open and, finally, crust over. When all lesions are crusted, the
child is generally considered to no longer be contagious or in a communicable stage. The other
findings would indicate that the child is most likely still contagious.
Concepts tested

Question 1063
The nurse is performing a physical assessment on a toddler. Which approach should the
nurse initially take when assessing toddlers?

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A Perform traumatic procedures first
B Use minimal physical contact initially in the exam
C Explain the exam in detail as areas are examined
D Proceed from head to toe in a sequential manner

Question Explanation
Correct Answer is B
Rationale: The nurse should approach a toddler slowly and use minimal physical contact initially
so as to gain the toddler's cooperation. Other approaches with this age group are to be flexible in
the sequence of the exam and give only brief simple explanations just prior to any action.
Concepts tested

Question 1064
The nurse on a pediatric oncology unit is developing a plan of care for an 8-year-old child
admitted for chemotherapy. Which intervention should the nurse include to meet the child's
developmental needs, according to Erikson's theory?
A Provide frequent reassurance and hugs to build trust
B Encourage the child to engage in activities while in the playroom
C Talk with the child about any concerns with their body image
D Request for the child's parents to stay overnight

Question Explanation
Correct Answer B
Rationale: According to Erikson, school-age children are in the stage of industry versus
inferiority. To help them achieve industry, the nurse should encourage this group of children to
carry out tasks and activities in their rooms or while in the playroom. The other interventions are
more appropriate for different developmental stages.
Concepts tested

Question 1065
<template>
A <template> Correct Answer
B <template>
C <template>
D <template>

Question Explanation
Correct Answer is A
Concepts tested

Question 1066
When teaching new parents prevention of sudden infant death syndrome (SIDS) what is the most
important practice a nurse should instruct them to do?
A Do not allow anyone to smoke in the home
B Place the infant in a supine position for sleep

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C Follow recommended immunization schedule
D Obtain a home monitor system to hear the sounds from the infant

Question Explanation
Correct Answer is B
Rationale: Research suggests that the cases of SIDS is reduced when newborns sleep on their
back. The theory behind SIDS is that the infant becomes hypoxic when they sleep due to
positional narrowing of the airway plus respiratory inflammation. Exposure to second-hand
smoke is a cause of SIDS and it is important that no one smokes in the home--the evidence
shows that the "back to sleep" campaign has drastically reduced the incidence of SIDS. There is
no association between immunizations and SIDS.
Concepts tested

Question 1067
A nurse in a well-child clinic examines many children on a daily basis. Which of these toddlers
requires further follow-up?
A A 20 month-old only using 2 and 3 word sentences
B A 13 month-old unable to walk
C A 24 month-old who cries during examination
D A 30 month-old only drinking from a sippy cup

Question Explanation
Correct Answer is D
Rationale: The toddler should be able to drink from an open cup between 16 and 17 months,
thus should not be drinking only from a sippy cup. It is not unusual for toddlers to cry during
exams. The toddler is usually walking by 18 months old. The toddler will have the language
development for 2 to 3 word sentences by age 2.
Concepts tested

Question 1068
A nurse is monitoring the contractions of a woman in labor. A contraction is recorded as
beginning at 10:00 am and ending at 10:01 am. Another begins at 10:15 am. A third contraction
begins at 10:30 am. What is the frequency of the contractions?
A 14 minutes
B 10 minutes
C 9 minutes
D 15 minutes

Question Explanation
Correct Answer is D
Rationale: Frequency is the time from the beginning of one contraction to the beginning of the
next contraction.

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Concepts tested

Question 1069
A nurse is teaching a group of college students about breast self-examination when a student
asks for the best time to perform the monthly self-exam. What is the best reply by the nurse?
A "Ovulation, or mid-cycle is the best time to detect changes."
B "Right after the period ends, when your breasts are less tender."
C "The first of every month, because it is easiest to remember."
D "Do the exam at the same day and time every month."

Question Explanation
Correct Answer is B
Rationale: The best time for a breast self-exam (BSE) is one week or seven days after the first
day of a menstrual cycle. This is when the breasts are no longer swollen or tender from hormonal
elevation.
Concepts tested

Question 1070
Two hours after the normal spontaneous vaginal delivery of a woman who is gravida 4 para 4,
the nurse notes that the fundus is boggy and displaced slightly above and to the left of the
umbilicus. What should be the initial nursing action?
A Call the health care provider (HCP) immediately.
B Ask the client to empty the bladder.
C Monitor pulse and blood pressure.
D Assess lochia for color and amount.

Question Explanation
Correct Answer is B
Rationale: A full bladder can displace the uterus and prevent contraction. After the woman
empties the bladder, the fundus should be assessed again. Assessing lochia is part of routine care
after delivery unless there is a copious amount there should not be a change in the vital signs of
the client. It is not necessary to notify the HCP at this time.
Concepts tested

Question 1071
The nurse is organizing play for a small group of hospitalized children. Which playroom activity
is appropriate for a group of 7-year-old children?
A Finger paints and water play
B Board games with rules
C "Dress-up" clothes and props
D Chess and television programs

Question Explanation
Correct Answer is B

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Rationale: The purpose of play for the 7-year-old is the development of cooperation through
team play or joining groups such as the Boy Scouts or Girl Scouts. Rules are a focus in this age
group. Logical reasoning and social skills are developed through play. Finger paints and water
play are appropriate for 3-year-old children. Dress up clothes and props are appropriate for 4 and
5-year-old children. While playing chess may be appropriate for 7-year-old children, Chess is
played with just 2 players and not a group. Television programs are not appropriate for this type
of activity.
Concepts tested

Question 1072
The nurse is discharging a 6-year-old child diagnosed with recurrent urinary tract infections
(UTIs). Which of the following is the most appropriate instruction to give the caregiver?
A Use plain water for the bath and shampoo the hair last.
B When laundering clothing, rinse several times.
C Have the child use antibacterial soaps while bathing.
D Increase bladder tone by delaying voiding.

Question Explanation
Correct Answer is A
Rationale: Management of urinary tract infections includes hygiene practices. This includes
using plain water for the bath and to shampoo the hair last, and rinse the genital area with plain
water after shampoo is rinsed from the hair. The child should not delay voiding as this could
promote UTIs. It is not necessary to rinse the laundry several times or use antibacterial soaps.
Concepts tested

Question 1073
The parents of a child who has suddenly been hospitalized for an acute illness state that they
should have taken the child to the pediatrician earlier. Which approach should the nurse use
when responding to the parents' comments?
A Explain the cause of the child's illness.
B Allow parents to express their feelings without judgment.
C Focus on the child's needs and recovery.
D Acknowledge that early care would have been better.

Question Explanation
Correct Answer is B
Rationale: Parents often blame themselves for their child's illness. Feeling helpless and angry is
normal and these feelings must be accepted. The nurse should not judge the parents in this
situation and make them feel as though they should have brought the child in earlier. As part of
the teaching, the nurse will explain the child's illness and needs, however it is not appropriate at
this time.
Concepts tested

Question 1074

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The nurse is monitoring oxygen saturation levels of preterm infants in the neonatal intensive care
unit (NICU). Which of the following complications of oxygen therapy in preterm infants is the
most common?
A Necrotizing enterocolitis
B Retinopathy of prematurity (ROP)
C Bronchopulmonary dysplasia (BPD)
D Hyperbilirubinemia

Question Explanation
Correct Answer is B
Rationale: In addition to birth weight and how early the infant is born, many factors contribute
to the risk of ROP. But prolonged exposure to high concentrations of oxygen will cause
irreversible damage to the eyes of preterm infants. Severe ROP is significantly reduced by
keeping SpO2 levels stable and within narrow target ranges. BPD develops as a result of an
infant's lungs becoming irritated or inflamed by mechanical ventilation, high levels of oxygen,
infections, as well as heredity. Necrotizing enterocolitis and hyperbilirubinemia are problems
associated with prematurity, but not oxygen therapy.
Concepts tested

Question 1075
The nurse is evaluating the growth of a 12-month-old child. Which finding would the nurse
expect to be present in the child?
A Two deciduous teeth
B Head is greater than the chest circumference
C Increased 10% in height
D Tripled the birth weight

Question Explanation
Correct Answer is D
Rationale: The birth weight usually triples by the end of the first year of life. Height usually
increases by 50% from birth length. A 12-month-old child should have approximately six teeth;
estimate the number of teeth by subtracting 6 from the age in months (12 - 6 = 6). By 12 months
of age, head and chest circumferences are approximately equal.
Concepts tested

Question 1076
While obtaining the history of a 2-week-old infant during the well-baby exam, the nurse finds
that the neonatal screening for phenylketonuria (PKU) was done when the infant was less than
24-hours-old. What is the priority nursing action?
A Schedule the infant for a repeat test in two weeks.
B Obtain a repeat blood test at this point.
C Document that the test results are pending.
D Contact the hospital of birth for the results.

Question Explanation

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Correct Answer is B
Rationale: Testing for PKU is most reliable when protein has been ingested. A repeat blood
specimen must be obtained by the third week of life if the initial specimen was taken from an
infant less than 24 hours-old. It is not appropriate to document the results are pending as the
specimen was collected when the newborn was less than 24 hours old. It is not necessary to call
the hospital for this same reason.
Concepts tested

Question 1077
A nurse has been teaching an apprehensive primipara who has had initial difficulty in nursing the
newborn. What observation at the time of discharge suggests that initial breast-feeding teaching
has been effective?
A The newborn refuses the supplemental bottle of glucose water.
B The mother feels calmer and talks to the baby while nursing.
C The mother awakens the newborn to feed whenever it falls asleep.
D The newborn falls asleep after three minutes at the breast.

Question Explanation
Correct Answer is B
Rationale: Early evaluation of successful breast-feeding can be measured by the client's voiced
confidence and satisfaction with the neonate. Refusing supplemental glucose water does not
indicate successful breastfeeding. Falling asleep within a few minutes of latching, the infant is
likely not getting enough milk.
Concepts tested

Question 1078
The nurse is assessing a client who states her last menstrual period was March 16, and she has
missed one period. The client reports episodes of nausea and vomiting. Pregnancy is confirmed
by a urine test. What should the nurse calculate as the estimated date of delivery (EDD)?
A April 8
B January 15
C February 11
D December 23

Question Explanation
Correct Answer is D
Rationale: Naegele's rule states: Add seven days and subtract three months from the first day of
the last regular menstrual period to calculate the estimated date of delivery.
Concepts tested

Question 1079
The nurse provides instructions to a new mother on the proper techniques for breastfeeding her
infant. Which statement by the mother indicates a need for additional instruction?
A "The baby should latch onto the nipple and areola areas."

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B "There may be times that I will need to manually express milk."
C "I should position my baby completely facing me with my baby's mouth in front of my
nipple."
D "I can switch to a bottle if I need to take a break from breast-feeding."

Question Explanation
Correct Answer is D
Rationale: Babies adapt more quickly to the breast when they are not confused about what is put
into their mouths and its purpose. Artificial nipples do not lengthen and compress the way the
human nipples (areola) do. The use of an artificial nipple weakens the baby's suck as the baby
decreases the sucking pressure to slow fluid flow. Babies should not be given a bottle during the
learning stage of breastfeeding.
Concepts tested

Question 1080
A parent asks the school nurse how to eliminate lice from a child's head. Which statement is the
appropriate response by the nurse?
A Apply a pediculicide as directed
B Wash the child's linen and clothing in a bleach solution
C Cut the child's hair short to remove the nits
D Apply warm soaks to the head twice daily

Question Explanation
Correct Answer is A
Rationale: Treatment of head lice usually consists of an application of a pediculicide. Parents
should be sure to follow the product directions. It is important that parents understand that no
product is 100% ovicidal and, consequently, some nits will survive. Parents will need to use a nit
comb to remove any surviving nits that cling to the hair shaft. In order to avoid reinfestation, bed
linens must be washed in hot water and dried in the dryer; toys and objects that cannot be washed
should be bagged.
Concepts tested

Question 1081
During the two-month well-baby visit, the mother explains that formula seems to stick to her
baby's mouth and tongue. Which assessment would provide the most valuable data for a nurse?
A Inspect the baby's mouth and throat
B Flush both sides of the mouth with normal saline
C Obtain cultures of the mucous membranes
D Use a soft cloth to attempt to remove the patches

Question Explanation
Correct Answer is D
Rationale: Candidiasis can be distinguished from coagulated milk when attempts to remove the
patches with a soft cloth are unsuccessful or trigger bleeding of the tongue under the white
substance.

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Concepts tested

Question 1082
The nurse is planning care for a 2-year-old hospitalized child. Which issue will produce
the most stress at this age?
A Separation anxiety
B Loss of control
C Bodily injury
D Fear of pain

Question Explanation
Correct Answer is A
Rationale: Toddlers experience separation from their parents as a major stressor. Separation
anxiety peaks in the toddler years and will produce the most stress at this age.
Concepts tested

Question 1083
A nurse is teaching a group of adults about modifiable risk factors for cardiovascular disease.
Which risk factor is most important to include?
A Physical exercise
B Weight reduction
C Smoking cessation
D Stress management

Question Explanation
Correct Answer is C
Rationale: Smoking cessation is a priority for clients at risk for cardiac disease. Smoking's
effects result in reduction of cell oxygenation and constriction of the blood vessels. All of the
other factors should be addressed at some point in time, but the priority modifiable cardiac risk
factor is smoking.
Concepts tested

Question 1084
The nurse working at a community health clinic is screening clients for risk factors of
hypertension. Which client is at highest risk for developing hypertension?
A A 60-year-old Asian American male.
B A 65-year-old African American male.
C A 40-year-old Caucasian female.
D A 55-year-old Hispanic female.

Question Explanation
Correct Answer is B
Rationale: The incidence of hypertension (HTN) is greater among African Americans than other
groups in the United States. Males have higher rates of HTN than females. Increased age also

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increases the risk for developing HTN. Therefore, the client with all of these risk factors is
at highest risk for developing hypertension.
Concepts tested

Question 1085
The community health nurse is planning a teaching session for a family with children about
safety and risk-reduction in their home. What information is most important to obtain prior to the
session to ensure the teaching is effective?
A The ages of the children in the home.
B The ages and occupations of the parents.
C The physical layout of the home.
D The number of children in the home.

Question Explanation
Correct Answer is A
Rationale: Although all of the information is important for the nurse to consider, the ages and
developmental levels of the children are the most important considerations for anticipatory
guidance associated with safety, and should be given priority when developing a teaching plan.
With this information, the nurse can individualize the teaching session to meet the specific needs
and risks of the children in the home.
Concepts tested

Question 1086
A parent asks about expected motor skill development for their 3-year-old child. Which activity
is considered a typical motor skill for that age?
A Riding a tricycle
B Jumping rope
C Tying shoelaces
D Playing hopscotch

Question Explanation
Correct Answer is A
Rationale: 3-year-old children are developing gross motor skills that require large muscle
movement. While there will always be some variation between children, movement milestones
typically include peddling a tricycle, standing on one foot for a few seconds, walking backwards
and jumping with both feet. The other activities listed require more coordination and fine motor
skills that are more typical for older children.
Concepts tested

Question 1087
The nurse is caring for a primigravida client who is in active labor. Which assessment finding
may be an early indication that the client is developing a complication of the labor process?
A The mother's blood pressure is 138/88 mmHg.
B The mother's temperature is 100° F (37.7° C).
C The cervical dilation is measuring 4 cm.

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D The fetal heart rate has been around 180 bpm for several minutes.

Question Explanation
Correct Answer is D
Rationale: The finding that indicates a possible complication of the labor process is the fetal
heart rate of 180 bpm for several minutes. The normal fetal heart rate is typically somewhere
between 120 and 160 bpm. Although the heart rate will fluctuate during labor and between
contractions, prolonged fetal tachycardia can be an early sign of hypoxia.
Concepts tested

Question 1088
A nurse in an obstetrics clinic is taking a health history from a 40-year-old woman in the first
trimester of pregnancy. Which information from the health history requires priority follow-up
from the nurse?
A She has been taking an ACE inhibitor for her blood pressure for the past 2 years.
B Her partner was treated for tuberculosis as a child.
C Her father and brother have type 1 diabetes.
D She has been taking 800 mcg of folic acid daily for the past year.

Question Explanation
Correct Answer is A
Rationale: A report by the client that she has been taking medications in the first trimester of
pregnancy should be the priority to follow-up on. ACE inhibitors are pregnancy category X, as
they may cause teratogenic effects on the developing fetus and increase the risk of birth defects.
The nurse should notify the primary health care provider (HCP) of this pertinent information.
Folic acid is recommended to take during pregnancy to aid in fetal neurological development.
While the family history of diabetes and tuberculosis are important to note, the priority is the
ACE inhibitor that the client is taking because it may be affecting fetal development.
Concepts tested

Question 1089
The nurse is talking on the phone with the parent of a 4-year-old child. The child was recently
diagnosed with varicella. Which statement by the nurse demonstrates appropriate teaching?
A "Papules, vesicles and crusts will be present at the same time."
B "The illness is only contagious when the lesions are present."
C "Chewable aspirin is the preferred analgesic for pain."
D "I recommend using an antiviral medication to relieve itching."

Question Explanation
Correct Answer is A
Rationale: It is appropriate to teach the parent to expect the different types of varicella
(chickenpox) lesions that will be present on the child's body at the same time. Children should
not be medicated with aspirin due to the possibility of developing Reye syndrome. A person with
chickenpox is contagious for 1 to 2 days before skin lesions appear and remain contagious until
all of the lesions have crusted over. Antiviral medications would not relieve itchy skin.

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Concepts tested

Question 1090
The nurse is using the new Ballard score to perform an assessment to determine the gestational
age of a newborn infant. The total score can range from -10 to 50. The infant's score is near 50.
What is a reasonable interpretation of this result?
A The baby experienced distress during labor.
B The baby is post-term.
C The baby is premature.
D The baby is small for gestational age.

Question Explanation
Correct Answer is B
Rationale: Birth weight and gestational age are important indicators of a newborn's health and
are used to identify any potential problems. A full-term pregnancy is usually 40 weeks. It's
important to assess when gestational age is uncertain or the infant is smaller or larger than
expected. The New Ballard scale can help differentiate, for example, between a small for
gestational age baby and one that is premature. The New Ballard scoring system adds up the
individual scores for 6 external physical assessments and 6 neuromuscular assessments. The total
score may range from -10 to 50. Premature babies have lower scores. Higher scores correlate
with post-term maturity. Fetal distress during labor tends to result in lower scores.
Concepts tested

Question 1091
A nurse is assessing the health status of several clients at a community health event. The nurse
should conduct a mental status examination on which clients?
A Clients who report memory lapses.
B Clients who display restlessness.
C All clients participating in the event.
D Clients with obvious signs of depression.

Question Explanation
Correct Answer is C
Rationale: A mental status assessment is a critical part of baseline information and should be a
part of every screening. This assessment serves as a screening tool for the nurse to assess for
mental status abnormalities. The tool evaluates the client's behavioral and cognitive functioning.
Concepts tested

Question 1092
A newborn baby that was delivered at home without a birth attendant is admitted to the hospital
for observation. The baby's initial temperature is 95° F (35° C). The nurse should recognize that
the newborn is at risk for which complication?
A Lowered basal metabolic rate
B Hypoxemia
C Hyperglycemia

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D Metabolic alkalosis

Question Explanation
Correct Answer is B
Rationale: This newborn has hypothermia and it at risk for cold stress. This can cause a variety
of physiologic stresses including increased oxygen consumption and reduced partial pressure of
oxygen in arterial blood or PaO2, i.e., hypoxemia. In this situation, the newborn must be warmed
immediately to increase its temperature to at least 97°F (36°C). Normal core body temperature
for newborns is 97.7° F-99.3° F (36.5° C-37.3° C)
Concepts tested

Question 1093
The nurse is teaching a community class about human immunodeficiency virus (HIV)
prevention. Which behavior increases the risk for HIV infection?
A Social contact with a person who has AIDS.
B Engaging in unprotected sexual encounters.
C Donation of blood to a local blood bank.
D Use of public bathroom facilities.

Question Explanation
Correct Answer is B
Rationale: Because human immunodeficiency (HIV) is spread through exposure to blood and
bodily fluids, unprotected intercourse and shared drug paraphernalia such as needles remain the
highest risks for acquiring HIV. The other activities are not at-risk behaviors for HIV.
Concepts tested

Question 1094
The home health nurse is planning a care conference for the family of a 2-year-old child with
cerebral palsy. Which goal should the nurse suggest to the family?
A Promote the child's optimal development.
B Prepare the child for independent toileting.
C Decide on a long-term care facility.
D Teach the child self-care skills.

Question Explanation
Correct Answer is A
Rationale: The primary goal of nursing care for the child is to promote the child's optimal
development. The child should be supported and encouraged to learn and grow to their fullest
potential. Self-care and toileting may not be appropriate goals for the child due to the cerebral
palsy. It is premature to discuss if the child should be placed in a long-term care facility.
Concepts tested

Question 1095
A pregnant client at 34 weeks gestation is diagnosed with a pulmonary embolism. Which of
these medications should the nurse plan to administer?

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A Oral warfarin
B Oral low-dose aspirin
C Subcutaneous enoxaparin
D Intravenous heparin

Question Explanation
Correct Answer is D
Rationale: Clients diagnosed with pulmonary embolism (PE), whether pregnant or not, are
initially treated with intravenous unfractionated heparin. Alternatively, low molecular weight
heparin such as enoxaparin can be used to treat women who are pregnant. Warfarin should never
be given during pregnancy due to its teratogenic effects. Although aspirin has anticoagulant
properties, low-dose aspirin therapy (81 mg) is more often used prophylactically, not for the
treatment of a PE.
Concepts tested

Question 1096
The nurse is teaching a group of adolescents about sexually-transmitted infections. Which should
the nurse emphasize as the most common sexually-transmitted infection?
A Herpes
B Human immunodeficiency virus (HIV)
C Gonorrhea
D Chlamydia

Question Explanation
Correct Answer is D
Rationale: Chlamydia is the most frequently reported bacterial sexually-transmitted infection in
the United States. This infection has subtle symptoms so an infected person is less likely to seek
medical attention and more likely to unknowingly infect others. Prevention is similar to safe sex
practices taught to prevent any sexually-transmitted infection including abstinence and the use of
condoms during intercourse.
Concepts tested

Question 1097
The parent of a 4-month-old infant asks the nurse about how to protect the child from sunburn.
Which of these statements is the best advice about sun protection for infants?
A "Dress the infant in lightweight long pants, long-sleeved shirts and brimmed hats."
B "Liberally apply a sunscreen with the minimum sun protective factor of 15 all over the child's
body."
C "You should keep the baby inside unless it's cloudy outside."
D "Sunscreen should not be used on children."

Question Explanation
Correct Answer is A

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Rationale: Infants under 6 months of age should be kept out of the sun or shielded from it. Even
on a cloudy day, the infant can be sunburned. A hat and light protective clothing should be worn.
Sunscreen is not generally recommended for infants under the age of 6 months; however, the
American Academy of Pediatrics states that it can be applied to small areas of the baby's skin
that are exposed to the sun (such as the baby's face or the back of the hands).
Concepts tested

Question 1098
An 18-month-old child is awaiting a renal transplant. When reviewing the child's health history,
the nurse notes that the child has not had the first measles, mumps, rubella (MMR)
immunization. Which action should the nurse take?
A An inactivated form of the vaccine can be given at any time.
B Live vaccines are withheld in children with renal chronic illness.
C The risk of the vaccine's side effects are too great and it should not be given.
D The vaccine should be given now, before the transplant.

Question Explanation
Correct Answer is D
Rationale: The measles, mumps and rubella (MMR) vaccine is a live virus vaccine, and should
be given at this time, pre-transplant. Post-transplant, immunosuppressive drugs will be given and
the administration of the live vaccine at that time would be contraindicated because of the child's
compromised immune system.
Concepts tested

Question 1099
The nurse is reviewing the lab results of a full term, 30-hour-old newborn infant. The nurse
knows that the first-time mother is Rh negative. Which of these findings is the priority to report
to the health care provider?
A Hematocrit of 52%
B Apgar score of 8 at birth
C Jaundice is observed
D Serum bilirubin of 11 mg/dL

Question Explanation
Correct Answer is D
Rationale: Jaundice is a common condition in newborns. But for a full-term infant who is 30
hours-old, a total serum bilirubin level of 11 mg/dL is high, indicating the possibility of
hemolysis due to Rh incompatibility. The concern about hyperbilirubinemia is increased because
the mother is Rh negative. Therefore, that finding is the priority finding to report to the health
care provider. The other findings are either normal (hematocrit) or not as important at this time.
Concepts tested

Question 1100
A community health nurse is teaching a new parent group about primary prevention of lead
poisoning in children. Which intervention should the nurse include?
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A Request chelation therapy from the child's pediatrician.
B Monitor the child for developmental delays.
C Boil tap water for 10 minutes prior to adding to formula or food.
D Use bottled water to add to any formula concentrate or powder.

Question Explanation
Correct Answer is D
Rationale: Lead exposure to children can result from multiple sources and can cause irreversible
and life-long health effects. No safe blood lead level in children has been identified. Even low
levels of lead in blood have been shown to affect IQ, ability to pay attention and academic
achievement. Lead-contaminated water continues to pose a risk for many communities in the
United States. Drinking water may become contaminated by lead from old lead pipes or the lead
solder used in sealing the water pipes in older communities, building and homes. To reduce the
risk of lead poisoning in infants in communities at risk for lead-contaminated water, a
preventative intervention is to use bottled water to prepare formula from concentrate or powder.
Boiling water will kill bacteria in water but does not remove the lead. Developmental delays are
an outcome of lead poisoning, not a preventative measure. Chelation therapy is a treatment
option for children diagnosed with high serum levels of lead; it is not a preventative treatment.
Concepts tested

Question 1101
The nurse is assessing a 1-day-old newborn infant. The nurse notices that the infant's breasts are
enlarged bilaterally with a thin, white discharge. Which action by the nurse is appropriate?
A Obtain a specimen of the fluid to check for glucose.
B Record the findings, noting they are normal.
C Notify the health care provider immediately.
D Ask the mother about medications taken during pregnancy.

Question Explanation
Correct Answer is B
Newborn infants of both sexes may have engorged breasts and may secrete milk during the first
few days to weeks after birth. This is a result of circulating maternal hormones after birth. This
typically resolves on its own in the first few weeks after birth.
Concepts tested

Question 1102
The nurse has been caring for the same client for 5 days. The client has been exhibiting
manipulative behaviors. The nurse becomes aware of feeling reluctant to interact and care for the
client. Which action should the nurse take?
A Talk with the client about the negative effects of their manipulative behaviors.
B Report the feelings of reluctance to an objective peer or supervisor.
C Develop a behavior modification plan for the client.
D Limit contact with the client to avoid reinforcement of the behaviors.

Question Explanation

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Correct Answer is B
Rationale: The nurse who experiences stress in a professional relationship with a client can gain
objectivity through discussion with other professionals. The nurse may wish to have a peer
observe the nurse-client interactions with this client for a shift and then have a debriefing of
reactions that can influence the nurse-client relationship in positive and negative ways.
Concepts tested

Question 1103
The nurse is caring for a woman in active labor. An internal fetal heart rate monitoring wire is in
place. Which fetal heart rate pattern indicates a possible complication of labor?
A Early decelerations
B Variable decelerations
C Periodic accelerations
D Late accelerations

Question Explanation
Correct Answer is B
Rationale: A deceleration in fetal heart rate (FHR) may be benign or
abnormal. Variable decelerations in FHR are often indicative of an interruption in the fetal
oxygen supply due to umbilical cord compression. This is a complication that should be reported
to the health care provider immediately.
Concepts tested

Question 1104
The nurse at a hypertension clinic has been teaching adult clients about modifiable risk factors.
Which client response would best indicate that the teaching was effective?
A Responses to verbal questions
B Reported behavioral changes
C Performance on written tests
D Completion of a mailed survey

Question Explanation
Correct Answer is B
Rationale: If the clients alter behaviors such as smoking, drinking alcohol and stress
management, these changes suggest that learning has occurred. Additionally, physical
assessments, observed behaviors and laboratory data (e.g., blood tests) may confirm risk
reduction.
Concepts tested

Question 1105
The parents of a 7-year-old child tell the nurse that their child has started to "tattle" on siblings.
In interpreting this new behavior, how should the nurse explain the child's actions to the parents?
A Insecurity and attention-getting are common motives.
B Attempts to control the family using new coping styles.
C The ethical sense and feelings of justice are developing.

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D Complex thought processes help to resolve conflicts.

Question Explanation
Correct Answer is C
Rationale: The child is developing a sense of justice and a desire to do what is right. At age 7,
children are increasingly aware of family roles and responsibilities. They also do what is right
because of parental direction or to avoid punishment. This age group, 6-12 years of age, is called
the school-aged group.
Concepts tested

Question 1106
The mother of a 2-month-old child calls the nurse at a pediatrician's office two days after the
child received the DTaP, inactivated polio vaccine (IPV), hepatitis B vaccine, and haemophilus
influenzae type B (HIB) immunizations. The mother reports that the baby feels warm, has cried
inconsolably for three hours, and has had several shaking spells. Which immunization would the
nurse expect to be responsible for these findings?
A DTaP
B IPV
C HIB
D Hepatitis B

Question Explanation
Correct Answer is A
Rationale: DTaP immunization is a vaccine that protects against diptheria, tetanus and pertussis
(whooping cough). The majority of reactions described in this question occur with the
administration of the DTaP vaccination. Contraindications to giving repeat DTaP immunizations
include the occurrence of severe side effects after a previous dose, as well as signs of
encephalopathy within seven days of the immunization.
Concepts tested

Question 1107
A client asks the nurse about including her 12-year-old son in the care of their newborn sister.
Which response is an appropriate initial statement by the nurse?
A "Focus on your son's needs during the first few days at home."
B "Suggest that your partner spend more time with your son."
C "Ask your son what he would like to do to help with the baby."
D "Tell your son what he can do to help with the baby."

Question Explanation
Correct Answer is C
Rationale: A 12-year-old boy is at the age where he may be interested in assisting his parents
with the care of a newborn sibling, and should be encouraged to do so with supervision. This will
promote bonding between all family members, and the older child will feel included with the
new changes in the family.
Concepts tested

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Question 1108
The community health nurse is reviewing the health records of several groups of children. In
which age group is noncongenital, idiopathic scoliosis most commonly identified?
A Infancy
B Preschool age
C Preadolescence
D Early adulthood

Question Explanation
Correct Answer is C
Rationale: Scoliosis is a common spinal deformity that can involve lateral curvature, spinal
rotation causing rib asymmetry, and thoracic hypokyphosis. Scoliosis is classified according to
age of onset: congenital (present at birth), infantile (birth up to 3 years of age); juvenile (in
children 3 to 10 years of age); and adolescent (occurring at 10 years of age or older). Scoliosis
may be caused by a number of conditions and may occur alone or in association with other
diseases. In most cases, however, there is no apparent cause, hence the name idiopathic scoliosis.
Idiopathic scoliosis is most commonly identified during the preadolescent growth spurt period.
Concepts tested

Question 1109
The nurse is caring for a pregnant woman. She is currently 42 weeks pregnant. The nurse knows
that which factor could result in negative outcomes for the fetus?
A Progressive placental insufficiency
B Low blood sugar levels
C Excessive fetal weight
D Depletion of subcutaneous fat

Question Explanation
Correct Answer is A
Rationale: The placenta functions less efficiently as pregnancy continues beyond 42 weeks.
Immediate and long-term effects may be related to hypoxia. These newborns are typically
meconium stained.
Concepts tested

Question 1110
The nurse in a pediatrician's office is assessing the growth of children during their school-age
years. Which finding is normal for this age group?
A Weight gain of about 4 to 6 lb (2 to 3 kg) per year
B Progressive height increase of 4 inches each year
C Little change in body appearance from year to year
D Decreasing amounts of body fat and muscle mass

Question Explanation
Correct Answer is A

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Rationale: The segment of the life span that extends from age 6 years to approximately age 12
years has a variety of labels, but is most often referred to as school-age or the school years.
Between ages 6 and 12 years, children grow an average of 5 cm (2 inches) per year to gain 30 to
60 cm (1 to 2 feet) in height and will almost double in weight, increasing 2 to 3 kg (4.4 to 6.6 lb)
per year.
Concepts tested

Question 1111
The nurse assesses delayed gross motor development in a 3-year-old child. The inability of the
child to do which action confirms this finding?
A Catch a ball
B Stand on one foot
C Ride a bicycle
D Skip on alternate feet

Question Explanation
Correct Answer is B
Rationale: At this age, gross motor development allows a child to balance on one foot.
Concepts tested

Question 1112
The home health nurse observes the client change an ileostomy pouch? Which action is best to
help prevent skin breakdown?
A Change the stoma pouch daily
B Apply antiseptic cream to reddened stoma
C Use deodorant soaps the contain lotion to clean the stoma
D Make sure the skin around the stoma is wrinkle-free

Question Explanation
Correct Answer is D
Rationale: The ileostomy pouch should be changed approximately every 5 to 7 days; the bag
should be emptied about every 4 to 6 hours. Before applying a pouch, the stoma and skin around
the stoma should be gently cleaned using mild soap and water and allowed to dry. A skin barrier
powder or other skin prep can be applied to intact skin around the stoma - but not to the stoma.
The skin around the stoma should be dry and wrinkle-free before applying a new pouch or wafer
to ensure a tight, leak-free seal.
Concepts tested

Question 1113
A parent asks the nurse about a Guthrie Bacterial Inhibition
test that was ordered for her newborn. Which point(s) should the
nurse discuss with the client prior to the test? Select all that apply.
A This test identifies an inherited disease
B Best results occur after the baby has been breastfeeding or drinking formula for two full days

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C Routine screening of newborn infants is not mandatory in the
United States
D Positive tests require dietary control for prevention of brain damage
E The test will be delayed if the baby's weight is less than 5 pounds (2.27 kg)
F The urine test can be done after six weeks of age

Question Explanation
Correct Answer is A, B, D, E, F
Rationale: Screening for PKU is mandated in all 50 states, though methods of screening vary.
The Guthrie Bacterial Inhibition Assay (BIA) is one test used to diagnose phenylketonuria
(PKU), a disease characterized by an enzyme deficiency. A blood sample is taken from the
baby&#39;s heel shortly after birth, with a follow-up test 7 to
10 days later. Test results are more accurate if the baby weighs more than 5 pounds and has been
regularly drinking milk for more than 24 hours. A urine test is normally done after six weeks of
age if a baby did not have the blood test.
Concepts tested

Question 1114
When assessing vital signs in children, the nurse knows that the apical pulse is preferred until the
radial pulse can be accurately assessed at about what age?
A One year
B Three years
C Two years
D Four years

Question Explanation
Correct Answer is C
Rationale: A child should be at least 2 years old to use the radial pulse to assess heart rate.
Concepts tested

Question 1115
A 52-year-old postmenopausal woman asks the nurse how frequently she should have a
mammogram. How should the nurse respond?
A "Once a woman reaches 50, she should have a mammogram yearly."
B "Yearly mammograms are advised for any women over 35."
C "Unless you had previous problems, every two years is best."
D "Your health care provider will advise you about your risks and the frequency."

Question Explanation
Correct Answer is A
Rationale: The American Cancer Society recommends a screening mammogram by age 40,
every one to two years for women 40 to 49, and every year from age 50 onward. If there are
family or personal health risks, other more frequent and additional assessments may be
recommended.
Concepts tested

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Question 1116
A 4-year-old child asks his parent: "Where do babies come from?" The parent asks the nurse for
guidance on how to most appropriately respond. What is the most appropriate response by the
nurse?
A "Children ask many questions, but are not looking for answers."
B "This question indicates interest in sex beyond this age."
C "Full and detailed answers should be given to any questions."
D "When a child asks a question, give a simple answer."

Question Explanation
Correct Answer is D
Rationale: During discussions related to sexuality, honesty is very important. However, honesty
does not mean imparting every fact of life associated with the question. When children ask one
question, they are looking for one answer. When they are ready, they will ask for more detailed
information.
Concepts tested

Question 1117
The nurse is teaching a group of clients about reducing the risk of skin cancer. Which statement
by the client indicates the need for additional teaching?
A "I wear sunglasses with ultraviolet protective lenses."
B "I found a sunscreen with a sun protective factor of 30."
C "I only tan in the controlled setting of a tanning booth."
D "I make sure to come inside between noon and 2 pm."

Question Explanation
Correct Answer is C
Rationale: Tanning booths and sun lamps are no safer than the natural sun in terms of cellular
damage and potential for developing skin cancer. The other self-help measures have positive
effects on reducing the chance of damage from ultraviolet rays.
Concepts tested

Question 1118
The community health nurse is teaching a group of parents about the negative or oppositional
behavior typically seen during toddlerhood. What would be the best intervention for this
behavior?
A Use patience and a sense of humor to deal with this behavior
B Offer the child a reward such as sweets to stop the behavior
C Assert authority over the child through strict limit setting
D Reprimand the child and give them a 15-minute "time out"

Question Explanation
Correct Answer is A

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Rationale: With anticipatory guidance regarding expected but challenging behaviors and
situations during toddlerhood, parents may need assistance in providing limits that prevent
normal, disruptive behaviors, such as temper tantrums, from becoming problems. Several
characteristics, especially negativism and ritualism, are typical of toddlers in their quest for
autonomy. As toddlers attempt to express their will, they often give a negative response to
requests. The word “no” can be the sole vocabulary. If scolded for doing something wrong, they
can have a temper tantrum and almost instantaneously pull at the parent's legs to be picked up
and comforted. Understanding and coping with these swift emotional changes is often difficult
for parents. Many parents find the negativism very frustrating and tend to give in to it, which
further threatens the child's search for acceptable methods of interacting with others. A less
authoritative or confrontational approach such as using patience and humor tends to work best in
those situations.
Concepts tested

Question 1119
The home health nurse is developing a plan of care for a client to self-manage their chronic
syndrome of inappropriate antidiuretic hormone (SIADH), due to lung cancer. Which
interventions should the nurse include? Select all that apply.
A Obtain a daily weight
B Increase intake of foods high in potassium
C Eliminate foods from the diet that are high in sodium
D Notify your health care provider for persistent headache and vomiting
E Restrict fluids to about 1 liter/day
F Increase fluids to 3 to 4 liters/day

Question Explanation
Correct Answer is A, B, D, E
Rationale: Syndrome of inappropriate antidiuretic hormone (SIADH) results from an
overproduction of ADH or the release of ADH despite normal or low plasma osmolarity. The
most common cause is cancer, especially small cell lung cancer. Interventions will focus on
treating the underlying cause and managing the fluid/circulatory overload and hyponatremia.
Chronic SIADH can be managed at home. Interventions should include daily weights to monitor
changes in fluid balance, a fluid restriction of 800 to 1,000 mL/day, adherence to prescribed
pharmacotherapy including diuretics and vasopressor receptor antagonists such as conivaptan
and tolvaptan, and prevention of electrolyte imbalances (hyponatremia, hypokalemia). A
persistent headache and vomiting can indicate an increased intracranial pressure due to fluid
overload and should be communicated to the health care provider.
Concepts tested

Question 1120
A 16-month-old child has just been admitted to the hospital. As the nurse assigned to this child
enters the hospital room for the first time, the toddler runs to the mother, clings to her and begins
to cry. What should be an initial action by the nurse?
A Discuss the appropriate use of "time-out"
B Explain that this behavior is expected

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C Explain that the child needs extra attention
D Arrange to change client care assignments

Question Explanation
Correct Answer is B
Rationale: During normal development, fear of strangers becomes prominent and begins around
age 6 to 8 months-old. Such behaviors include clinging to parent, crying and turning away from
the stranger. These fears and behaviors extend into the toddler period. In the toddler period,
separation anxiety is at its peak. As the child ages the behavior has a tendency to wane.
Concepts tested

Question 1121
A 15-month-old child presents to the primary care office for follow-up after hospitalization for
Kawasaki disease which involved immunoglobulins. The nurse should recognize that which
scheduled immunizations will be delayed?
A Diptheria, tetanus, pertussis (DTaP)
B Haemophilus Influenzae Type b (Hib)
C Mumps, measles, rubella (MMR)
D Inactivated polio vaccine (IPV)

Question Explanation
Correct Answer is C
Rationale: Medical management of Kawasaki involves administration of immunoglobulins.
Measles, mumps, rubella (MMR) is a live virus vaccine. Following administration of
immunoglobulins, live vaccines should be held due to possible interference with the body's
ability to form antibodies.
Concepts tested

Question 1122
The nurse is assigned to work on an adolescent medical-surgical unit. Which of these client
needs would the nurse expect to observe?
A Privacy, autonomy, peer interactions
B Independence, confidence, narcissism
C School performance, reading, journal writing
D Interest in sports, competition, being right

Question Explanation
Correct Answer is A
Rationale: Adolescents display the need for privacy, autonomy and peer interaction concurrent
with an evolving sense of identity.
Concepts tested

Question 1123
A nurse is caring for a 5-year-old child whose left leg is in skeletal traction. Which activity
would be an appropriate diversional activity?

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A Play hand-held games
B Throw bean bags
C Kick balloons with right leg
D Play "Simon Says"

Question Explanation
Correct Answer is A
Rationale: Immobilization with traction must be maintained until bone ends are in satisfactory
alignment and with adequate regrowth of the bone. Activities that increase mobility interfere
with the goals of treatment.
Concepts tested

Question 1124
The nurse is caring for older adults who live in a long-term care setting. Which activity
would most effectively meet the growth and developmental needs for older adults?
A Transportation for shopping trips
B Reminiscence groups
C Aerobic exercise classes
D Regularly scheduled social activities

Question Explanation
Correct Answer is B
Rationale: According to Erikson's theory, older adults need to find and accept the
meaningfulness of their lives, or they may become depressed, angry and fear death. Reminiscing
contributes to successful adaptation by maintaining self-esteem, reaffirming identity, and
working through loss. Erikson identifies this developmental challenge of the elderly as "ego
integrity versus despair."
Concepts tested

Question 1125
A nurse is preparing to assist a mother with breastfeeding for the first time. Which of the
following is a priority?
A Assist the mother with helping the newborn to latch appropriately
B Give the mother several illustrated pamphlets
C Darken the room and allow for privacy for the initial feeding
D Inform the client that breastfeeding is a skill for both the mother and newborn

Question Explanation
Correct Answer is A
Rationale: Immediate breastfeeding after birth is associated with physiological benefits for the
newborn and mother. While educating about breastfeeding is important, it is essential to ensure
the infant has latched appropriately. Darkening the room may be appropriate for subsequent
feedings, but it is important for the nurse to support the mother and newborn during the initial
feeding.
Concepts tested

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Question 1126
The parent of an 8-month-old infant asks the nurse if the child's language development is
appropriate for this age. Which sounds should the nurse anticipate at this age? Select all that
apply.
A Meaningful words and single vowel sounds such as "ah," "eh," and "uh"
B Squeals and yells to signal happiness or displeasure
C Vocalizes in response to voices
D Babbles in a rhythm similar to spoken language
E Coos, gurgles, and laughs aloud

Question Explanation
Correct Answer is A, B, C, E
Rationale: In the first few weeks of life, crying communicates unmet needs for infants. The
language developmental milestones are coos and other vocalizations and differentiated crying at
1 to 3 months, simple vowel sounds, such as "ah," "eh," and "uh," at 4 to 5 months, squealing
and yelling and imitating speech at 9 to 12 months, and 2 or 3 recognizable words that are
connected to meaning and babbling meaningless sounds in a pattern similar to speech at 12
months.
Concepts tested

Question 1127
The nurse is collecting data from an adolescent client. Which of the following issues should the
nurse address? Select all that apply.
A "How many sexual partners have you had in the past six months?"
B "How are things going at home?"
C "Have you gotten in any trouble lately?"
D "Have you decided what you are going to do after high school?"
E "Where are you currently living?"
F "Are you currently having conflicts with someone close to you?"

Question Explanation
Correct Answer is A, B, E, F
Rationale: Several professional organizations have published guidelines aimed at improving and
maintaining health care for adolescents and young adults. The American Academy of Pediatrics,
American Academy of Family Physicians, American Medical Association, and U.S. Preventive
Services Task Force have similar guidelines for the health promotion of adolescents. These
guidelines emphasize the need to provide health services to adolescents that meet their physical
and emotional needs including physical growth and development, social and academic
indicators, emotional well-being and violence, substance use, and injury prevention. Closed-
ended questions about the client's plans after high school and if they have been in trouble are
non-therapeutic and not appropriate in this situation.
Concepts tested

Question 1128

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The nurse is speaking with the parents of a 5-year-old boy who is diagnosed with hemophilia A.
The parents recently underwent genetic counseling that showed that the mother is a carrier and
the father is unaffected. The parents are asking the nurse what the chances are of having another
child with this genetic disorder. How should the nurse respond?
A "There is a 50% probability that another male child would have this disease."
B "All daughters will be carriers of this disease."
C "There is a 25% probability that daughters will be a carrier of this disease."
D "All of your male children will have this disease."

Question Explanation
Correct Answer is C
Rationale: Hemophilia A is a sex-linked recessive trait seen almost exclusively in males. When
the carrier mother and the unaffected father are pregnant, there are four possible outcomes:

 a 25% (one in four) chance of having a son without hemophilia

 a 25% (one in four) chance of having a son with hemophilia
 a 25% (one in four) chance of having a daughter who is a carrier
 a 25% (one in four) chance of having a daughter who is not a carrier
Concepts tested

Question 1129
The nurse is teaching a group of women in a community clinic about osteoporosis. Which
explanation should the nurse include?
A It is important to increase calcium intake and weight-bearing exercise.
B It is best to avoid foods high in purine, such as bacon, liver, and shellfish.
C Performing regular range-of-motion exercises will help with inflamed joints.
D Ice, rest, and ibuprofen will help with the symptoms of osteoporosis.

Question Explanation
Correct Answer is A
Rationale: Osteoporosis (OP) is a chronic, progressive metabolic bone disease marked by low
bone mass and the deterioration of bone tissue, leading to bone fragility and an increased risk of
fractures. Care focuses on proper nutrition, calcium supplementation, exercise, drugs, and the
prevention of falls. Osteoporosis is often mistaken for osteoarthritis (OA). Ice, rest, NSAIDs, and
range-of-motion exercises are used to treat symptoms of OA and/or rheumatoid arthritis (RA).
Purine-rich foods need to be avoided with gout. Purine-rich foods increase uric acid production,
which worsens the symptoms of gout.
Concepts tested

Question 1130
The nurse is caring for a 4-year-old child. The parents state they must leave the hospital but will
return at 6 pm. After they leave, the child asks when he will be able to see his parents. Which
option is the best response by the nurse?
A "They will be back right after you eat supper."
B "When the clock hands are on the numbers 6 and 12."

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C "In about two hours, you will see them."
D "After you play awhile, they will be here."

Question Explanation
Correct Answer is A
Rationale: Time is not completely understood by preschoolers. Preschoolers interpret time with
their own frame of reference of activities that they have experienced. Thus, it is best to explain
time in relation to a known and common event.
Concepts tested

Question 1131
During the 1-month well-baby checkup, the parents respond to questions about their newborn.
Which of the parents' comments is of greatest concern to the nurse?
A "We notice the baby is fussy and cries a lot."
B "The baby does not sleep for longer than two hours at a time."
C "When the baby spits up, it shoots across the room."

Question Explanation
Correct Answer is C
Rationale: Spit-up that shoots across the room is indicative of projectile vomiting. Projectile
vomiting, chronic hunger, poor weight gain, and distended upper abdomen are the clinical
manifestations of pyloric stenosis. Hypertrophic pyloric stenosis (HPS) occurs when the
circumferential muscle of the pyloric sphincter becomes thickened resulting in elongation and
narrowing of the pyloric canal. This produces an outlet obstruction and compensatory dilation,
hypertrophy, and hyperperistalsis of the stomach. This condition usually develops in the first few
weeks of life, causing nonbilious vomiting, which occurs after feeding. Projectile vomiting may
develop, and the infant is fussy and hungry after vomiting. Infants with HPS have nonbilious
vomiting in the early stages. Vomiting usually begins at 3 weeks of age but can start as early as 1
week and as late as 5 months. Vomiting usually occurs 30-60 minutes after feeding and becomes
projectile as the obstruction progresses. Initially, the infant is hungry and irritable, but prolonged
vomiting may lead to dehydration, weight loss, and failure to thrive. The other comments
indicate normal behavior for a 1-month-old infant.
Concepts tested

Question 1132
The nurse is preparing to assess a 3-year-old using the Denver II Developmental Test. The
child’s mother asks the nurse to explain the purpose of the test. Which statement by the nurse is
correct?
A "It helps to determine the development of motor function."
B "It assesses a child's development in several categories."
C "It measures a child’s intelligence level and compares it to a standard.”
D "It evaluates psychological responses to certain stimuli."

Question Explanation

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Correct Answer is B
Rationale: The Denver II Developmental Test is a screening test to assess children from birth
through six years of age in personal/social, fine motor adaptive, language, and gross motor
development. This screening test determines the highest level of functioning in these areas at the
time of the examination. The screening is quick and inexpensive, but any low scores will need to
be evaluated by more precise exams. The screening does not include psychological responses to
stimuli or intelligence levels. It does not solely test for the development of motor function.
Concepts tested

Question 1133
While caring for a newborn, the nurse notes a high-pitched cry, irritability, and lack of interest in
feeding. The nurse suspects the newborn is experiencing neonatal abstinence syndrome. Which
intervention is most appropriate for this newborn?
A Dim the lights and reduce the noise in the room
B Remove the swaddling blanket from the newborn
C Do not allow the newborn to use a pacifier
D Offer the newborn formula every four hours

Question Explanation
Correct Answer is A
Rationale: A high-pitched cry, irritability, poor feeding, increased respiratory rate, fever,
vomiting, and diarrhea are all clinical manifestations of neonatal abstinence syndrome (NAS).
NAS is a term used to describe the behaviors exhibited by the infant exposed to drugs in utero.
Appropriate treatment of NAS includes reducing environmental stimuli (dimming the lights in
the room, reducing noise in the room, speaking in a soft voice), swaddling, oscillating (vibrating)
cribs, and pacifiers.
Concepts tested

Question 1134
The home health nurse is evaluating the plan of care for a 15-year-old male client with muscular
dystrophy. The client is mostly immobile and unable to care for himself. The client is at risk for
depression due to which issue?
A Lack of trust
B Loss of control
C Insecurity
D Dependence

Question Explanation
Correct Answer is D
Rationale: A 15-year-old adolescent would be in the stage of development identity vs. role
confusion (Erikson). Since this adolescent is dependent on others, it will be difficult for him to
find his own identity. Adolescents may react to dependency with rejection, uncooperativeness, or
withdrawal.
Concepts tested

Question 1135
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The nurse is performing a routine assessment on a six-month-old infant. The child's mother states
that the child weighed 7 pounds 8 ounces at birth. Which would be an appropriate finding for the
weight of the child at this visit?
A Triple the birth weight
B Double the birth weight
C Add two pounds each month
D Gain six ounces each week

Question Explanation
Correct Answer is B
Rationale: Appropriate growth and development of a child is an indicator of adequate nutrition,
good health, and absence of chronic illness. Although growth rates vary, infants normally double
their birth weight by six months. At 12 months, the weight should be triple the birth weight.
Important anthropometric measurements for the pediatric population include height or length,
weight, body mass index (BMI), and head circumference. The head circumference will generally
be measured at every routine health care provider visit until the child is 2-years-old. The
measurements will be recorded on a graph and compared to previous measurements and to
percentiles of their peers. Children falling between the 5th and 95th percentile are considered to
have a normal growth range.
Concepts tested

Question 1136
The nurse is reviewing the written orders for a newly admitted client. The nurse has difficulty
reading the health care provider's handwriting. Which action should the nurse take first?
A Leave the order for the oncoming staff to follow up on
B Ask the pharmacy for assistance in the interpretation
C Contact the charge nurse for an interpretation
D Call the provider for clarification of the order

Question Explanation
Correct Answer is D
Rationale: The nurse should call the health care provider to clarify this order. Relying on another
person's interpretation of the order is risky. It is not appropriate to leave the order for the
oncoming shift to follow up. Order entry systems are minimizing these types of problems.
Concepts tested

Question 1137
The nurse is reviewing the previous assessment findings for a newborn. The nurse notes that the
first APGAR score was 8 and the next score was 9. Which category of the APGAR test is most
likely the reason for the improved score?
A Heart rate
B Cry
C Muscle tone
D Color

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Question Explanation
Correct Answer is D
Rationale: The APGAR test is an assessment used to evaluate and monitor a newborn's physical
condition at 1 minute and 5 minutes after birth. The APGAR test evaluates five categories
including A- appearance (skin color), P- pulse (heart rate), G- grimace (reflex irritability), A-
activity (muscle tone), and R- respiratory (respiratory effort). These categories are rated on a 0 to
2 scale. A score of 0 indicates an absent or poor response and 2 indicates a normal response. A
normal APGAR score ranges from 8 to 10 and no medical intervention is needed other than
supporting respiratory effort and thermoregulation. It is common for the newborn to experience
acrocyanosis. This occurs when the body is pink and the extremities are blue and would be
scored a 1. This is the most common APGAR score deduction.
Concepts tested

Question 1138
The nurse is providing prenatal education to a client who has just found out she is 8 weeks
pregnant. The woman asks how the health care provider (HCP) knew that she was pregnant by
just looking inside her vagina. Which response is the best explanation for this?
A Pronounced softening of the cervix
B Plug of very thick mucus
C Slight rotation of the uterus to the right
D Bluish coloration of the cervix and vaginal walls

Question Explanation
Correct Answer is D
Rationale: Chadwick's signs are a bluish-purple coloration of the cervix and vaginal walls. It
develops at 6 to 8 weeks of gestation and is caused by an increased blood supply to the area.
Other early signs of pregnancy include Hegar's signs (a softening of the cervical isthmus) and
Goodwell's sign (a softening of the cervix). While these are early signs of pregnancy, the HCP
would need to compress and palpate the tissue to assess these findings. The HCP would not see
the mucus plug. The mucus plug dislodges and passes out of the body just prior to labor.
Concepts tested

Question 1139
The nurse is teaching a 10-year-old child prior to heart surgery. Which form of explanation
is best for this client?
A Provide the child with a booklet to read about the surgery
B Provide a verbal explanation just prior to the surgery
C Explain the surgery using a model of the heart
D Introduce the child to another child who had heart surgery three days ago

Question Explanation
Correct Answer is C
Rationale: According to Piaget, the school-age child is in the concrete operations stage of
cognitive development. The use of something concrete, such as a model, will help the child
understand the explanation of the heart surgery. The other options are not appropriate for the
developmental age, or they are not therapeutic methods of teaching children.
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Concepts tested

Question 1140
The nurse is obtaining a health history from a 14-year-old client. Which method is appropriate
for this client?
A Have the mother present to verify the information
B Use the same type of language as with adult clients
C Focus the discussion on behaviors of the peer group
D Allow the client the opportunity to express feelings

Question Explanation
Correct Answer is D
Rationale: Adolescents need to express their feelings during their health history. This should be
encouraged by the nurse. Generally, adolescents will talk freely when provided with privacy and
a nonthreatening environment. Discussing the peer group is important but not the priority. If the
nurse uses the same language as with adult clients, the adolescent may not understand the
questions.
Concepts tested

Question 1141
The nurse in a pediatrician's office is performing an assessment on an 8-month-old infant. Which
finding should be reported to the health care provider?
A Toes fan out when the lateral sole of the foot is stroked
B Falls forward when in a seated position
C Lifts head from the prone position
D Rolls from abdomen to back

Question Explanation
Correct Answer is B
Rationale: The infant should be able to sit unassisted after approximately 6-months-old. The
infant falling forward indicates that this developmental milestone has not been met and should be
reported to the health care provider. The infant rolling and lifting their head are expected
findings. The Babinski reflex is elicited by stroking the lateral sole of the foot from heel to toe.
From birth to approximately 12-months-old, the expected response is fanning out of the toes.
Concepts tested

Question 1142
The nurse reviews an order to administer Rho(D) immune globulin to an Rh-negative woman
after the birth of her Rh-positive newborn. Which assessment is a priority before the nurse gives
the injection?
A Gravida and parity
B Previous RhoGAM history
C Newborn's blood type
D Coombs test results

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Question Explanation
Correct Answer is D
Rationale: Rho(D) immune globulin is given only if antibody formation has not occurred. A
negative Coombs test confirms antibodies have not been formed in the mother. If the Coombs
test is positive, the medication is of no value. Rho(D) immune globulin is recommended for Rh-
negative mothers between 28 and 32 weeks of gestation and within 72 hours after birth. Rh-
negative mothers should receive Rho(D) immune globulin at any time when there is a risk of
blood mixing, including a miscarriage, an abortion, an ectopic pregnancy, or an amniocentesis.
This medication provides temporary (approximately 12 weeks) passive immunity and will need
to be repeated during subsequent pregnancies. It is important to note that Rho(D) immune
globulin is considered a blood product. Clients should provide consent and be educated about the
effects of this medication. The administration of blood products is not accepted by some cultures
and religions. The nurse should accept the client's decision regarding this medication.
Concepts tested

Question 1143
The nurse is caring for a nullipara client who, at 12-weeks gestation, is beginning prenatal care.
The client has just learned she is positive for human immunodeficiency virus (HIV). Which of
the following statements by the nurse is important for the client to understand regarding infection
prevention for her baby?
A "Breastfeeding is recommended because the health benefits outweigh the risks of HIV
transmission"
B "Pregnancy is known to accelerate the course of your illness."
C "Medication for HIV will be started immediately after birth for both you and your baby."
D "A cesarean section will be scheduled before your membranes rupture."

Question Explanation
Correct Answer is D
Rationale: According to research, administration of antiviral medications during pregnancy, a
cesarean birth before membranes rupture, and exclusive formula feeding have significantly
reduced the incidence of perinatal transmission of HIV from mother to child. The nurse should
work to encourage the mother to engage with her prenatal care and educate her about the benefits
of medication for HIV during pregnancy and cesarean delivery. Pregnancy is not known to
accelerate HIV.
Concepts tested

Question 1144
A mother has been exclusively breastfeeding her 6-month-old. She requests information about
meeting the nutritional needs of her infant. What information should the nurse provide?
A Decrease the number of times per day the infant receives breast milk
B Offer finger foods to encourage self-feeding
C Include a variety of food choices with meals and snacks
D Gradually add iron-rich pureed meat and cereal to the infant's diet

Question Explanation
Correct Answer is D
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Rationale: Pureed iron-rich meat, meat alternatives, and/or iron-fortified cereal are the first
complementary foods that are introduced to infants. The mother will continue to breastfeed while
introducing these foods. The next food transition is strained or mashed foods, and then finger
foods may be introduced. By the age of 1 year, children should have a regular schedule of meals
and snacks. Breastfeeding may continue during all these transitions.
Concepts tested

Question 1145
The nurse is speaking with the parents of a 3-year-old child who are concerned about the child
holding its breath during a temper tantrum. Which action should the nurse take?
A Recommend that the parents give in when the child holds their breath to prevent anoxia
B Instruct the parents on how to reason with the child about possible harmful effects
C Advise the parents to monitor the child because breathing often resumes automatically
D Educate the parents on how to administer rescue breaths and chest compressions

Question Explanation
Correct Answer is C
Rationale: Temper tantrums are common during the toddler years and represent normal
developmental behaviors. Temper tantrums commonly occur when the child is ill, hungry,
frustrated, or tired; some children may use temper tantrums to get parental attention, get
something they want, or avoid having to do something they do not want to do. The majority of
tantrums last 5 minutes or less. During a tantrum, the child may lie down on the floor, kick their
feet, and scream as loud as possible. Some have learned the effectiveness of holding their breath
until the parent gives in. The nurse should offer anticipatory guidance and advise the parents to
not give in to the negative behavior, ensure a consistent response by all caregivers, and praise
and reward positive behavior. The other actions are not appropriate or helpful for this
developmental stage.
Concepts tested

Question 1146
A nurse is caring for a client with bipolar disorder. The nurse reads in the client’s medical record
that the client was awake the previous night experiencing an acute manic episode. Which of the
following interventions should the nurse include when planning care for this client?
A Offer a warm shower before bedtime
B Limit visitors during the day
C Provide frequent rest periods during the daytime
D Encourage stimulating activities throughout the day

Question Explanation
Correct Answer is C
Rationale: A client who is experiencing an acute manic episode will exhibit restlessness, going
from activity to activity with heightened emotional response. A client who was awake all night
from a manic episode will need rest periods throughout the day. Encouraging stimulating
activities can exacerbate the manic episode. While a warm shower before bed could be relaxing,
it will not prevent the client from experiencing insomnia from the manic episode. Limiting
visitors could decrease simulation but does not impact the effects of the manic episode.
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Concepts tested

Question 1147
The nurse is planning care for a client with bipolar who is experiencing an acute manic episode.
Which action is a priority for the nurse to implement?
A Encourage the client to perform hygiene care
B Advise the client to participate in group therapy
C Instruct the client to drink fluids every hour
D Tell the client to report when symptoms get worse

Question Explanation
Correct Answer is C
Rationale: When caring for a client with bipolar who is experiencing an acute episode, the
priority actions for the nurse are to keep the client safe and prevent injury. During an acute manic
episode, the client will have extreme restlessness and physical activity may be difficult to
control. The nurse should implement actions to keep the client hydrated, rested, and safe. The
client in the acute manic episode will not have the cognitive focus to attend group therapy,
perform hygiene care, and report changes in condition.
Concepts tested

Question 1148
The clinic nurse is interviewing a client who is being evaluated for psychiatric care. Which
statement by the client would support a diagnosis of a manic episode of bipolar disorder?
A “I often need to take several naps during the day.”
B “I noticed that I have been eating more at night while watching television.”
C “I plan on quitting my job so I can devote more time to social media.”
D "I have skipped going to the gym for the past week.”

Question Explanation
Correct Answer is C
Rationale: Bipolar disorder is a group of disorders that has cycles of depression and irritable or
erratic moods. When a client is experiencing a manic episode of bipolar disorder, the client will
have an intense mood, where the client may make irrational choices, such as quitting a job. The
client may have grandiose ideas of becoming famous. A client who reports sleeping more often,
increasing eating, or skipping routine activities may be experiencing depression.
Concepts tested

Question 1149
The nurse is assessing a client who has a history of anxiety. The client states, “I always think I
leave the stove on; I must have obsessive-compulsive disorder.” Which statement would be
appropriate for the nurse to make?
A "Are there any triggers to this feeling?”
B “Can you describe how you feel when you have that thought?”
C "Do you worry about other things?”
D “Does it happen every day?”

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Question Explanation
Correct Answer is B
Rationale: Obsessive-compulsive disorder is a neurological disorder where the client experiences
intrusive thoughts (obsessions) and ritualistic behaviors (compulsive). The client will report
having a recurring thought, such as leaving the stove on. The thought is persistent, and the client
cannot focus on anything else. The nurse should ask the client to describe how they feel when
experiencing the intrusive thought. With OCD, there is no distinct trigger to the intrusive
thought. Asking if the client worries about other things does not assess how the thought is
processed by the client. Often with OCD, the intrusive thoughts are ongoing, without any time
constraints.
Concepts tested

Question 1150
The nurse is preparing to complete a health history for a newly admitted client. The nurse
observes the client squeezing and twisting their hands together and notes rapid breathing. The
client states they are feeling sick to their stomach. Which statement should the nurse make?
A “You seem uncomfortable, we can wait to finish this.”
B “Maybe if you sit down in the chair, you will feel relaxed."
C “I can get you a medication for your stomach.”
D “I can give you some privacy to allow you to process the situation."

Question Explanation
Correct Answer is A
Rationale: Moderate to severe anxiety causes a person to have one focus. The client is not ready
to participate in a health history, and it should be rescheduled for a later time. The nurse should
stay with the client to offer assistance if needed but should never tell them to relax.
Concepts tested

Question 1151
The hospice nurse is providing care to a client with terminal cancer. The client states, “This pain
is getting unbearable; I just want you to end it all.” Which response by the nurse would be most
appropriate?
A "I can only imagine how hard this is for you."
B "What you are asking me to do it illegal."
C “I think we need to talk to your family.”
D “You do not really mean that.”

Question Explanation
Correct Answer is A
Rationale: Clients who have terminal disease will often voice feelings of helplessness or despair.
A client who is also experiencing pain may express frustration and state that they want to die.
This can be challenging for the nurse. The nurse should respond with empathy, validating the
client’s feelings. The nurse should avoid comments that dismiss the client’s feelings, such as
referring back to family or stating that the client does not mean it. While assisted suicide is
illegal, stating that does not create a therapeutic relationship with the client.
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Concepts tested

Question 1152
The nurse is providing care to a client with borderline personality disorder who has a history of
manipulative behavior. The client gives the nurse a painted rock and states “This is a gift for you
because you are the best nurse.” Which statement by the nurse would be appropriate?
A “That is nice that you think I am the best nurse.”
B “I will keep this at the desk for everyone to see.”
C “I am unable to accept, but I am wondering what this gift means to you.”
D “That is very pretty, but it is against the rules to take gifts.”

Question Explanation
Correct Answer is C
Rationale: Clients with borderline personality disorder will use manipulative behaviors to control
caregivers. Giving gifts and praising others is a common manipulative technique used by
individuals with BPD. When provided with a gift and verbal praise, the nurse should respond by
putting the focus back on the client by asking the importance of the object. Keeping the object,
complimenting the client for the praise, or justifying why they cannot keep the object validates
the behavior.
Concepts tested

Question 1153
The clinic nurse is reviewing the dietary history of an adolescent female client. The client states
“I have been counting my calories; I do not want to gain weight.” Which statement by the nurse
would be appropriate?
A “Monitoring your calories now will help you stay a healthy weight into adulthood.”
B “As long as you eat at least three meals a day you should be fine.”
C “You do not look like you are overweight.”
D “Let’s talk about the types of foods you eat during the day.”

Question Explanation
Correct Answer is D
Rationale: Adolescence is a period of rapid physical, emotional, social, and sexual maturation in
which the rate of growth can vary among individuals. Nutrient needs for adolescence are
increased during this period of growth. Weight consciousness is often an issue among
adolescents, especially female clients. When assessing the dietary history of an adolescent
female client who reports counting calories, the nurse should explore the types of foods the client
eats. Clients who are at risk for developing eating disorders may express concern about gaining
weight. The nurse should assess the types and amounts of food the client is eating.
Concepts tested

Question 1154
The nurse is caring for a client who is experiencing an acute phase of schizophrenia and is
exhibiting positive symptoms. Which finding should the nurse expect to observe?
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A The client reports that the call bell is a tracking device.
B The client avoids eye contact.
C The client refuses to get out of bed.
D The client has difficulty with eating.

Question Explanation
Correct Answer is A
Rationale: The symptoms of schizophrenia are categorized as positive, negative, cognitive, and
mood. Positive symptoms refer to symptoms that add to a client’s personality, such as delusions,
hallucinations, and perceptions that are not based in reality. Negative symptoms refer to
symptoms that take away from the client’s personality, such as loss of motivation, inability to
experience pleasure, and feeling of emptiness. Cognitive symptoms refer to the client’s inability
to process information, inability to focus or pay attention, and difficulty with memory. Mood
symptoms refer to when the client is depressed, anxious, or suicidal.
Concepts tested

Question 1155
The nurse is preparing to administer prescribed medication to a client with paranoid
schizophrenia. The client states, “I can’t take that; you are trying to poison me.” Which statement
should the nurse make?
A “Why would you think I would give you poison?”
B “I understand that fear; would you like to see the packaging?”
C “Would you like me to tell you about the medication?”
D “Are you refusing to take your medication?”

Question Explanation
Correct Answer is B
Rationale: When communicating with a client with paranoid schizophrenia, the nurse should
speak indirectly to the client, identify with the client’s feelings, avoid rationalizing but share in
the mistrust, and provide the client with options. Offering to show the client the packaging
addresses their fears of being poisoned. Telling the client about the medication does not address
the delusion of the medication being tampered with. Asking about refusing the medication or
trying to rationalize the thought will increase the client’s paranoia.
Concepts tested

Question 1156
The nurse is caring for a client who is Hispanic and is newly diagnosed with depression. Which
statement by the client would indicate to the nurse a cultural issue that impacts the client’s
understanding of the diagnosis?
A “I plan on attending the group therapy session.”
B “My family will help me figure out how to deal with this.”
C “My close friends are staying in touch.”
D "I plan on telling my employer.”

Question Explanation

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Correct Answer is B
Rationale: In some cultures, the diagnosis of mental health is considered a stigma. For clients
who are Hispanic, mental health issues are dealt with in the family and not to be discussed with
strangers. This could impact the client’s ability to receive treatment.
Concepts tested

Question 1157
The nurse is preparing to administer prescribed medication to a client who is Native American.
The nurse enters the room and observes a Shaman performing a healing ritual for the client.
Which action should the nurse take?
A Ask the Shaman to wait outside the room
B Wait in the room until the Shaman is done with the ritual
C Leave the room and return when the healing ritual is finished
D Administer the medication while the Shaman continues the ritual

Question Explanation
Correct Answer is C
Rationale: Shamans are tribal leaders or medicine men that are used in the Native American
culture to relieve illness. The culturally competent nurse should allow privacy for the healing
ritual and return when it is completed. The culturally competent nurse should incorporate the
client’s beliefs into the client’s care as long as the health belief and practice are safe.
Concepts tested

Question 1158
The nurse is caring for a client who is Asian and is post-operative 24 hours from an
appendectomy. The client is hesitant to get out of bed. Which response would be the most
appropriate for the nurse to make?
A “You need to get up and walk to prevent complications.”
B “Can you describe what you are feeling when you try to move?”
C “I will come back later and help you get up.”
D “Would like to wait until your family arrives to get out of bed?”

Question Explanation
Correct Answer is B
Rationale: The client who is hesitant to move and get out of bed may be expecting pain. Clients
who are Asian tend to control their emotions and expressions of physical discomfort in front of
strangers. Telling the client to get up and walk to prevent complications is important, however,
the nurse needs to assess why the client is hesitating to get up. Leaving the client or waiting for
the family does not address the reason why the client is hesitant to get up.
Concepts tested

Question 1159
The charge nurse observes the staff nurse collecting the health history of a client whose primary
language is Spanish. Which action by the nurse would require the charge nurse to intervene?
A Requests the client’s adolescent child to answer questions

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B Utilizes the facility telephonic interpreting system
C Has a bilingual nurse assist with the health history
D Asks for assistance from a certified interpreter

Question Explanation
Correct Answer is A
Rationale: When caring for a client who does not speak English, the nurse should first utilize a
certified interpreter. If a certified interpreter is unavailable, the nurse should then use the
telephonic interpreting system or a bilingual staff member. The nurse should never use family
members to interpret.
Concepts tested

Question 1160
While performing hygiene care for a pediatric infant, the nurse notes a soiled string of yarn
around the infant's neck. Which action should the nurse take?
A Ask the parent the purpose of the string
B Remove the string and tie it to the infant's clothes
C Wash the string with soap and water
D Place the string in a container and give to the parent

Question Explanation
Correct Answer is A
Rationale: The culturally competent nurse would ask the parent the meaning of the string.
Washing the string with soap and water does not address the purpose of the string or safety. The
nurse should not just remove the string and tie it to the clothes or just remove the string without
first assessing the purpose. The nurse should involve the parent in the decision-making.
Concepts tested

Question 1161
The nurse is reviewing the health history of a client during an annual wellness visit. The nurse
notes that the client is not up to date with vaccinations. Which statement should the nurse make?
A “Will you provide consent to receive required vaccinations?”
B “Is there a reason your vaccination record is incomplete?”
C “Can you describe your personal beliefs about vaccinations?”
D “Have you ever received vaccinations in the past?”

Question Explanation
Correct Answer is C
Rationale: During the health history, the nurse should use culturally congruent statements that
explore the client’s beliefs and values. The choice to receive vaccinations is often based on
personal beliefs and values. The nurse should explore the client’s beliefs before asking for
consent to receive vaccinations. Asking about previous vaccinations or the reason for the
incomplete record can be accusatory to the client.
Concepts tested

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Question 1162
The home health nurse is conducting a health history interview with a client who does not speak
English. Which action should the nurse take when communicating with the client?
A Use simple words with simple actions
B Write out all questions using appropriate medical terms
C Request for a family member to translate
D Access the telecommunication interpreter

Question Explanation
Correct Answer is D
Rationale: When speaking with a client that does not speak English, the nurse should access the
telecommunication interpreter. If an interpreter is unavailable, the nurse can speak in simple
terms while using actions. The nurse should maintain a moderate, low tone of voice and avoid
shouting or talking loudly. The nurse should avoid using medical terms, and the client may not
be able to read English or use family members to translate. When asking questions, the nurse
should discuss one topic at a time and avoid conjunctions.
Concepts tested

Question 1163
The nurse is collecting the health history of a client admitted to the medical-surgical unit. The
client states “At midnight, I am supposed to be observing my monthly fast for my religion.”
Which statement should the nurse make?
A “I will request a prescription for intravenous fluids from your healthcare provider.”
B “Could you move your fast day to after you are discharged from the hospital?”
C “You can refuse to accept your meal trays from dietary.”
D “Can you describe to me what occurs during your fast?”

Question Explanation
Correct Answer is D
Rationale: The nurse should assess and plan interventions that meet the client’s religious needs.
For a client who reports the need to participate in a monthly fast, the nurse should gather more
information related to the process, including specific restrictions and timeframe. There is no
indication that the client requires IV fluids. Telling the client to refuse meal trays or moving the
fast to another day does not address the client’s needs.
Concepts tested

Question 1164
The nurse is assessing a client’s spirituality during the hospital admission process. Which
statement should the nurse make?
A “Are you a member of a church?”
B “Do you believe in God?”
C “How do you practice your religion?”
D “Can you describe what gives you meaning in life?”

Question Explanation

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Correct Answer is D
Rationale: Religion and spirituality are important aspects of a client that can influence their
healthcare. When assessing a client’s spirituality, the nurse should not make assumptions
regarding the client’s needs. The nurse should explore the client’s personal belief system to
identify how to meet the client’s spiritual needs during the hospital admission.
Concepts tested

Question 1165
The nurse is reviewing the medical record for a client who is a Jehovah’s Witness. Which
prescription should the nurse clarify with the healthcare provider?
A Influenza vaccination
B Pain medication
C Type and cross for blood transfusion
D Dinner after sunset

Question Explanation
Correct Answer is C
Rationale: Jehovah’s Witnesses are prohibited from taking blood or blood products. The nurse
should clarify the prescription for type and cross for blood transfusion with the healthcare
provider. Clients who are Muslim may require meals after sunset during holy days. Clients who
are Christian Scientists may refuse conventional treatments, such as pain medication or
vaccinations.
Concepts tested

Question 1166
Which actions by the nurse demonstrate caring practices? Select all that apply.
A Sitting with a client who is crying
B Holding a client’s hand during a procedure
C Asking the client about their hobbies
D Providing a client with advice
E Involving the client’s family

Question Explanation
Correct Answer is A, B, C, E
Rationale: A nurse demonstrates caring in practice by knowing the client, using therapeutic
touch, listening, and involving the family. Offering advice is not a caring act; the nurse provides
education and information but does not express personal opinions to clients.

Question 1167
The home health nurse is visiting with an older adult client who recently moved in with their
adult child. Which statement by the client would indicate to the nurse the client might be
experiencing mistreatment?
A “I recently added my daughter on to my bank account.”
B “I had an appointment to replace my eyeglasses.”
C “I have joined a church group that meets during the day."

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D “I try to help my daughter with preparing meals.”

Question Explanation
Correct Answer is A
Rationale: Older adults are at risk for mistreatment, which is the intentional acts or lack of care
by a caregiver towards the client. Mistreatment can be neglect, which would be a failure to
provide social interactions and basic food, water, and physical aids, such as eyeglasses. Financial
abuse refers to denying the client access to their personal resources, stealing money, or coercing
the client to sign contracts.
Concepts tested

Question 1168
The nurse is caring for a family who recently experienced a house fire. Which actions by the
family indicates to the nurse resiliency?
A The family keeps visiting the site of the fire.
B The family has been attending group therapy.
C The family has not replaced its belongings.
D The family is focused on the cause of the fire.

Question Explanation
Correct Answer is B
Rationale: Resiliency is the ability to respond to stressful events in a healthy way. A family who
experienced a traumatic event, such as fire, will demonstrate resiliency through coping strategies
that promote moving forward, such as accepting help from outside sources. Actions, such as
reliving the events, focusing on the cause, or not moving forward may not be coping with the
event.
Concepts tested

Question 1169
The nurse is caring for a client that fell at home and is planning to move in with their adult child.
Which statement by the client would require the nurse to assess the family dynamics?
A “My other adult child is also willing to help out.”
B “I will try to make myself useful when I move into their home.”
C “I will miss my home that I lived in for so long.”
D “My adult child has been preparing my grandchildren for my arrival.”

Question Explanation
Correct Answer is B
Rationale: Older adult clients are often faced with moving from their homes into a skilled
nursing facility or with family. The loss of their home and possessions can be challenging for the
adult client. However, a loss of self-concept and freedom, along with the feeling of being a
burden, is a concern. Families can also experience caregiver strain. The nurse should assess the
family dynamics to ensure a healthy outcome.
Concepts tested

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Question 1170
During a family assessment, which statement by the nurse would assess the family functioning?
A “Have there been any recent changes within the family?"
B “Who do you consider members of the family?”
C “What holidays does the family celebrate?”
D “Anyone in the family with a specific problem?”

Question Explanation
Correct Answer is C
Rationale: A family assessment focuses on collecting data about the family structure,
developmental assessment, and family functioning. Family structure focuses on who are
considered members of the family, including those that do not live in the home. Developmental
assessment focus on how families adapt during changes and difficult times, such as if someone is
having a problem or recent changes within the family. Family functioning identifies how each
person behaves in the family and what the family does as a unit, such as celebrate holidays.
Concepts tested

Question 1171
The emergency nurse is caring for a client who has a visitor requesting to see the client. Which
statement is most appropriate for the nurse to make?
A “What is your relationship to the client?”
B “Are you family?”
C “How do you know the client?”
D “Is the client expecting you?”

Question Explanation
Correct Answer is A
Rationale: Family units are comprised of different people with different roles. The traditional
framework of families has shifted to include non-genetic related family members such as friends.
When assessing a client’s family, the nurse should focus on the relationship the individual has
with the client.
Concepts tested

Question 1172
The nurse is assessing the safety of an adolescent client. Which statement by the client would
require the nurse to intervene?
A “My dog died, and I am thinking of getting a new one.”
B “My friends at school think I dress weird.” Correct Answer
C “My teacher is tutoring me for my math class.”
D “My parents monitor my internet use.”

Question Explanation
Correct Answer is B
Rationale: Adolescents are at increased risk for suicide when faced with feelings of decreased
self-worth and hopelessness. The nurse should assess for factors that can impact an adolescent

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client’s ability to cope or handle stressful situations. An adolescent who reports a lack of social
support may be a victim of bullying, which will require the nurse to intervene. An adolescent
who looks forward to new things, such as a pet, or seeks help from others, such as a tutor, is
demonstrating appropriate coping skills. Family involvement demonstrates a support system.
Concepts tested

Question 1173
The nurse observes a client who is newly diagnosed with cancer crying. Which statement by the
nurse most demonstrates a caring practice?
A “Let me close the door, and I can pull up a chair so we can talk." Correct Answer
B “I know this must be overwhelming; there are many things to be grateful for.”
C “You should discuss your feelings with your family.”
D “I can give you some privacy and check on you later.”

Question Explanation
Correct Answer is A
Rationale: A nurse who demonstrates caring practice will listen to the client, taking time to be
present. Closing the door, sitting next to the client, and allowing the client to express feelings are
caring actions. The nurse should not try to distract the client from their feelings or place the
burden on the client.
Concepts tested

Question 1174
The nurse is caring for a client who was newly diagnosed with cancer. The client states, “I am
doing ok today.” Which nonverbal body language observed by the nurse would require the nurse
to follow up?
A The client is looking down and avoiding eye contact.
B The client clasps their hands while nodding their head.
C The client shifts in bed while pulling up covers.
D The client smiles, then begins to read a book.

Question Explanation
Correct Answer is A
Rationale: Nonverbal communication can provide the nurse with subtle information about the
client. Nonverbal communication, exhibited in body language, can also indicate if the client is
being honest about answering questions. A client who looks away, avoiding eye contact while
reporting feeling fine, might not be answering truthfully about their feelings. Nonverbal
communication such as nodding and smiling would indicate that the client is comfortable.
Concepts tested

Question 1175
The nurse is assisting a client to ambulate for the first time following hip surgery. Which
statement by the client would indicate the client is exhibiting positive intrapersonal
communication?
A "I am going to look silly walking with the cane.”

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B “I know this will be difficult, but I can handle the challenge."
C “I think I should wait to try walking until the incision is healed."
D “I will probably fall, requiring a longer time in the hospital.”

Question Explanation
Correct Answer is B
Rationale: Intrapersonal communication refers to the communication within one’s self, which is
positive affirmation. Positive intrapersonal communication includes statements that are
encouraging and supportive, such as stating the ability to tackle challenges. Negative
intrapersonal communication includes statements that indicate defeat or making fun of
themselves.
Concepts tested

Question 1176
The nurse is completing a health history for a middle-aged client. The client states, "I just got
divorced last month." Which statement by the nurse would be most appropriate?
A "How has the divorce impacted your health?"
B "You will meet the right person when you are ready."
C "A lot of people get divorced."
D "Was that your first marriage?"

Question Explanation
Correct Answer is A
Rationale: When communicating with clients, the nurse should listen to the client and provide
support or encouragement. The nurse should avoid interpretation of the client’s words or discuss
personal opinions. The nurse should be truthful, focusing on the client’s concerns and feelings.
The nurse should ask questions that encourage the client to discuss openly their feelings.
Concepts tested

Question 1177
During a client interview, which action by the nurse demonstrates the orientation phase of the
helping relationship?
A Encourage the client to describe feelings about their health
B Develop appropriate interventions to meet the client’s goal
C Review the client’s electronic medical record
D Prioritize the health concerns identified by the client

Question Explanation
Correct Answer is D
Rationale: The phases of a healthy relationship provide structure to the client-nurse relationship.
The preinteraction phase focuses on reviewing data, including the client’s electronic medical
record. During the orientation phase, the nurse will begin to observe the client, assess the client’s
health status, and prioritize health concerns. The nurse will encourage the client to express
feelings, provide information, and take actions to meet goals during the working phase.
Concepts tested

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Question 1178
The nurse is admitting a client to the hospital. The client states “Hospitals make me anxious ever
since my last visit.” Which of the following would be the most appropriate response by the
nurse?
A “Are you usually anxious about unknown situations?”
B “Can you tell me more about that experience?”
C "Do you have any questions about this admission?”
D “Are you here for the same reason?”

Question Explanation
Correct Answer is B
Rationale: Using therapeutic communication, the nurse should encourage the client to explore
their feelings and express any concerns. Asking direct questions can make a client defensive,
which could lead to further anxiety or fear.
Concepts tested

Question 1179
The nurse is caring for a client who has been diagnosed with terminal cancer and is quietly
crying. Which response by the nurse would be most appropriate?
A "I am going to sit here next to you.”
B "Being sad is an expected feeling."
C "You should call your family.”
D "I can only imagine what you are feeling.”

Question Explanation
Correct Answer is A
Rationale: When observing non-verbal behavior, such as crying, the nurse should demonstrate
empathy by being present with the client. The nurse should sit with the client, allowing the client
the opportunity to express their feelings. Sympathy, such as expressing a personal opinion, and
assuming how the client feels are not therapeutic communication techniques. Telling the client to
call their family puts the burden on the client to solve the issue by themselves.
Concepts tested

Question 1180
The nurse is caring for a client with a lower extremity fracture who is on bed rest. The client
states, “I need to go home so I can take care of my family.” Which response by the nurse
demonstrates the therapeutic communication technique of focusing?
A “You feel responsible for taking care of your family?”
B "It must be frustrating to be unable to care for your family.”
C “Can you tell me more about your concerns for your family?”
D “When your family was here, they seemed fine.”

Question Explanation
Correct Answer is C

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Rationale: Focusing communication technique centers the conversation on specific factors or
concepts, such as concern about family. Clarifying restates the client’s statement to ensure
correct understanding. Empathy is verbalizing an understanding of the client’s feelings. Sharing
observations is when the nurse comments on what was observed.
Concepts tested

Question 1181
The emergency department (ED) nurse is caring for assigned clients. The culturally competent
nurse is aware that which client is at the greatest risk for cultural disparity?
A The client who is Caucasian who is reporting chest pain
B The client who recently immigrated from Mexico who fell from a ladder
C The client who is an African American who has a history of COPD
D The client who is a Native American who was admitted with flu-like symptoms

Question Explanation
Correct Answer is B
Rationale: Clients who are from different cultures that are newly exposed to new cultures, such
as a client who recently immigrated, are at risk of healthcare disparities. The client who recently
immigrated has not experienced the culture of the healthcare system and could experience
challenges receiving culturally competent care. The other clients have assimilated into the
culture.
Concepts tested

Question 1182
The nurse is reviewing the health history of a client who is Native American. Which statement
made by the client would be the priority for the nurse to follow up?
A “My diet consists of fish and fry bread.”
B “I try to meditate twice a day to keep my balance with nature.”
C “When I get headaches, I use herbal medication prepared by the Shaman.”
D "I drink alcohol occasionally, but all of my family members do.”

Question Explanation
Correct Answer is D
Rationale: When collecting health history, the nurse should assess for cultural physiological
variations that could impact the client’s health. Common health problems specific to the client
who is Native American are related to alcohol consumption, such as cirrhosis of the liver and
fetal alcohol syndrome. The nurse should educate the client on the risks associated with alcohol
intake. It is common among Native Americans to use herbal medication, which the nurse would
further assess the type and use but is not the priority. Meditation is a non-pharmacological stress
reduction technique. Dietary intake is important to assess when preventing heart disease and
diabetes but is not the priority.
Concepts tested

Question 1183

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The charge nurse overhears a staff nurse and unlicensed assistive personal (UAP) discussing the
care of a client who is Hispanic and had abdominal surgery. The UAP reports to the nurse “The
client states the pain medication is not working.” Which statement by the staff nurse would
require the charge nurse to intervene?
A “I will have to call the healthcare provider.”
B “Was the client just sitting up in bed?”
C “We should check the client’s vital signs.”
D “Did the client describe the pain?”

Question Explanation
Correct Answer is B
Rationale: Cultural bias can cause nurses to make quick judgments and assessments of a
situation. The bias is often based on nurses’ backgrounds and personal experiences. Often, these
biases are unconscious, or not realizing they have these views. A nurse whose first response is to
ask if the client is sitting up in bed when reporting pain is demonstrating a cultural bias. This
implies that the client is not really in pain if they are just sitting up in bed. Checking the pain,
gathering more information about the client’s pain, or reporting the pain to the healthcare
provider are appropriate actions for the nurse to take.
Concepts tested

Question 1184
The graduate nurse is researching how to implement culturally congruent care into practice.
Which action should the graduate nurse take first?
A Explore personal beliefs and values
B Read current literature on healthcare disparities
C Attend a conference on culture and nursing
D Interview nurses from different cultures

Question Explanation
Correct Answer is A
Rationale: Culturally congruent care focuses on providing a case based on the client’s cultural
beliefs, practices, and values. Before a nurse can implement culturally congruent care, the nurse
should explore personal beliefs and values. Understanding one’s personal beliefs and values
provide a foundation to then understand another person’s culture. Once the nurse has explored
their beliefs, then reading current literature, attending a conference, and interviewing other
nurses will further expand the nurse’s understanding.
Concepts tested

Question 1185
The nurse is caring for a client with constipation. The client believes in the philosophical concept
of yin and yang and requests only cold food for treatment. Which food should the nurse remove
from the client’s meal tray?
A Milk
B Fruit salad
C Bran cereal

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D Honey

Question Explanation
Correct Answer is C
Rationale: Clients who believe in the philosophical concept of yin and yang identify certain
conditions that are hot and cold. If a condition is considered hot, such as constipation, the client
will prefer to eat cold foods, such as chicken, dairy, fresh vegetables, fruits, and honey. Cold
conditions, such as cancer or pneumonia, are treated with hot foods, such as cereals or eggs.
Concepts tested

Question 1186
The nurse is implementing culturally congruent care into practice. Which action by the nurse
demonstrates cultural knowledge?
A Create a blog about personal reflections
B Volunteer with a community group
C Participate in a monthly education session
D Develop a data collection tool for client interviews

Question Explanation
Correct Answer is C
Rationale: Cultural competency theory focuses on five interrelated concepts of awareness,
knowledge, skill, encounter, and desire. A nurse who demonstrates cultural knowledge will seek
out education related to culture, such as participating in a monthly education session. Cultural
awareness is the process of self-examination, which can be demonstrated by creating a blog
about personal reflections. Cultural skill is the ability to conduct a cultural assessment, which can
be demonstrated by developing a data collection tool. Cultural encounter is the process of
directly engaging with culturally diverse clients, such as when volunteering with a community
group.
Concepts tested

Question 1187
The nurse is caring for a client who is terminally ill and recently immigrated to the United States.
The nurse understands that to provide quality end-of-life care for the client, which action by the
nurse should be a priority?
A Make every effort to involve the client and the client's family with end-of-life care
B Understand the client's personal and cultural views regarding death and dying
C Arrange for end-of-life care to be provided by staff familiar with the client's culture
D Share the client's concerns regarding the dying process with the interdisciplinary care team

Question Explanation
Correct Answer is B
Rationale: Differences in beliefs, values, and traditional health care practices are relevant when
planning end-of-life care. It is the nurse's responsibility to become familiar with the client's
personal and cultural views to provide the most effective and appropriate end-of-life care. It may
not be practical to arrange for care to be provided by the staff familiar with the client’s culture.

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Concepts tested

Question 1188
The charge nurse overhears two new graduate nurses talking in the breakroom. One graduate
nurse state “I hate getting reports from the older nurses; they are just too slow.” The charge nurse
should understand that the nurse is demonstrating which of the following?
A Stereotyping
B Discrimination
C Oppression
D Acculturation

Question Explanation
Correct Answer is A
Rationale: Stereotyping is an assumed belief about a group of people, such as believing that older
people are slow. Discrimination would be refusing to receive a report from an older nurse based
on age. Oppression is policies that would provide a disadvantage to older nurses, such as creating
schedules that do not allow time off between shifts. Acculturation is the assimilation into a
culture.
Concepts tested

Question 1189
The nurse is providing end-of-life care for a client with terminal cancer. Which statement by the
client would indicate to the nurse the client is coping with the care?
A “I am not ready to discuss this with my family.”
B “I cry so easily these days.”
C “I am just ready for it to be over.”
D “I am writing down my memories in a journal.”

Question Explanation
T Answer is D
Rationale: Clients who are experiencing end-of-life care will go through the stages of grief and
loss. A client who is coping with end-of-life care will exhibit behaviors of accepting the
diagnosis, such as discussing with family and reflecting on one’s life. Clients who speak of a
speedy death or cry easily may not be coping with end-of-life care and will require additional
support.
Concepts tested

Question 1190
The nurse is caring for a client who is has been diagnosed with terminal cancer. The client states
"If I can just see my adult child marry, I will be ok with dying.” Which stages of dying should
the nurse understand that the client is experiencing?
A Bargaining
B Denial
C Depression
D Acceptance

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Question Explanation
Correct Answer is A
Rationale: The five stages of dying is the process that a client will go through when grieving and
accepting pending death. In the denial stage, the client will not acknowledge the death and
pretend it is not occurring. In the bargaining stage, the client will try to negotiate or barter for
more time. During the depression stage, the client will exhibit signs of grieving, such as crying.
In the acceptance stage, the client has come to terms with the pending death and has peace with
the outcome.
Concepts tested

Question 1191
The hospice nurse is assessing a client who is actively dying. Which finding should nurse
understand as a final sign of impending death?
A Increased respiratory rate
B Glazing of the eyes
C Loss of hearing
D Decreased blood pressure

Question Explanation
Correct Answer is C
Rationale: The physical manifestations at end of life include glazing of the eyes, decreased blood
pressure, and increased respiratory rate. The loss of hearing is the last sense to disappear
indicating the final stages of the end of life.
Concepts tested

Question 1192
A hospice nurse is caring for a client with terminal pancreatic cancer who is receiving end-of-life
care. The client states, “I do not want to eat or be fed.” Which statement should the nurse make?
A “I understand your choice and will inform the healthcare provider."
B “Choosing not to eat is a very painful way to die.”
C “We can discuss this option further and then you can make your decision.”
D “You can try clear liquids instead of solid foods.”

Question Explanation
Correct Answer is A
Rationale: The client has the right to make decisions about their end-of-life care. If the client
decides to not receive care, such as eating, the nurse should respect the client’s rights and report
to the healthcare provider. The other options do not respect the client’s decision.
Concepts tested

Question 1193
The nurse is speaking with the spouse of a client who has terminal cancer. Which statement
made by the client’s spouse indicates appropriate coping?
A “It takes me a little longer to fall asleep at night.”

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B “There are a lot of things I have to do.”
C “I try to set aside a few minutes to myself each day.”
D “I am not sure if I know how to help my spouse.”

Question Explanation
Correct Answer is C
Rationale: The nurse will need to assess the need for psychological support for the family of
clients with a terminal disease. The family who has difficulty sleeping or is overwhelmed with
caring for the client will require psychosocial support.
Concepts tested

Question 1194
The nurse is caring for a client who was newly diagnosed with cancer. The client states “Am I
going to die?” Which response would be most appropriate for the nurse?
A “You will receive the best care that your healthcare provider can give.”
B “It is too early to be concerned about dying.”
C “Would like to talk about how you feel?”
D “Is that your biggest fear about the diagnosis?”

Question Explanation
Correct Answer is C
Rationale: When communicating with clients, the nurse should understand that verbal
communication is a social interaction requiring effective skills to promote a therapeutic
relationship. The nurse should be truthful, open-minded, and knowledgeable in communicating
with clients. The nurse should avoid providing personal opinions, dismissing the client’s
concerns, or attempting to adjust the client’s perception of the situation. The nurse should
encourage the client to explore feelings and further communicate needs.
Concepts tested

Question 1195
A nurse is caring for a client with stage IV cervical cancer who is receiving prescribed
chemotherapy. The client states, “I don’t want any more chemotherapy, but my children insist I
keep going.” Which statement should the nurse make?
A “Your children just want you alive as long as possible.”
B “I would keep fighting if I were you.”
C “I can discuss the process with you to stop treatment.”
D “You need to think about the outcome of your decision.”

Question Explanation
Correct Answer is C
Rationale: A client has the right to make decisions about their care. The role of the nurse is to
support the client in these decisions and provide the client with appropriate information.
Concepts tested

Question 1196

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The hospice nurse is reviewing the medical record for a client who is receiving palliative care.
Which prescriptions should the nurse expect? Select all that apply.
A Provide skin moisture barrier cream
B Apply artificial tear eyedrops
C Perform mouth care every hour
D Administer oxygen 2 L/min via nasal cannula
E Obtain vital signs two times a day

Question Explanation
Correct Answer is A, B, C, D
Rationale: Palliative care focuses on interventions that promote comfort at end of life. Applying
moisture barrier cream, administering artificial tear eye drops, mouth care, and administering
oxygen provides comfort. Obtaining vital signs does not provide comfort and does not provide
benefits to the client.
Concepts tested

Question 1197
The nurse is caring for a client who is actively dying and is experiencing delirium. Which of the
following is an appropriate action by the nurse?
A Obtain a prescription for restraints
B Avoid touching the client
C Hold pain medications
D Decrease environmental stimuli

Question Explanation
Correct Answer is D
Rationale: A client who is experiencing delirium, which is a state of confusion, disorientation,
restlessness, and anxiety. The nurse should provide the client with a quiet, well-lit room. The
nurse should calm the client by staying close and using a calm voice, and slow strokes of the
skin. The nurse should administer pain medication to a client who is actively dying. Restraints
should be avoided by clients who are actively dying.
Concepts tested

Question 1198
The nurse is caring for a client with terminal cancer. When discussing the plan of care with the
daughter, which statement would indicate the daughter is experiencing anticipatory grief?
A “I have been in touch with our church to plan my mother’s services.”
B “My mother loves roses. I will bring some to cheer her up.”
C “We are going to fight this; my mother is a strong woman.”
D “The family is planning a birthday celebration for my mother.”

Question Explanation
Correct Answer is A
Rationale: Anticipatory grief is the experience of the client or family members that prolongs or
predicts the impending loss. During anticipatory grief, the client or family member may engage

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in activities that prepare or complete tasks related to the actual loss, such as planning funeral
services.
Concepts tested

Question 1199
The nurse is assessing a client who reports experiencing an increase in environmental stressors.
Which finding would indicate to the nurse that the client has long-term physiological effects of
the stress?
A Weight loss of 15 lbs
B Hypotension
C Tachycardia with rest
D Hypoglycemia

Question Explanation
Correct Answer is C
Rationale: Clients who report experiencing environmental stressors will have an increase in the
flight or fight response. The signal of stress triggers the hypothalamus, which activates the
autonomic nervous system. Clients will exhibit physiological symptoms of stress. Long-term
effects include weight gain, hypertension, tachycardia with rest, and hyperglycemia.
Concepts tested

Question 1200
The nurse is collecting the health history of a client who was admitted from the emergency
department. The client states “I already told the other nurse all of this information.” Which is the
most appropriate response by the nurse?
A “I can review what has been documented in your medical record.”
B “Here is a list of information I still need to collect.”
C “Confirming what you have reported is to ensure we provide safe care.”
D “We can continue the health history after I complete my assessment.”

Question Explanation
Correct Answer is C
Rationale: The nurse is responsible for collecting and validating subjective data from clients.
When taking care of a client following a transfer or admission, the nurse should review with the
client the history collected. The nurse should explain to the client that reviewing and validating
the client’s history is to promote safe care and avoid any errors. The nurse can review
information in the medical record, but it still needs to be validated with the client. Collecting the
health history is best completed before the physical assessment.
Concepts tested

Question 1201
The nurse is collecting the demographic data of a client. Which statement by the nurse
demonstrates inclusive therapeutic communication?
A “Are you married?”
B “What is your sexual preference?”

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C “What is your spouse’s gender?”
D “Do you have a partner?”

Question Explanation
Correct Answer is D
Rationale: When interviewing clients, the nurse should be aware of heterosexist biases. Inclusive
communication should focus on asking questions that provide information about the client
without judging, isolating, or omitting a client’s choices or beliefs. When collecting demographic
data, the nurse should ask questions that are open to anyone, such as using "partner" instead of
"spouse," "wife," or "husband." The nurse should avoid direct questions that imply the client is
heterosexual or require the client to declare an identity.
Concepts tested

Question 1202
When conducting an environmental risk assessment for a family using an ecomap. Which finding
would indicate a social risk for the family?
A The children are homeschooled.
B One parent works outside the home.
C The family attends church services together.
D A relative visits daily to assist with preparing meals.

Question Explanation
Correct Answer is A
Rationale: When assessing the environmental health of a family, the nurse will gather
information about relationships and connections to social units. Families that have contact
outside the core family, such as attending church services, visits with relatives, and working
indicate a support network. Children who are homeschooled may be at risk due to a decrease in
social connections.
Concepts tested

Question 1203
The community health nurse is discussing concerns with a client during a family assessment. The
client states “How do we ensure our adolescent will not experiment with drugs?” Which is the
best statement for the nurse to make?
A “Set clear boundaries that are enforced.”
B “Discuss the risks of doing drugs.”
C “Monitor social media activity.”
D “Engage in family activities several times a week.”

Question Explanation
Correct Answer is D

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Rationale: Substance use and abuse is a major stress and issue with families. To decrease the risk
for substance abuse and use in children, families should be encouraged to engage in activities
together, build close relationships with the family, and model behavior by family members. Strict
boundaries, discussing the risks, and monitoring social media are not preventive measures.
Concepts tested

Question 1204
The home health nurse is visiting with a client who experienced the loss of a spouse. The client
states, “I can’t believe this has happened; what will I do?” What statement by the nurse would be
appropriate?
A “It is difficult to experience unexpected loss.”
B “You can focus on the good memories.”
C “It will take time, but it will get easier.”
D “Tell me more about what you are feeling.”

Question Explanation
Correct Answer is D
Rationale: Listening attentively to the client and encouraging the client to talk are appropriate
responses by the nurse for the client who is experiencing bargaining, according to Kubler-Ross’s
stages of grieving.
Concepts tested

Question 1205
The hospice nurse is caring for a client who is actively dying. The client’s adult child states “I
don’t think I can stay and watch.” Which response would be appropriate for the nurse to make?
A “I understand, but you may regret your choice.”
B “It is okay; during the dying process the person will not know who is present.”
C “Is there another family member you can ask to stay?”
D “Can you describe to me your concerns?”

Question Explanation
Correct Answer is D
Rationale: The nurse should recognize when the family of a client who is actively dying requires
support. Encouraging the family members to discuss their concerns will also support the client.
During the dying process, the nurse should encourage the client’s family to be present. However,
if a family member voices concerns, the nurse should provide the family member with support
and have them explore their feelings.
Concepts tested

Question 1206
The nurse is providing care for an elderly client who was just admitted to the facility. During the
admission process, the client's family reports that the client has been having increasing episodes
of forgetting things and misplacing important items. Which of the following statements should
the nurse include each time they check on the client?
A"I will just leave the lights on in the room. That will make it easier for you to get up."

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B "Your call light is in your hand, and I will check on you every hour."
C "Let's just put on the bed alarm. I will leave all four side rails up."
D "Why don't we leave the television on for you? You can leave it on all night."

Question Explanation
Correct Answer is B
Rationale: In the early stages of cognitive decline, it is important to provide reality orientation by
informing the client where their call light is and establishing a routine of hourly checks. Both of
these will help to reassure the client and family about the client's safety. It would be important to
reduce external noise and light stimuli. The nurse might be able to leave a night light if that
makes the client feel safe but not leave on all the lights in the room. The bed alarm would need
to be activated, but leaving all four side rails up is a restraint, which is not appropriate for this
client.
Concepts tested

Question 1207
The nurse is caring for a client who has expressed some anxiety about an upcoming surgery.
Which response by the nurse would be most therapeutic?
A "Tell me more about how you are feeling."
B "Don't think about all the things that could go wrong. Stay positive."
C "You will feel much better after the surgery."
D "You should read more about the procedure before you worry."

Question Explanation
Correct Answer is A
Rationale: Therapeutic communication includes using silence, open-ended questions,
clarification statements, and reflection. In this situation, the nurse is asking for clarification and
additional information for better understanding. The nurse should avoid using responses such as
closed-ended questions, advice-giving, reassuring statements, arguing, asking "why," and giving
other judgmental responses.
Concepts tested

Question 1208
The nurse is meeting a client for the first time. The client tells the nurse that he does not take his
medication as prescribed. Which response by the nurse would be most therapeutic?
A "Tell me more about your reason for not taking the medication as prescribed."
B "If the medication is too expensive, we can call your health insurance plan for you."
C "You must take your medication otherwise your condition will worsen."
D "If you continue to be noncompliant, there is nothing more we can do for you."

Question Explanation
Correct Answer is A
Rationale: Therapeutic communication includes using silence, open-ended questions,
clarification statements, and reflection. In this situation, the nurse should explore the reasons for
non-compliance before proceeding. Shaming a client is not therapeutic nor does it show a

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genuine concern for the client's well-being. The nurse also should not assume that a lack of
financial resources is the reason for not taking the medication. The nurse should avoid using
nontherapeutic responses, such as closed-ended questions, advice-giving, arguing, asking "why,"
and other judgmental responses.
Concepts tested

Question 1209
The nurse is reviewing the chart of a client whose spouse died two years ago. What clinical
manifestation(s) would indicate that the client is suffering from complicated grieving? Select all
that apply.
A The client attends a monthly support group for widowed spouses.
B The client states that they have trouble sleeping and frequent nightmares.
C The client refuses to attend church services and social gatherings.
D The client expresses interest in online dating websites.
E The client is unable to talk about their spouse without crying uncontrollably.

Question Explanation
Correct Answer is B, C, E
Rationale: Grief can occur in response to any significant personal loss (e.g., death or divorce).
After an individual suffers a loss, they should go through a mourning process that is
characterized by feelings of sadness, anger, guilt, and despair. If an individual does not
experience mourning after a loss, this is considered a maladaptive grief response. Although
individuals move through the stages of grief and mourning at different times, routinely grieving
lasts about a year. After the client moves through the phases of mourning, they should be able to
look back on the loss of their loved one without crying uncontrollably. Once the client has
moved through the phases of mourning and accepted their loss, they will often pursue new
experiences and challenges. Support groups facilitate the grieving process and educate
individuals about normal grieving patterns. Once the client has moved through the phases of
mourning and accepted their loss, they will often pursue new relationships. Clients who suffer
from complicated grieving can experience insomnia, nightmares, and somatic symptom
disorders.
Concepts tested

Question 1210
The nurse is caring for a client admitted to the hospital with a history of post-traumatic stress
disorder (PTSD). Which of the following actions by the nurse would represent appropriate care
of the client?
A Identify coping strategies used by the client when stressful situations arise
B Provide privacy for the client if nightmares or flashbacks occur
C Avoid talking the about the disorder and traumatic experience(s) with the client
D Assign a different nurse each shift to care for the client

Question Explanation

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Correct Answer is A
Rationale: Post-traumatic stress disorder (PTSD) is a reaction to a trauma (e.g., rape, kidnapping,
war, etc.) that can last up to months or even years. Characteristics of PTSD include depression,
aggressive behavior, survivor's guilt, nightmares, flashbacks, destructive behavior, emotional
outbursts, etc. Clients with PTSD have difficulties forming trusting relationships. In order to
facilitate trust between the client and the nursing staff, assign the same staff member to the client
as often as possible. The nurse should stay with the client during periods of flashbacks and
nightmares to help allay fears and reassure the client that they are safe. Allow the client to
express feelings about the trauma at their own pace. Acknowledge and validate the client's
concerns. Discuss the client's coping strategies developed in response to trauma and stressful
situations. Identify the difference between using helpful and maladaptive strategies.
Concepts tested

Question 1211
A client with a history of bipolar disorder is admitted to the hospital after a suicide attempt.
Which of the following interventions should the nurse include in the client's plan of care?
A Discourage the client from expressing negative emotions
B Place the client in a private room away from the nurses' station
C Develop a contract with the client that states they will not harm themselves
D Search the client's room every 24 hours for unsafe objects

Question Explanation
Correct Answer is C
Rationale: The nurse should develop a temporary contract with the client that states they will not
harm themselves. The contract will allow the client to assume responsibility for their safety. The
nurse should actively listen to the suicidal client and encourage them to express their feelings
and emotions. Expressing emotions will allow the client to resolve unhealthy hostility and take
control of their life. The nurse should closely observe a client who is at risk for suicide. Place the
client in a room close to the nurses' station and do not assign them to a private room. To create a
safe environment, the nurse should perform room searches as needed to keep harmful objects
away from the client (e.g., glass items, alcohol, sharp objects, and belts).
Concepts tested

Question 1212
A client is admitted to the hospital after falling at home and is given an opioid analgesic for pain.
Two days later, the client develops delirium. What clinical manifestation(s) should the nurse
monitor the client for? Select all that apply.
A Fluctuating emotions
B Disturbances in sleep-wake pattern
C Confusion that will last several months
D Rambling, incoherent speech
E Gaps in long-term memory

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Question Explanation
Correct Answer is A, B, D
Rationale: Delirium is an acute disorder that is characterized by a change in cognition, which
develops quickly over a short period of time. Predisposing risk factors for delirium include
anesthesia, dehydration, electrolyte disturbances, sleep deprivation, and opioid pain medications.
Disturbances in the sleep-wake cycle can occur in clients with delirium. The symptoms of
delirium typically last for days or weeks but not months. The client with delirium thinks in a
disorganized pattern and thus speaks randomly and incoherently. The client with delirium can
develop emotional instability that is manifested by fear, anxiety, and apathy. The client with
delirium is easily distracted and has difficulties focusing on tasks. Memory loss, especially long-
term, is not associated with acute delirium but is often seen in clients with dementia.
Concepts tested

Question 1213
The nurse is preparing interventions for a client with major depression who has been showing
signs of impaired social interaction. Which intervention should the nurse implement initially?
A Provide activities that allow for decision-making
B Provide activities that improve concentration and focus
C Provide activities that include group interaction
D Provide activities that require minimal concentration

Question Explanation
Correct Answer is D
Rationale: Clients with depression who are struggling to interact with others should be given
time to adjust to the therapeutic environment or milieu. The nurse will accomplish this
by initially providing the client with activities that require minimal concentration. Once the client
shows signs of improved mood and concentration, the nurse should implement the other
interventions.
Concepts tested

Question 1214
The nurse is concerned that a client with a history of anorexia nervosa may be experiencing a
recurrence of the condition. Which of the following findings would support the nurse's
concern? Select all that apply.
A Weight loss
B Lack of exercise
C Recent hair loss
D Elevated blood pressure
E Constipation

Question Explanation
Correct Answer is A, C, E

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Rationale: Hair loss, constipation, and weight loss are all potential manifestations of anorexia
nervosa. Excessive exercising, not a lack of exercise, is often associated with anorexia nervosa.
Elevated blood pressure is not a clinical manifestation of anorexia nervosa.
Concepts tested

Question 1215
A client reports to the nurse that they must check to make sure that the iron is unplugged 10
times before leaving the house. The nurse understands that the client is attempting to:
A Keep others in the home safe
B Prevent a depressive episode
C Teach family members about safety
D Reduce personal anxiety

Question Explanation
Correct Answer is D
Rationale: A client's motivation for the obsessive/compulsive checking of the iron is to decrease
their own personal anxiety. The behavior will not cause a depressive episode and is not
motivated by malicious intention or safety awareness.
Concepts tested

Question 1216
A nurse is caring for a client with a personality disorder. The client states that the nurse "doesn't
know what she is doing because all the other nurses let him take his coffee into his room.” The
nurse recognizes the client's statement as what type of behavior?
A Violent behavior
B Suicidal behavior
C Impulsive behavior
D Manipulative behavior

Question Explanation
Correct Answer is D
Rationale: Clients with personality disorders tend to have self-esteem issues. Because of this, the
client will try to manipulate staff members by making false claims in an attempt to get the person
to do as they wish. Attempts to manipulate are attempts to show superiority and deny one's own
feelings of not being in control.
Concepts tested

Question 1217
A client newly diagnosed with schizophrenia tells the nurse that she thinks that the employees at
the fitness center are conspiring against her to have her membership revoked. Which response by
the nurse is most therapeutic?
A "You know that cannot be true."
B "You must not have taken your medication yet."
C "What proof do you have?"

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D "Feeling this way must be frustrating and scary."

Question Explanation
Correct Answer is D

Question 1218
The nurse is talking with a client with a history of sexual abuse who suddenly becomes tearful
and stares out the window after seeing a rose on the table. Which intervention should the nurse
implement based on the client's behavior?
A Determine if the client should be left alone to think
B Determine if the client is having a flashback
C Remind the client that the roses are a symbol of love
D Remind the client that the abuse is over

Question Explanation
Correct Answer is B
Rationale: Clients who have experienced a traumatic experience such as sexual abuse often
experience flashbacks as a result of a trigger. Triggers can be visual, auditory, tactile, or
olfactory. The other interventions would not be supportive or therapeutic.
Concepts tested

Question 1219
A female client is admitted for a breast biopsy. She says, tearfully, to the nurse, "If this turns out
to be cancer, and I have to have my breast removed, my partner will never come near me."
Which of these statements would be the best response by the nurse?
A "I hear you saying that you have a fear of the loss of love."
B "You sound concerned that your partner will reject you."
C "Are you wondering about the effects on your sexuality?"
D "Are you worried that the surgery would lead to changes?"

Question Explanation
Correct Answer is D
Rationale: By simply asking about changes, the nurse is encouraging further discussion without
focusing on a specific issue. This technique of therapeutic communication will allow the client to
decide what to talk about next. It is best to allow the client to identify the exact nature of the
problem. The nurse can explore more specific concerns when the client verbalizes them, such as
loss of love, rejection, and the effects on sexuality.
Concepts tested

Question 1220
The nurse is developing a plan of care for a client diagnosed with post-traumatic stress disorder.
Which potential interventions should the nurse plan for? Select all that apply.
A Opioid analgesics
B Selective serotonin reuptake inhibitors
C Eye movement desensitization and reprocessing

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D Cognitive behavioral therapies
E Treadmill stress test

Question Explanation
Correct Answer is B, C, D
Rationale: Two medications approved by the Food and Drug Administration (FDA) for the
treatment of post-traumatic stress disorder (PTSD) are the selective serotonin reuptake inhibitor
(SSRI) antidepressants sertraline and paroxetine. There are other medications that are helpful for
specific PTSD symptoms. Most people who experience PTSD undergo some type of
psychotherapy, most commonly cognitive-behavioral therapy (CBT) and/or group
psychotherapy, eye movement desensitization and reprocessing (EMDR), and hypnotherapy. A
stress test is used for diagnostic cardiac issues, and opioid analgesics are used to treat moderate
to severe pain, not PTSD.
Concepts tested

Question 1221
A client is admitted to the medical-surgical unit following a motor vehicle accident. Twelve
hours after admission, the client becomes diaphoretic, tremulous, and irritable, and the client's
pulse and blood pressure are elevated. The client states to the nurse, "I have to get out of here."
Which is the most likely cause for the client's symptoms and behavior?
A Dissatisfaction with hospital care
B Anxiety related to being hospitalized
C Early stage of alcohol withdrawal
D Shock related to the injuries

Question Explanation
Correct Answer is C
Rationale: The client is exhibiting signs and symptoms of alcohol withdrawal, such as sweating,
tremors, hyperactivity, hypertension, and tachycardia. The client most likely wants to leave the
hospital to obtain alcohol. The client must be monitored very closely for progression to more
severe alcohol withdrawal symptoms, including seizures and delirium tremens (DTs). Not being
satisfied with the care and anxiety or shock related to the accident are unlikely to be the cause for
the physical and behavioral manifestations that the client is exhibiting.
Concepts tested

Question 1222
The nurse is caring for a client who was seriously injured in a bus accident. Several people were
killed in the accident, including the client's son. The client's spouse, who was not injured, has
had frequent outbursts of yelling at the staff. The client’s spouse is now threatening legal action
due to "inadequate care." Which interventions should the nurse implement? Select all that apply.
A Notify the health care provider about the situation
B Notify hospital security to remove the client’s spouse

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C Provide information about grief support groups
D Request a change in client assignment
E Allow the spouse to express their feelings

Question Explanation
Correct Answer is C, E
Rationale: Anger and frustration are common reactions when a person is experiencing a sudden,
traumatic loss. The nurse should allow the spouse to verbalize their feelings because this can
help with the grief process. The nurse can provide both the client and spouse with referrals to
grief support groups. Notifying the health care provider is not needed at this time. Presently, the
spouse is not posing a danger to the client, staff, or other visitors, so removal is not needed.
Changing the client assignment would not facilitate a therapeutic nurse-client relationship and
the development of trust between the client, the client’s spouse, and the health care team.
Concepts tested

Question 1223
Question 19
A client at 39-weeks gestation has just delivered and experienced a fetal demise. The client's
partner is at the bedside. Which nursing actions are appropriate at this time? Select all that apply.
A Ask the parents if they would like to perform any special cultural rituals for the infant
B Clean and wrap the baby and offer it to the parents to view or hold if desired
C Stay with the parents and offer supportive care to both of them
D Place the infant on the maternal abdomen, skin-to-skin
E Offer the option of an autopsy to determine cause of death

Question Explanation
Correct Answer is A, B, C
Rationale: Staying with the parents at this moment and offering physical and emotional support
is appropriate. It is also appropriate to prepare the infant in a way that demonstrates care and
respect for the baby and to offer everyone the opportunity to view and/or hold the infant as they
desire. Placing a newborn on the mother's abdomen would be appropriate for a live birth but
inappropriate for this situation. The nurse should ask if there are cultural or religious rituals they
would like to perform or have performed for their infant. Although an autopsy should eventually
be discussed, it would not be appropriate immediately after the birth.
Concepts tested

Question 1224
The nurse is providing care for a client who has been diagnosed with terminal cancer. The nurse
notes that the client's wife is not visiting very often. When she does visit the client, she only
stays for a brief time, stands in the corner, and does not approach the client during interactions.
Which of the grieving processes is the client's wife most likely experiencing?
A Anticipatory grief
B Death anxiety

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C Perceived loss
D Disenfranchised grief

Question Explanation
Correct Answer is A
Rationale: In cases of terminal illness, family members may begin the grieving process before
the client has passed away. This is known as anticipatory grief. The result of anticipatory grief is
the family member becomes distant and detached from the client, and the client feels isolated and
alone. Death anxiety is worry or fear related to dying that may be seen with a grieving child.
Disenfranchised grief is when the individual cannot acknowledge the loss, perhaps because of an
unrecognized loss, such as abortion or suicide. Perceived loss is a loss that cannot be verified by
others, such as a loss of self-esteem or a loss of control.
Concepts tested

Question 1225
The nurse is working with a group of clients who have eating disorders. The clients are to have
their weight taken wearing only a hospital gown and underwear. No street clothing is allowed.
Which is the most appropriate explanation for this practice?
A Symbolically removes barriers between the client and staff
B Eliminates the risk of hiding objects in clothing or shoes
C Promotes feelings of success with gaining weight
D Allows the nurse to better assess the client's skin

Question Explanation
Correct Answer is B
Rationale: Some of the goals of treating anorexia nervosa are to restore clients to a healthy
weight and to normalize eating patterns. Clients should be weighed in the morning after they
have voided. They should only wear a hospital gown and underwear; wearing street clothing
allows the client to hide objects in their pockets or shoes that will add weight and make it appear
as if the client is getting better. Some therapists believe the client should initially be weighed
"blind" (backing up onto the scale), so they can't see the numbers. Regardless of how it is done,
being weighed is anxiety-provoking for the client and must be approached with sensitivity and
compassion.
Concepts tested

Question 1226
A client is transported to the emergency department with minor injuries suffered during a home
fire. The client exhibits intense anxiety after learning that the home was completely destroyed.
Which intervention should the nurse implement first?
A Determine what community and personal support resources are available
B Provide a brochure on methods that promote relaxation
C Suggest that the client rent an apartment with a sprinkler system
D Explore the feelings of grief associated with the loss of the home

Question Explanation

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Correct Answer is A
Rationale: The client is experiencing a crisis situation, and it is important to provide available
resources. Although the sudden loss of a home can cause significant emotional distress, the most
important initial intervention focuses on identifying community resources and obtaining
assistance for housing and other immediate needs. Information about home safety, relaxation
exercises, and grief counseling can wait until the client's basic need for shelter is met.
Concepts tested

Question 1227
A client of South American heritage refuses emergency treatment until a curandero is called. A
curandero is a type of folk healer. What should the nurse understand about the client’s request?
A The nurse must first obtain approval from the client’s health care provider.
B The client's superstitious beliefs will interfere with appropriate treatment.
C The use of holistic healing practices will eliminate the need for medical treatment.
D Culturally competent care should incorporate the client’s preferences.

Question Explanation
Correct Answer is D
Rationale: Providing culturally competent nursing care means a commitment to incorporating a
client’s cultural preferences and beliefs about health and illness in their plan of care. A curandero
is a folk healer (or shaman) who tends to use a holistic approach that includes herbs, aromas, and
rituals to treat the ills of the body, mind, and spirit. Many times a curandero or other type of folk
healer will work with traditional Western health care providers to help the client achieve optimal
health. Approval from the health care provider is not required, and alternative healing
approaches can complement but not necessarily eliminate the need for traditional treatments.
Concepts tested

Question 1228
The nurse is caring for a client with schizophrenia who reports seeing spiders crawling on the
walls, over the bed, and on the food tray but denies feeling spiders crawling on their skin. The
nurse examines the client’s room and determines that there are no spiders in the room. How
should the nurse document the interaction in the client’s medical record?
A Client claims that there are spiders all over the place. Reoriented to reality and reassured that
the spiders have left.
B Client complains of spiders in their room. Reminded that there are no spiders present.
C Client reports seeing spiders in their room. No spiders found upon inspection. Client seems to
experience visual hallucinations.
D Client is imagining spiders in their room. Educated about hallucinations related to
schizophrenia.

Question Explanation
Correct Answer is C
Rationale: Documentation should be factual and nonjudgmental and describe objectively what
transpired. Words like "complains", "imagining," and "claims" have a disapproving and negative
undertone. It is important to follow up on the client's statements by looking to see if there are
indeed spiders in the room. When the client sees something that is not present, this is called a
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visual hallucination. The other choices do not describe the interaction accurately. Adding
information such as "educated on" should only be documented if the education actually occurred.
Concepts tested

Question 1229
A client with a diagnosis of depression has recently been acting suicidal and is now more social
and energetic than usual. Smiling, the client tells the nurse, "I've made some decisions about my
life." Which is the best response by the nurse?
A "I'm so glad to hear that you've made some decisions."
B "Are you thinking about killing yourself?"
C "I will make sure to document that in your medical record."
D "You need to discuss your decisions with your therapist."

Question Explanation
Correct Answer is B
Rationale: A suicide risk assessment uses direct rather than indirect language. The client's
behavior in the scenario is highly suspicious that the client has probably made a plan to commit
suicide. When the nurse assesses a client's suicide ideation, it is important to identify and
distinguish ideas (thoughts) from plans (intentions). This requires very direct questions such as
"Are you thinking about harming (or killing) yourself in any way?" The other responses are not
direct enough, restate information that is already known, and do not assess if the client has made
a plan.
Concepts tested

Question 1230
An 8-year-old child is admitted to the inpatient pediatric mental health unit. After the child's
parent leaves, the child cries inconsolably and refuses to eat dinner. Which action by the nurse
is most appropriate?
A Tell the child that they will not be allowed to play with others if they do not eat
B Explain that the parent will be upset if the child does not cooperate
C Offer to play a card game with the child
D Remind the child of the expectation to eat some of the dinner

Question Explanation
Correct Answer is C
Rationale: The most appropriate intervention is one that aligns with the child's developmental
stage and provides emotional safety for the child. Play can be used as a distraction for a child of
this age and facilitates the development of a safe and trusting relationship. Play also helps
children express their feelings more easily (through toys instead of words). A simple card game
would be appropriate to use with an 8-year-old child. The other actions are non-therapeutic or
punitive and should be avoided.
Concepts tested

Question 1231

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The nurse is caring for a young adolescent client who was involved in a motor vehicle crash
where several of the client’s friends died. Which initial psychological response to the loss would
the nurse expect from the client?
A Acceptance
B Denial
C Aggression
D Depression

Question Explanation
Correct Answer is B
Rationale: Denial is typically the first (initial) stage in the grief process and coping with a loss.
The other behaviors tend to be seen later during the grieving process with acceptance of the loss
being the final step or phase.
Concepts tested

Question 1232
The nurse is reviewing information about traditional Chinese medicine. Based on the Chinese
cultural belief system, illness is usually attributed to which cause?
A A failure to keep the physiological processes of life in balance with nature
B The lack of access to traditional Chinese herbs and teas in the United States
C The absence of recommended childhood vaccinations
D The differences in cultural norms between Chinese and Western societies

Question Explanation
Correct Answer is A
Rationale: A common belief in traditional Chinese medicine proposes that health is regulated by
the opposing forces of yin and yang. Under normal conditions, there is a dynamic equilibrium of
these two physiological processes. Yin is the negative force characterized by darkness, cold, and
emptiness. Yang is the positive force that represents light, warmth, and fullness. Illness occurs
when the balance between yin and yang is broken. The other explanations as reasons for illness
are incorrect.
Concepts tested

Question 1233
The nurse is caring for a female client with a body mass index of 45. Which conditions should
the nurse plan to discuss with the client due to the risks associated with her weight? Select all
that apply.
A Gallstones
B Hyperthyroidism
C Obstructive sleep apnea
D Chronic obstructive pulmonary disease
E Breast cancer
F Coronary artery disease

Question Explanation

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Correct Answer is A, C, E, F
Rationale: A client with a body mass index (BMI) of 40 or greater is considered extremely (i.e.,
morbidly, severely) obese. A number of health risks are associated with obesity, including
obstructive sleep apnea (OSA), colorectal and breast cancer, gallstones, and cardiovascular
diseases (e.g., hypertension, atherosclerosis, and coronary artery disease). Chronic obstructive
pulmonary disease (COPD) is associated with smoking or exposure to smoke. Hyperthyroidism
is not associated with being overweight or obese.
Concepts tested

Question 1234
The nurse is admitting a 15-year-old client with a fracture of the arm that requires surgery. The
adolescent is crying and unwilling to talk. Which action by the nurse would be most appropriate
at this time?
A Try to distract the client with a computer game
B Give the client some privacy
C Make arrangements for friends to visit
D Reassure the client that the surgery will go fine

Question Explanation
Correct Answer is B
Rationale: A 15-year-old adolescent needs the opportunity to process and express any emotions
privately. The nurse should facilitate privacy in whatever manner possible. It is important for the
nurse to address any concerns directly. Providing false reassurance by stating that there won't be
any problems in surgery may be seen as disingenuous. Using "distraction" is not an age-
appropriate response with an adolescent. Friends may visit later when the time is more
appropriate.
Concepts tested

Question 1235
The nurse is caring for a female client who is a victim of domestic violence. The client tells the
nurse that she told the batterer that she needs a little time away. The nurse should counsel the
client to expect which most likely response from the batterer?
A With acceptance, realizing that the relationship is in trouble
B With a new commitment and an opportunity to seek counseling
C With relief, welcoming the separation as a means to become a better person
D With fear of rejection, resulting in increased rage toward the client

Question Explanation
Correct Answer is D
Rationale: Individuals who commit domestic violence are usually characterized as persons with
low self-esteem. They are pathologically jealous, very possessive, and consider their partner as a
possession. When the battered client shows any signs of independence, the batterer will most
likely feel threatened, become angrier, and increase attempts to keep her isolated from others and
totally dependent on him. He may demand to know where she is at every moment because he
achieves power and control through intimidation.
Concepts tested
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Question 1236
An American Indian tribal leader visits his newborn son at the hospital and performs a traditional
ceremony that involves feathers and chanting or singing. Which action by the nurse is an
example of cultural competence?
A The nurse discussed the situation with a fellow nurse and decides to contact social services to
perform a home evaluation before the newborn is discharged.
B The nurse begins a discussion with the client’s parent by asking, "Can you tell me about other
traditions that your tribe uses?"
C The nurse notifies the nursing supervisor to request that the parent stop chanting or singing
because of noise concerns for other clients.
D The nurse silently reflects about their own biases regarding American Indians and how they
can influence how to approach the client’s parent.

Question Explanation
Correct Answer is D
Rationale: Providing culturally competent care begins with an in-depth self-examination of one's
own background and recognition of one’s biases, prejudices, and assumptions about other
people. American Indian/Alaska Natives encompass diverse tribal groups with differing
practices, traditions, and ceremonies. Tribal traditions may vary, but similarities across traditions
include the use of sweating and purging, herbal remedies, and ceremonies in which a shaman (a
spiritual healer) makes contact with spirits to ask their direction in bringing healing to people and
promoting wholeness and healing.
Concepts tested

Question 1237
The nurse is admitting a client to the outpatient mental health unit and notices that the client is
shifting positions frequently, wringing their hands, and avoiding eye contact. Which intervention
would be most appropriate at this time?
A Ask the client what they are feeling at this moment
B Assess the client for auditory hallucinations
C Accept the behavior as a side effect of medication
D Refocus the discussion on a less anxiety-provoking topic

Question Explanation
Correct Answer is A
Rationale: An initial step in establishing a therapeutic client-nurse relationship is to use the
senses and assess, observe, and identify the client's behavior. The nurse should then seek
validation from the client of the accuracy of observations and interpretations. This can be
accomplished by asking the client directly what they are currently feeling or thinking. The nurse
should avoid making assumptions or drawing conclusions based on the limited visual data. The
client may simply need to use the restroom but might be reluctant to communicate this
elimination need.
Concepts tested

Question 1238
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A client who is believed to be homeless is brought to the emergency department by the police.
The client is wearing dirty and torn clothes, has difficulty concentrating, is unable to sit still, and
speaks in a loud tone of voice. Which nursing intervention would be most appropriate for the
client at this time?
A Distract the client by offering snack foods and magazines to read
B Place the client in a single room that is quiet and further away from others
C Speak with the police officers and insist that the client is taken to the local homeless shelter
D Place the client in seclusion and begin the process of an involuntary admission

Question Explanation
Correct Answer is B
Rationale: Unfortunately, many homeless individuals in the United States suffer from mental
illness and a lack of access to appropriate services. It is not uncommon for those individuals to
be brought to an emergency room by local law enforcement. The client in the scenario appears to
exhibit symptoms of mania. To be placed in a dark, quiet room with minimal stimulation will
help reduce the overstimulation of the client. By preventing behavioral escalation, this approach
promotes safety for the client and staff. The client is not exhibiting aggressive behaviors so
seclusion or involuntary admission is not appropriate at this time. Attempting to distract the
client does not help during a manic episode. The client requires appropriate mental health
services and should not be taken to a shelter at this time.
Concepts tested

Question 1239
The nurse at a college health center is performing an assessment on a 20-year-old student. The
student reports that they have legally obtained and used medical marijuana for migraine
headaches. Which priority teaching should the nurse provide to the client?
A "There is a concern that marijuana impairs the structure of lung tissue."
B "Frequent use of marijuana may affect your short-term memory."
C "It is important to avoid driving while under the influence of marijuana."
D "Marijuana use may decrease the body's ability to resist infections."

Question Explanation
Correct Answer is C
Rationale: Although the information about the potential effects of marijuana is correct and based
on research, it is not appropriate for the nurse to focus or comment on. The
nurse's priority should be to reinforce safety with the client and remind the client to refrain from
driving due to the effects of marijuana on mental alertness and concentration while operating a
vehicle.
Concepts tested

Question 1240
The nurse is assisting a client with substance use disorder to deal with issues of guilt. Which
statement by the nurse is most appropriate?
A "You've caused a great deal of pain to your family. It will take time for them to forgive you."

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B "Don't worry; it is a typical response due to your drinking behavior and will eventually go
away."
C "What do you feel most guilty about? What steps can you begin to take to help you lessen this
guilt?"
D "Don't focus on the guilty feelings. These feelings will only lead to drinking and taking
drugs."

Question Explanation
Correct Answer is C
Rationale: Therapeutic communication is key for clients with substance use disorder (SUD) who
are struggling with feelings of guilt. The nurse should encourage the client to get in touch with
their feelings and to utilize problem-solving steps to help resolve the feelings of guilt. This is
accomplished by asking open-ended questions that prompt the client to reflect and think about
their past behavior. The other responses are nontherapeutic.
Concepts tested

Question 1241
The nurse is working at an adult daycare program. An older adult client who has been diagnosed
with a neurocognitive disorder (dementia) is crying and repeatedly saying, "I want to go home.
Call my mommy to come get me." Which intervention by the nurse is most appropriate?
A Inform the client that they must wait until the program ends at 5 pm to leave
B Direct the client to a group activity while reorienting them to person and place
C Give the client detailed information about what the client will be doing throughout the day
D Engage with the client and prompt the client to join an exercise group

Question Explanation
Correct Answer is D
Rationale: Comfort and distraction are key approaches when working with this type of client.
They are the kindest and most effective actions for clients who have varying degrees of a
neurocognitive disorder, commonly referred to as dementia. The distressed, disoriented client
should be gently engaged with and distracted with an easy activity to reduce fear and increase a
sense of safety and security. Reorientation is often ineffective, especially when the client is
upset. Being forced to be in a group may exacerbate the client's behavior. The other actions are
not appropriate for this situation.
Concepts tested

Question 1242
The nurse in the emergency department suspects domestic violence as the cause of a client's
injuries. Which action should the nurse take first?
A Refer the client to a victim advocate
B Interview the client privately
C Photograph the specific injuries and include with documentation
D Ask the client if there are any old injuries

Question Explanation

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Correct Answer is B
Rationale: It is critical to separate the client from anyone who came in with the client, whether it
be a partner or friend, and interview the client in private. With the use of the nursing process, the
nurse’s first action when a client is unstable or has potential problems is further assessment of
the situation. The correct answer is the one most focused on gathering more information. During
the private intake assessment, the nurse would possibly institute the other actions in the
remaining options.
Concepts tested

Question 1243
The palliative care nurse is developing a plan of care for a client diagnosed with terminal cancer.
Which goal should be the priority?
A Collaborate with the interdisciplinary team
B Ensure the client is free from pain
C Discuss the options for advance directives
D Refer the client's family to support services

Question Explanation
Correct Answer is B
Rationale: Following Maslow's hierarchy of needs, the nurse should prioritize the physiologic
needs of the terminally ill client, e.g., effective pain management. After the client's physiological
needs have been met, the nurse should focus on the other goals.
Concepts tested

Question 1244
The school nurse is developing education materials for teachers on how to improve
communication with students with autism spectrum disorders (ASDs). Which information should
the nurse include?
A Engage the child in role play to communicate.
B Use facial expressions and gestures when speaking.
C Provide the child with written documents to help communication.
D Avoid eye contact to prevent making the child nervous

Question Explanation
Correct Answer is B
Rationale: Autism spectrum disorders (ASDs) are neurodevelopmental disorders that cause
challenges in verbal and nonverbal communication, social interaction and repetitive behavior.
Communication impairments range from delayed to no verbal speech and varying ability in
interpreting nonverbal cues. Certain techniques can be used to facilitate communication in
children with autism such as using nonverbal motions to help convey what is being orally
communicated. Facial expressions, gestures and body language will all help a child with autism
understand verbal language better. The other approaches are not suitable communication
techniques for a child with ASD.
Concepts tested

Question 1245
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The nurse in a pediatrician's office is completing a physical assessment on an adolescent male
recently diagnosed with growth hormone deficiency. The adolescent is withdrawn and doesn't
make eye contact. He states, "I don't know why I am here, it's too late to help me anyway." What
is the best response by the nurse?
A "Tell me more about what you mean by too late to help."
B "Stay positive. Things will get better."
C "Have you thought about killing yourself?"
D "Do you want the doctor to come in and talk to you?

Question Explanation
Correct Answer is A
Rationale: Growth hormone deficiency results from an insufficient secretion of growth hormones
from the pituitary gland. A deficiency in this hormone results in abnormally slow growth and
short stature with normal body proportions. Often the diagnosis is not made until adolescence
when the child's difference in stature compared to peers is dramatically distinctive. It is common
for the child to feel sadness, anger and confusion. It is important for the nurse to provide
emotional support by allowing the child to express his or her feelings. Asking an open-ended
question and gently encouraging the client to verbalize their feelings is a therapeutic
communication technique and the best way to respond in this situation. Based on the client's
response, the nurse can decide on how to proceed.
Concepts tested

Question 1246
The nurse in a well-baby clinic is speaking with the parents of a 2-month-old infant who has
been colicky, not sleeping well and crying a lot. The parents seem tired and frustrated and tell the
nurse that they have been having frequent arguments. How should the nurse respond?
A "A new baby is a lot of work. Have you thought about finding a sitter?"
B "Arguing in front of the baby will hurt its development."
C "Being new parents can be frustrating. What have you tried to help the baby sleep?"
D "I think it is necessary for me to notify social services. "

Question Explanation
Correct Answer is C
Rationale: Shaken baby syndrome (SBS) is a form of child abuse where an infant or young child
is violently shaken. SBS can cause intracranial bleeding, retinal hemorrhage and death. SBS is
often triggered by inconsolable crying and caregiver frustration. Parents who are lacking sleep
and have infants who continuously cry are at greater risk for shaking their infant. The nurse
should respond in a therapeutic manner. By reaffirming the parents' feelings and inquiring about
what the parents have tried to help the baby sleep with a positive, open-ended question allows
the parents to verbalize their feelings. This will help the nurse determine what actions to take
next. The other responses are presumptive and nontherapeutic.
Concepts tested

Question 1247

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A hospice nurse is caring for a terminally ill child in the home. The child's parent is tearful,
angry and overly focused on what life will be like after the child has died. What is
the best approach for the nurse to take with the parent?
A Encourage the parent to spend more time with the child's siblings.
B Remind the parent not to let the child witness their feelings and grief.
C Refer the parent to a social worker or grief counselor.
D Discuss the grieving process and differences in ways people grieve.

Question Explanation
Correct Answer is D
Rationale: Goals of hospice care include care for the child and the child's immediate family.
Interventions are focused on physical, psychological, social, and spiritual needs. The parent is
exhibiting signs of anticipatory grief. A person experiencing anticipatory grief feels and
expresses grief emotions before their loved one dies. It is important for the nurse to recognize
this type of grief and to assist the parent with coping with their feelings. Discussing the grieving
process helps to facilitate understanding of what the parent is feeling and experiencing. The goal
would be to support the parent in focusing on the present and making the most of the time they
have left with their child. The other approaches do not facilitate understanding and appropriate
management of anticipatory grief.
Concepts tested

Question 1248
The nurse is admitting a severely injured client to the emergency department. The family
member who accompanied the client is screaming at the nurse, "Someone better start doing
something right away!" Which statement would be the best response by the nurse?
A "You have no right to speak to me this way. You need to calm down."
B "If you do not calm down, I will notify the local police."
C "I can't think when you are yelling at me. Please talk in a normal voice."
D "I know you are upset. I need you to calm down or I will call security."

Question Explanation
Correct Answer is D
Rationale: The family member’s controlling response is related to the stress of the situation and
fear that their loved one might die. The challenge for the nurse is to apply interventions that de-
escalate the family member’s response to the stressful or traumatic event. The key to effective
limit-setting is acknowledging that the family member is upset, using commands to express the
desired behavior (e.g., "I need you to calm down.") and providing logical and enforceable
consequences for non-compliance (e.g., calling security). The nurse should keep a comfortable
distance from the agitated person, speak calmly, and stay at eye level
Concepts tested

Question 1249
The nurse is admitting a client who does not speak English. Which of the following interventions
should the nurse include when caring for the client? Select all that apply.
A Plan on taking twice as long as usual to complete nursing interventions.

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B Pay attention to any effort by the client to communicate.
C Use a trained medical interpreter provided through the facility's interpreter services.
D Make a note of the client's preferred language in their medical record.
E Verify that the client's 9-year-old child speaks English well before asking the child to
translate.
F Speak in a loud voice and use exaggerated hand gestures to communicate with the client.

Question Explanation
Correct Answer is A, B, C, D
Rationale: Providing culturally competent care requires the nurse to advocate for clients who do
not speak English or whose English proficiency is limited. Advocating for those clients can be
accomplished by noting the client's preferred language in their medical record and using an
agency interpreter or interpreter services. The nurse should only use a trained medical
interpreter, especially for sensitive tasks such as obtaining informed consent. Using an interpreter
will require more time than usual, and therefore the nurse should plan to take extra time when
caring for the client. Not all interactions with the client will require a qualified interpreter. Show
respect for the client by paying close attention to the client's attempts to communicate with the
health care team. It is recommended to speak in a low, moderate voice and avoid excessive hand
gestures, because they can give the impression that the nurse is angry and yelling at the client.
The nurse should avoid using children as interpreters.
Concepts tested

Question 1250
The nurse is admitting a client to an inpatient crisis unit with a diagnosis of acute mania. The
client has been placed in seclusion and it is now time for the client's dinner. Which action should
the nurse take next?
A Allow the client to eat in the dining room.
B Hold the client's meal until seclusion is over.
C Obtain a contract with the client for safe behavior.
D Serve the client's dinner in the seclusion room.

Question Explanation
Correct Answer is D
Rationale: Seclusion is ordered by a health care provider (HCP) and requires continuous
observation by the nurse, unless the order is discontinued or amended. Seclusion is used for the
management of violent behavior that jeopardizes the safety of the client and staff members, and
when less restrictive interventions have been ineffective. Meals can be eaten in the seclusion
room with the nurse continuing the 1:1 observation. Meals must be offered on time and should
not be withheld. A contract for safe behavior will most likely not be effective during acute
mania. Once the client is deemed "safe" and cooperative, the client should be able to eat in the
dining room with other clients.
Concepts tested

Question 1251

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Which action by a client receiving hospice care might indicate to the nurse that the client is
struggling to meet developmental tasks in the end-stage of life?
A Reports that they can't forgive themselves or others for shortcomings.
B States that they feel calm even when their health changes are chaotic.
C Repeatedly discusses past life events and experiences with visitors.
D Establishes a power of attorney over their finances and health care.

Question Explanation
Correct Answer is A
Rationale: Expected milestones for a client experiencing end-of-life include closure to worldly
affairs such as finances, and at times activities and social relationships. This is indicated by the
client's acceptance of the need for estate planning and an emotional withdrawal from worldly
values, with a shift in focus to the transcendent, which can be found in discussing higher powers,
transcendent beliefs and values, or feelings of acceptance or calm, even as their health
deteriorates. Reminiscing and relating the past, as well as reconciling it and accepting it are also
healthy milestones. The client who is unable to forgive themselves or others may be struggling at
the end-of-life to meet these milestones.
Concepts tested

Question 1252
A client is in the rehabilitation phase after experiencing severe facial burns. Which behavior by
the client best indicates that the client is coping effectively with the injury?
A The client asks for information about a support group for burn survivors.
B The client plans to work from home after discharge from the facility.
C The client is looking forward to attending their high school reunion.
D The client appears cheerful when the spouse visits.

Question Explanation
Correct Answer is C
Rationale: Looking forward to attending an event is future-oriented. The client will likely see
others who they have not seen in some time, indicating acceptance of one's new appearance.
Resuming work is a positive sign but working from home may indicate the client does not want
to be exposed to others in person. A support group is also a good idea but is not as indicative of
self-acceptance as attending a large social event. A cheerful mood with the spouse is a positive
sign but this is a one-on-one interaction with someone the client is most likely comfortable with.
Concepts tested

Question 1253
The nurse is talking with a client with schizophrenia when the client abruptly says, "The moon is
full. Astronauts walk on the moon. Walking is a good health habit." Which is
the best description for the client's speech pattern?
A Word salad
B Loose associations
C Flight of ideas
D Neologisms

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Question Explanation
Correct Answer is B
Rationale: Clients with schizophrenia often experience disorganized thinking that can manifest in
various speech patterns. With loose associations, thinking is characterized by speech in which
ideas shift from one unrelated subject to another. Typically, the individual with loose
associations is unaware that the topics are unconnected. Neologisms refers to making-up or
inventing words that have personal meaning to the client but make no sense to others. Flight of
ideas describes the nearly continuous flow of speech, jumping from one unconnected topic to
another. Word salad refers to stringing together real words into nonsensical "sentences" that have
no meaning for the listener.
Concepts tested

Question 1254
The nurse is developing a plan of care for a client with a substance use disorder. Which nursing
problem should be the priority?
A Impaired social relationships
B At risk for injury
C Alterations in thought processes
D Disturbed self-esteem

Question Explanation
Correct Answer is B
Rationale: Substance use and abuse often impairs judgment which increases the risk of accidents
and injuries. Studies indicate that alcohol is a factor in more than 50% of motor vehicle fatalities,
53% of all deaths from accidental falls, 64% of fatal fires and more than 80% of suicides.
Although the nurse should include interventions to address the other problems, the priority is to
prevent the client from sustaining an injury, either accidental or self-inflicted.
Concepts tested

Question 1255
A client tells the nurse, "I have something very important to tell you if you promise not to tell
anyone." Which is the best response by the nurse?
A "I am required to report everything to your doctor."
B "That depends on what you tell me."
C "I must document all information you tell me."
D "I cannot make you such a promise."

Question Explanation
Correct Answer is D
Rationale: Secrets are inappropriate in therapeutic relationships, and are counterproductive to the
therapeutic efforts of the interdisciplinary team. Secrets may be related to risk for harm to self or
others. The nurse should help the client understand the rights, limitations and boundaries
regarding confidentiality and professional relationships by directly stating to the client that such
a promise cannot be made. Although documenting the client’s statements and reporting them, if

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indicated, to the health care team is also appropriate, they do not help to set boundaries for the
client’s manipulative behavior.
Concepts tested

Question 1256
During a conversation with a client who has osteoarthritis, the client says, "I am so frustrated
with this disease and my disabilities." What is the best response by the nurse?
A "Has your spouse been supportive of your diagnosis?"
B "Can you tell me more about what is frustrating you?"
C "What medications have you been taking for pain?"
D "Do you use any assistive devices to help you walk?"

Question Explanation
Correct Answer is B
Rationale: Osteoarthritis (OA) is characterized by the progressive deterioration and loss of
cartilage in one or more joints. OA is a chronic condition that may cause permanent changes in
lifestyle. In this scenario, the nurse should collect more data about the specific cause of the
client's frustration and disabilities to help develop an appropriate plan of care. The other options
about pain medications, assistive devices and spousal support are relevant but the nurse first
needs to collect more data about what specifically is frustrating the client.
Concepts tested

Question 1257
The nurse is caring for a client who refuses to take their prescribed medications because the
client prefers to take alternative, herbal preparations. Which action should the nurse take first?
A Discuss the herbal preparations with the client
B Report the behavior to the client's family
C Explain the importance of medication to client
D Contact the client's primary care provider

Question Explanation
Correct Answer is A
Rationale: Following the nursing process, the first action the nurse should take is to further
assess the situation. The nurse must look at all the factors that influence the client's refusal.
Although it is important to contact the HCP, it would not be the first action to take. It is
important for clients to be informed about the management of their medical conditions.
However, providing more information to the client is not as important as figuring out why they're
not taking their prescribed medications. Notifying the client's family would violate client
confidentiality and should only be done under certain circumstances.
Concepts tested

Question 1258

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The nurse is caring for a client who is the victim of intimate partner violence. The nurse
understands that during the "tension building" phase, the client is most likely to experience
which feeling?
A Anger
B Optimism
C Compassion
D Helplessness

Question Explanation
Correct Answer is D
Rationale: Intimate partner violence is all about gaining and maintaining control over the victim.
In the 'tension building phase', the victim senses the rising tension in the abuser. The victim tries
to appease the abuser and then feels guilty when the appeasement does not work. They also
believe that no one can help them. Instead of feeling angry, victims of abuse feel helpless,
depressed and anxious. Victims may become more compliant or withdrawn; they cannot allow
themselves to become angry or fight back. Victims of intimate partner violence do not feel
optimistic or compassionate. They often have poor self-esteem, which makes them more
vulnerable to abuse.
Concepts tested

Question 1259
The nurse has established a therapeutic relationship with a client. The nurse understands that a
therapeutic nurse-client interaction occurs when the nurse performs which of the following
actions?
A Attempts to interpret the client's patterns of communication
B Encourages the client to engage in evaluating the nursing care and services they are receiving
C Praises the client for suppressing their feelings and emotions
D Advises the client on ways to resolve their problems

Question Explanation
Correct Answer is B
Rationale: The nurse must work with clients to ensure that all interactions meet the therapeutic
needs of the client. A nurse-client relationship develops through the exchange of positive
communication. In a therapeutic nurse-client interaction, the nurse should not advise a client how
to solve their problems. Clients should be given the support to make their own decisions. The
nurse should not encourage the client to suppress their feelings. Clients should be encouraged to
verbalize their feelings. The nurse should encourage the client to be a participant in their plan of
care. This would include encouraging the client to engage in evaluating the nursing care and
services they are receiving. The nurse should not attempt to interpret the client's communication.
Communication should be clarified in order to ensure that the nurse has received the correct
message.
Concepts tested

Question 1260
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The psychiatric nurse is caring for a client experiencing mania related to bipolar disorder. The
client has lost 12 pounds (5.5 kg) over the last three weeks. The client frequently paces the unit
and is difficult to redirect. Which intervention should the nurse implement to promote nutritional
intake?
A Insert a nasogastric tube for enteral tube feedings
B Ask the client's family to bring food for the client
C Offer the client high calorie finger-foods
D Allow the client to eat meals in their room

Question Explanation
Correct Answer is C
Rationale: Clients with bipolar disorder who are experiencing mania exhibit increases in energy,
restlessness, and distractibility. These clients may demonstrate a reduction in caloric intake and
subsequent weight loss due to their inability to sit and eat meals. Therefore, promoting adequate
nutrition is paramount and the client should be offered high calorie, finger foods so that they can
eat while on the move. The other interventions would not be appropriate for this client or helpful
in promoting nutritional intake.
Concepts tested

Question 1261
The office nurse is speaking with a client who is in recovery from alcohol use disorder. The
client asks, "Will it be okay for me to just drink at special family gatherings?" Which response
by the nurse is most appropriate?
A "At this phase you have to be very careful not to lose control. Therefore, confine your
drinking only to family gatherings."
B "At your next Alcoholic Anonymous meeting, discuss the possibility of limited drinking with
your sponsor."
C "You must abstain from drinking alcohol for the rest of your life since you are at high risk for
becoming addicted again."
D "Since you are in recovery, you need to get in touch with your feelings. Do you want a drink?"

Question Explanation
Correct Answer is C
Rationale: Recovery from alcohol requires total abstinence from the desired substance. To take
one drink has a high potential for the client to return to addictive behaviors. The nurse should
answer questions honestly and provide factual information. Therefore, the most appropriate
response is for the client not to return to drinking alcohol; even at family or social gatherings.
The client should abstain from drinking any alcohol.
Concepts tested

Question 1262
The nurse is caring for a client who voluntarily admitted herself to the substance abuse unit. The
next day the client says to the nurse, "My partner told me to get treatment or we would have to
get divorced. I don't believe I really need treatment, but I don't want my partner to leave me."
Which of the following responses by the nurse would be most appropriate?

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A "In early recovery it's quite common to have mixed feelings. Perhaps it would be best to seek
treatment on an outpatient basis."
B "In early recovery it's quite common to have mixed feelings. I didn't know you had been
pressured to come."
C "In early recovery it's quite common to have mixed feelings. Let's discuss the benefits of
sobriety for you."
D "In early recovery it's quite common to have mixed feelings. Unmotivated people can't get
well."

Question Explanation
Correct Answer is C
Rationale: Only the correct option focuses on the client and the client's problem. This is the best
response because it gives the client the opportunity to decrease ambivalent feelings by focusing
on the benefits of sobriety. The other options are not therapeutic and do not have the client's best
interests at heart. The option about being pressured to come might encourage clients to project
blame for their behavior on someone else. The option of outpatient care might be a goal for this
client, but it is inappropriate to suggest outpatient counseling at this time. To label the client's
behavior as "unmotivated" might simply reinforce the client's ambivalence about treatment.
Concepts tested

Question 1263
The nurse is caring for a client who exhibits delusional behaviors and refuses to eat because of a
belief that the food is poisoned. Which of the following responses should be the initial response
by the nurse?
A "You think that someone wants to poison you?"
B "These feelings are a symptom of your illness."
C “You're safe here. I won't let anyone poison you."
D "Why do you think the food is poisoned?"

Question Explanation
Correct Answer is A
Rationale: This response acknowledges perception of the client's comment through a reflective
question. This reflective question presents an opportunity for discussion, clarification of meaning
and expressing doubt. It also provides for verification of the nurse's perceptions and the client's
communication.
Concepts tested

Question 1264
The nurse is called to the front desk of a health clinic where an angry client is loudly demanding
a refill for a previous prescription of alprazolam. "I feel nauseated, I'm stressed with work and
caring for my mother who has dementia is so stressful that I can't sleep. I want a prescription,
now!" What action should the nurse take?
A Provide the client with pamphlets and a referral to a self-help group for caregivers of the
elderly.
B Take the client to a quiet room and assess for acute withdrawal from benzodiazepines.

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C Inform the client that the physician will be with her soon and she should have a seat in the
waiting room.
D Anticipate the need for flumazenil to counteract the effects of alprazolam.

Question Explanation
Correct Answer is B
Rationale: Alprazolam (Xanax) is a benzodiazepine. Benzodiazepines have abuse potential. The
client is demonstrating several signs of acute withdrawal from benzodiazepines, including
irritability, sleeplessness and nausea. The priority action would be to assess the client for acute
withdrawal and anticipate a tapering dose. While the physician will need to evaluate the client,
the nurse can take a history, perform a nursing assessment and establish a therapeutic
relationship. The client will eventually need a variety of referrals to help with identified
stressors, but this can wait until after treatment for withdrawal. Flumazenil is a benzodiazepine
receptor antagonist and precipitates acute withdrawal.
Concepts tested

Question 1265
The nurse is admitting a client to an acute inpatient psychiatric unit. Which approach would
be most useful to gather information from the client?
A Allow the client to talk about whatever they want
B Observe the client's nonverbal behaviors carefully
C Elicit the client's description of experiences and thoughts
D Adhere to preplanned interview goals and structure

Question Explanation
Correct Answer is C
Rationale: Psychiatric nurses must gather assessment data on admission that is accurate and
comprehensive. Active listening to focused discussions about behaviors, feelings and insights
will assist the nurse to develop and implement a personalized plan of care. Subjective data
collection is important. Psychological assessment helps the nurse to understand the client; to help
provide the best care possible; and help the individual to obtain optimal health. Observing
nonverbal behavior would not be the first priority in the assessment. However, it would be
appropriate to look at dress, motor activity and mood. The nurse should not allow the client to
talk about whatever they want. An admission assessment can be a lengthy process. The nurse
should not strictly adhere to a preplanned interview goals and structure. They need to adapt to
client's needs.
Concepts tested

Question 1266
The nurse is caring for a mother who is Roman Catholic and has just given birth in an ambulance
on the way to the hospital. The neonate is in critical condition with little expectation of surviving
the trip to the hospital. Which of the following requests should the nurse anticipate and be
prepared for?
A Place a thread around the neonate's neck or wrist
B Baptize the neonate on the way to the hospital

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C A church elder will be at the hospital to perform a "laying of the hands"
D Point the neonate's face toward Mecca

Question Explanation
Correct Answer is B
Rationale: Baptism on the way to the hospital would be the correct response. Roman Catholics
believe that if an individual is gravely ill, they should receive the Sacrament of the Anointing of
the Sick (e.g., Last Rites) by a priest. Baptism of an infant would also be required if the
prognosis was grave. Anyone may perform this if the infant is gravely ill. Other health-related
practices or beliefs for Roman Catholics include requesting amputated limbs to be buried,
accepting of blood product transfusions, believe in life after death and feel autopsy and organ
donation is acceptable. After someone's death, Muslims may want to wash the body and point
their deceased loved one's face toward Mecca. Mormons believe in divine healing with the
laying on of hands. Buddhists may place a thread around the neck or wrist after death.
Concepts tested

Question 1267
The nurse working in a community clinic occasionally follows up with a client who has a history
of substance abuse. To evaluate the client's progress, the nurse should recognize that which of
these behaviors is the most resistant to therapy?
A Rationalization comments
B Continued drug use
C Recurrence of crises
D Missed appointments

Question Explanation
Correct Answer is B
Rationale: Continued use of any drug or addictive substance demonstrates lack of commitment to
the treatment program. This fact must be understood by the nurse as part of the disease of
addiction. This behavior is termed resistant behavior.
Concepts tested

Question 1268
The nurse is admitting a client diagnosed with a panic disorder. Which of the following
assessment findings by the nurse, is a classic finding of clients experiencing a panic attack?
A Predictable episodes
B Sense of impending doom
C Compulsive behavior
D Fear of common activities

Question Explanation
Correct Answer is B
Rationale: The feeling of overwhelming and uncontrollable doom is a classic finding of a panic
attack. The client experiencing a panic attack feels intense apprehension and terror. The client is
not able to function during an attack. Additional findings may include chest pain, shortness of

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breath, tachycardia, numbness and tingling in hands, and dizziness. Panic attacks can last from a
few minutes or longer. They can occur multiple times throughout the day. The other options may
be associated with a panic disorder, but are not classic findings of an actual attack. Panic attacks
have an unpredictable onset and there is usually no stimuli or trigger. Fear can induce anxiety
and a possible panic attack. Clients can also use compulsive behaviors to control their anxiety.
Concepts tested

Question 1269
The nurse is admitting a client with lower abdominal pain, difficulty swallowing, nausea and
fatigue; who is agitated, tachycardic and reports being "too sick to return to work." The client is
diagnosed with somatoform disorder. Which of the following should the nurse consider, about
the client's behavior, when developing the client's plan of care?
A It is manipulation to avoid work responsibilities
B It may respond to psycho-educational strategies
C It could be modified through reality therapy
D It is controlled by the subconscious mind

Question Explanation
Correct Answer is D
Rationale: Persons with somatoform disorder do not intend to feign illness. Their complaints are
not under their conscious control. Showing intention to use feigned physical complaints to
accomplish some goal is called "malingering" or a factitious disorder.
Concepts tested

Question 1270
The nurse is caring for a client who practices Chinese medicine. Which of the following
therapeutic goals would be the priority for the client?
A Respect life
B Maintain a balance of energy
C Restore yin and yang
D Achieve harmony

Question Explanation
Correct Answer is C
Rationale: For followers of Chinese medicine, health is maintained through the balance between
forces of yin and yang. According to Chinese medicine, the body is held together by meridians;
which are connected in terms of structure, function, and pathology. Chinese medicine views the
body as a balance of yin (cold) and yang (hot) forces. Maintaining a balance between yin and
yang achieves health and wellness. Within Chinese medicine, disease is believed to arise from an
internal imbalance of the two, leading to a blockage in the flow of energy and of blood along the
body's meridians. Using Chinese medicine restores flow and maintains the body in a state of
harmony preventing illness. Methods aimed at maintaining health with Chinese medicine include
acupuncture, acupressure, meditation, cupping, etc. Maintain balance of energy, achieving
harmony and respect for life are not practices of Chinese medicine.
Concepts tested

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Question 1271
The nurse is caring for a client with a history of anorexia nervosa. The nurse finds a container of
pills in the client's room. The client tells the nurse, "They are antacids for stomach pain." Which
would be the best response by the nurse?
A "Tell me about the stress you've been feeling."
B "It's not safe to take pills to lose weight."
C "Are you taking the pills to lose weight?"
D "The pills don't look like antacids."

Question Explanation
Correct Answer is A
Rationale: The nurse should ensure that all interactions meet the therapeutic needs of the client.
Asking the client to talk about current stressors that might be causing the stomach pain is an
open-ended question. Asking open-ended questions can elicit more information about the
situation and helps to form a deeper understanding of the client. This statement is the best
response by the nurse. Asking the client if they are taking pills to help them lose weight is
appropriate, but it is not the most therapeutic response for this situation. It is also considered a
close-ended question. Telling the client that the pills don't look like antacids is considered
challenging. It forces the client to defend their statement. Challenging a client is considered
nontherapeutic communication. Telling the client that taking pills to lose weight is considered
judgmental. Judgments place negative values on the client and is considered a nontherapeutic
communication technique.
Concepts tested

Question 1272
The nurse in the intensive care unit is caring for a 2-day-old child who recently underwent
surgery of a meningomyelocele due to spina bifida. While accompanying the grandparents to the
room, which response would the nurse first anticipate of the grandparents?
A Disbelief
B Frustration
C Anger
D Depression

Question Explanation
Correct Answer is A
Rationale: Spina bifida is a birth defect that affects a person’s spine and spinal cord. Spina bifida
can range from mild to severe, depending on the type of defect and accompanying complications.
A meningomyelocele is when the spinal cord and the meninges protrude through the child’s
back. This requires surgical intervention due to the child being at high risk for developing
bacterial meningitis. This news can be devastating to parents and grandparents, as they suffer
from a variety of emotional experiences. The first phase of the grieving process is denial or
disbelief. The nurse should anticipate this response and be available to answer any questions the
family has regarding their loved one. The following stages are anger, bargaining, depression, and
acceptance. Clients may often times go back and forth between stages or never achieve
acceptance.
Concepts tested
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Question 1273
A client scheduled for surgery with general anesthesia refuses to remove their dentures prior to
leaving the unit for the operative room. What would be the most appropriate nursing action?
A Explain to the client that the dentures must come out as they may get lost or broken in the
operating room
B Notify the operating room nurse and the anesthesia department of the client's refusal
C Ask the client if they would prefer to remove their dentures in the perioperative area
D Ask the client why they are refusing to take their dentures out prior to the procedure

Question Explanation
Correct Answer is C
Rationale: To foster a professional relationship with the client, the nurse should inquire about
personal preferences. Clients anticipating surgery may experience a variety of fears. Allowing
the client a choice and a sense of control over the situation fosters the client’s self-esteem and
self-concept.
Concepts tested

Question 1274
Ask the client why they are refusing to take their dentures out prior to the procedure
A Tooth decay, enlarged parotid glands
B Metabolic acidosis, ulcerative colitis
C Aspiration pneumonia, dysphagia
D Bacterial gastric infections, spastic colon

Question Explanation
Correct Answer is A
Rationale: Dental erosion and parotid gland enlargement occur as a result of the purging. These
are common complications of binge eating followed by self-induced vomiting. Often these
clients will have a callous on one of the fingers on either hand. This is from the use of the finger
to gag self until emesis occurs.
Concepts tested

Question 1275
The nurse is caring for a client who has generalized anxiety disorder (GAD). While developing a
plan of care, which intervention would be most appropriate to implement?
A Learn self-help techniques
B Express any anxious feelings
C Establish contact with reality
D Become desensitized to past trauma

Question Explanation
Correct Answer is A
Rationale: Generalized anxiety disorder (GAD) causes a person to have excessive, persistent
anxiety and worry about activities and events. The person may have difficulty with control and

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this affects how they physical feel which may lead to depression. It would be most appropriate
for the nurse to have the client explore alternative coping mechanisms to decrease levels of
anxiety to a manageable level. Along with the nurse, a counselor will be able to assist the client
in learning self-help techniques to enhance their abilities to cope with anxiety.
Concepts tested

Question 1276
A nurse is caring for a client who suffers from major depressive disorder. During which time
does the nurse know the client would be at highest risk for a suicide attempt?
A Seven to 14 days after initiation of antidepressant medication and psychotherapy
B Within 1 to 2 days after being admitted to an unfamiliar inpatient facility.
C Within 24 to 48 hours following an angry outburst with staff or the client's family.
D When the client is removed from the security room and placed in an individual room

Question Explanation
Correct Answer is A
Rationale: As the depression lessens, clients often have renewed energy to implement their plan
of suicide. Thus, the discharge plan needs to inform the family members of what behaviors of the
client to monitor for. The characteristic alert is a sudden change in the client's mood to elation or
happiness that was not present before the sudden change.
Concepts tested

Question 1277
After eating lunch, an adolescent client diagnosed with anorexia nervosa states, "I shouldn't have
eaten all of that sandwich. I don't know why I ate it. I wasn't even hungry." Which
term best describes the psychological response the client is experiencing?
A Anxiety
B Guilt
C Fear
D Bloating

Question Explanation
Correct Answer is B
Rationale: When people with anorexia lose control and eat more than they believe to be
appropriate, they tend to experience guilt. The client's statements are best described as
expressions of feeling guilt about eating the sandwich. Self-hate and guilt are often elevated in
adolescents with anorexia nervosa and treatment strategies should take this into consideration
when developing treatment options. The other terms do not pertain to the client's feelings of guilt
about eating the sandwich.
Concepts tested

Question 1278
The nurse on a medical surgical unit is caring for a client who has just been diagnosed with
breast cancer. When entering the client's room, the client loudly says to the nurse: "Get out of my
room, I don't want to see anyone right now!" What action should the nurse take?

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A Validate the client's feelings and return later
B Tell the client that they are being inappropriate
C Accept the client's statement and leave without comment
D Notify the client's health care provider

Question Explanation
Correct Answer is A
Rationale: The client just received a distressing diagnosis and is most likely experiencing
feelings of anger and fear. Those are appropriate and expected reactions and responses to a
stressful event. The nurse should validate and acknowledge the client's feelings. This can be
accomplished by a statement like, "I can see that you are upset right now." The nurse's role and
responsibilities include supporting the client during this time of stress and the nurse should make
sure to return after giving the client some time to process the news. This can be accomplished by
telling the client, "How about I come back in 30 minutes." The other actions are either
nontherapeutic or not indicated at this time.
Concepts tested

Question 1279
A client diagnosed with diabetes mellitus is referred for home care. During a care conference, a
family member expresses concerns that the client seems depressed. When planning the initial
home visit, which intervention should the nurse implement first?
A Inquire about use of alcohol or other non-prescribed substances
B Observe the client's affect and behavior during the visit
C Administer a standardized tool that measures depression
D Obtain a family health history, including emotional problems or mental illness

Question Explanation
Correct Answer is B
Rationale: An initial home visit should consist of getting to know the client, establishing trust
and building a therapeutic nurse-client relationship. Then the nurse should use the nursing
process and begin with a physical assessment including visual inspection and observations;
therefore, the nurse should first observe the client’s affect and behavior during the visit to gather
more data and ascertain if the family's concerns were valid and the client's emotional state merits
further assessments and interventions.
Concepts tested

Question 1280
The visiting nurse makes a postpartum visit to a married female client and her husband. Upon
arrival, the nurse observes that the client has a black eye and numerous bruises on her arms and
legs. What should be the initial nursing intervention?
A Leave the home because of the unsafe environment
B Interview the client in private about the injuries
C Call the police to report indications of domestic violence
D Confront the husband about the condition of his wife

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Question Explanation
Correct Answer is B
Rationale: It is a correct approach to assume domestic violence with further assessment. Separate
the suspected abused person from the partner until any battering has been ruled out by
conversation in a private location in the home. No information is given of the situation that
would warrant to leave or to call the police. To confront the partner is never a correct approach.
This should be left to the authorities.
Concepts tested

Question 1281
The nurse is caring for a 19-year-old client who was paralyzed from a car accident. Which
statement indicates that the client is using the mechanism of “suppression”?
A "It was the other drivers fault! They were going too fast!"
B "I'd rather not talk about it right now."
C "I don't remember what happened to me."
D "My mother is heartbroken about this."

Question Explanation
Correct Answer is C
Rationale: Suppression is willfully putting an unacceptable thought or feeling out of one's mind.
A deliberate exclusion, "voluntary forgetting," is generally used to protect one's own self-esteem.
Concepts tested

Question 1282
The nurse reviews the history of a client diagnosed with depression and anhedonia. What
statement is consistent with the symptom of anhedonia?
A An expression of persistent suicidal thoughts
B A report of difficulty falling and staying asleep
C A lack of enjoyment in usual pleasures in life
D Reduced senses of taste and smell

Question Explanation
Correct Answer is C
Rationale: Anhedonia is a symptom of depression that is described as the inability to feel
pleasure. Certain things in life are not enjoyed such as riding a bike, listening to music, or
hearing a baby laugh. There are two different types of anhedonia; social, not wanting to spend
time with other people, and physical, not enjoying physical sensations (a hug, a particular food).
Anhedonia can make developing or maintaining relationships challenging.
Concepts tested

Question 1283
A client diagnosed with delusional thoughts states to the nurse, “Don’t waste good food on me.
I’m dying from this disease I have.” Which statement by the nurse would be most appropriate?
A "Try to eat a little bit, breakfast is the most important meal of the day."
B "None of the laboratory reports show that you have any physical disease."

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C "I know you believe that you have an incurable disease, but you need to eat."
D "You need some nutritious food to help you regain your weight."

Question Explanation
Correct Answer is C
Rationale: The most appropriate response of the nurse should not challenge the client’s
delusional beliefs. This statement forms an alliance by providing reassurance of a desire to help
the client.
Concepts tested

Question 1284
A client who is recovering from alcoholism asks the nurse, "What should I do when I start to
recognize relapse triggers?" Which statement by the nurse is most appropriate?
A "Exercise daily and get involved in activities that will cause you not to think about drinking."
B "When you have an impulse to stop in a bar, contact sober friends and talk with them."
C "Go to an AA meeting that week when you feel the urge to drink."
D "Let's talk about possible options you have when you recognize these relapse triggers in
yourself."

Question Explanation
Correct Answer is D
Rationale: This option encourages the process of self-evaluation and problem solving and
provides avoidance of telling the client what to do. Encouraging the client to brainstorm about
the response to relapse trigger options validates the nurse's belief in the client's personal
competency. These behaviors reinforce a coping strategy that will be needed when the nurse is
not available to offer solutions.
Concepts tested

Question 1285
The nursing instructor is teaching a group of nursing students about therapeutic communication
with clients. Which of the following statements demonstrates appropriate therapeutic
communication?
A "You look very sad. How long have you been this way?"
B "I understand that you lost your partner. I don’t think I could go on if that happened to me."
C "You look upset. Tell me what you are feeling right now."
D "I’d like to know more about your family. Tell me about them."

Question Explanation
Correct Answer is C
Rationale: Giving broad opening statements and making observations are examples of
therapeutic communication. To ask about the client’s family is not supported by any assessment
data provided. Therefore, this approach would not be therapeutic in the absence of a reason to
inquire about the client’s family. To comment about a lost partner is incorrect because of an
inappropriate personal remark by the nurse. To make a comment of the client looking sad is
appropriate. However, to ask about the narrow focus of "how long have you been this way" is

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not as therapeutic as the correct option. The correct answer offers the client a broad opportunity
to talk about concerns.
Concepts tested

Question 1286
The nurse is teaching the parents of an adolescent who recently attempted suicide about suicide
prevention. The nurse should include which warning signs? Select all that apply.
A Enrolls in a community art class
B States feeling trapped with no way out
C Keeps away from family and friends
D Starts giving away prized possessions and collectibles
E Exhibits dramatic changes in mood
F Introduces new partner to family and friends

Question Explanation
Correct Answer is B, C, D, E
Rationale: Individuals may provide both behavioral and verbal clues as to their intent to attempt
suicide. Examples of behavioral clues include giving away prized possessions, getting financial
affairs in order, writing suicide notes, withdrawing from loved ones, no longer participating in
favorite activities, a sudden lift in mood, or dramatic changes in mood from extreme anger/rage
to deep hopelessness. Verbal clues may be both direct and indirect, such as '"feeling trapped" and
seeing "no way out."
Concepts tested

Question 1287
The nurse works with clients in an outpatient substance abuse treatment program. Which
intervention is indicated to prevent relapse and promote a successful recovery? Select all that
apply.
A Discharge clients who fail random drug tests
B Counseling about alternative coping skills
C Participate in group psychotherapy
D Medication-assisted treatment
E Refer clients for mental health assessments

Question Explanation
Correct Answer is B, C, D, E
Rationale: Treatment for substance use disorder (SUD) includes medications, especially for
alcohol and opioid abuse, counseling and group psychotherapy, attendance at mutual help
groups, such as Alcoholics Anonymous or Narcotics Anonymous, and learning new ways to
cope with cravings and urges to use. Many drug-addicted individuals also have other mental
disorders and should be assessed by health care professionals. Like other chronic diseases,
relapse is likely, and some individuals may fail random drug tests. This doesn't mean that
treatment is a failure but that additional modifications and treatment are needed.
Concepts tested

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Question 1288
The psychiatric nurse is developing a plan of care for a newly admitted client with acute paranoia
and delusions. Which intervention should the nurse include?
A Provide interactions to assist the client to build trust in the staff
B Convince the client that the hospital staff is trying to help
C Help the client to enter into group recreational activities
D Arrange the environment to limit the client's contact with other clients

Question Explanation
Correct Answer is A
Rationale: It is important to establish trust with the client as a foundation for communication and
a therapeutic nurse- and staff-client relationship. The other interventions are not appropriate for a
client who is currently experiencing delusional and paranoid thoughts.
Concepts tested

Question 1289
After the death of a client, the family approaches the nurse and requests that a family member be
allowed to perform a ritual bath on the deceased client prior to moving the body. What would be
the most appropriate response by the nurse?
A "A ritual bath will have to wait until after postmortem care."
B "I will have to check on hospital regulations and policies."
C "Is there anything you need from me to perform the bath?"
D "These procedures have to be carried out by our staff."

Question Explanation
Correct Answer is C
Rationale: Rituals are processes that allow the bereaved to acknowledge the reality of death.
Religious rituals, specifically, offer meaning and provide hope within the context of the
particular faith tradition. The nurse should inquire about the family's wishes for rituals or
observances following death and respect the family's request. The other options are inappropriate
and culturally insensitive.
Concepts tested

Question 1290
The nurse is working in a locked behavioral health unit and is admitting a new client. The client
is trembling and appears fearful. Which initial action by the nurse would be best for the client?
A Give the client orientation information and review the unit rules and regulations
B Ask a mental health technician to take the client to their room and measure vital signs
C Take the client to the community day room and introduce the client to everyone
D Introduce self to the client and accompany the client to their room

Question Explanation
Correct Answer is D
Rationale: Anxiety is triggered by a change that threatens an individual's sense of security. The
nurse should remain calm, minimize stimuli, and move the client to a safer and quieter setting.

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This client is not ready to interact with others or listen to unit rules. It would not be the correct
response to assign care to another staff person.
Concepts tested

Question 1291
The nurse is caring for a client with paranoid thoughts. The client believes that the food is
poisoned. What is the most appropriate statement the nurse can make at this time?
A "The food has been prepared in our kitchen and is not poisoned."
B "Let's see if your partner could bring food from home."
C "Here; I will pour a little of the juice in a medicine cup to drink it to show you that it is OK."
D "If you don't eat, I will have to suggest for you to be tube-fed."

Question Explanation
Correct Answer is B
Rationale: For a client having active delusions, reassurance will be ineffective. Asking the
partner to bring food from home prevents arguing with the client and doesn't agree with the
delusion. Offering a feeding tube may imply the client's delusion is real. Offering reassurances,
such as the safety of the kitchen, or having the client sample the food is not appropriate in the
midst of a delusion.
Concepts tested

Question 1292
The nurse is working in a psychiatric unit and is caring for a client with severe mental illness.
The client has been involuntarily hospitalized to meet which of the following goals?
A Return to independent functioning
B Reorientation to reality
C Protection from harm to self or others
D Elimination of findings

Question Explanation
Correct Answer is C
Rationale: Involuntary hospitalization may be required for persons considered dangerous to self
or others or for individuals who are considered gravely disabled. The other options are goals
associated with other situations of less severe diagnoses of mental illness. The other options of
returning to independent function, elimination of findings, and reorientation to reality are goals
for less severe mental illness.
Concepts tested

Question 1293
The nurse in a long-term care facility is assigned to the dementia unit. The nurse would
anticipate a reduction in which of the following functions for these clients?
A Endurance, strength, and mobility
B Learning, creativity, and judgment
C Balance, flexibility, and coordination
D Hearing, speech, and sight

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Question Explanation
Correct Answer is B
Rationale: Dementia is not a single disease but a general term used to describe symptoms, such
as impairments to memory, communication, and thinking. There are many causes of dementia,
and although we generally associate dementia with aging, we know that it is due to degenerative
changes to the brain. The other options include other expected changes due to aging but do not
necessarily indicate cognitive impairment related to dementia.
Concepts tested

Question 1294
A client is admitted to a psychiatric unit with reports of delusions. What behaviors, if observed
by a nurse, would be consistent with delusional thought patterns?
A Panic and multiple physical complaints
B Suspiciousness and distrust
C Flight of ideas and hyperactivity
D Anorexia and hopelessness

Question Explanation
Correct Answer is B
Rationale: Clinical features of paranoid delusional disorder include extreme suspiciousness,
jealousy, distrust, and a belief that others intend to invoke harm. Panic, multiple physical
complaints, anorexia, and hopelessness may be associated with depression. Flight of ideas and
hyperactivity are associated with mania.
Concepts tested

Question 1295
A nurse is caring for a client postop after the construction of a permanent colostomy. The client
begins to cry, saying "I'll never be attractive again with this ugly red thing." What should be the
first action taken by the nurse?
A Arrange a consultation with a sex therapist experienced in working with colostomy clients
B Invite the partner to participate in colostomy care after viewing an instructional video
C Encourage the client to discuss feelings about the colostomy
D Suggest sexual positions that hide the colostomy

Question Explanation
Correct Answer is C
Rationale: One of the greatest fears of clients with a colostomy is the fear that sexual intimacy is
no longer possible. However, the client's personal feelings about the stoma and colostomy care,
as well as the client's specific concerns, need to be assessed to accurately identify the problem(s)
to be solved. An assessment should occur before specific suggestions for dealing with sexual
concerns are given.
Concepts tested

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Question 1296
The nurse is providing care for an elderly Mexican-American migrant worker after an accident.
To facilitate communication, the nurse should initially take which of these actions?
A Request a Spanish interpreter
B Use pictures, letter boards, or hand gestures
C Speak to the client through the family or coworkers
D Evaluate the client's ability to speak English

Question Explanation
Correct Answer is D
Rationale: Despite the cultural heritage, a nurse cannot make assumptions that the client does not
understand nor speak English. Stereotyping is to be avoided. The nurse should evaluate if the
client is comfortable with and has the ability to understand or speak English. Until the nurse
determines the client's ability to speak and understand English, an interpreter of any type is not
needed nor is it necessary to use other means of communication.
Concepts tested

Question 1297
The nurse is caring for clients diagnosed with personality disorders. Which of the following
describes an appropriate intervention to deal with the behaviors associated with clients with
personality disorders?
A Encourage dependency in order to develop ego controls
B Accept the client and the client's behavior unconditionally
C Set consistent limits to be enforced around-the-clock
D Point out inconsistencies in speech patterns to correct thought disorders

Question Explanation
Correct Answer is C
Rationale: Treatment approaches for personality disorder diagnosis include restructuring the
personality, assisting the person with the advancement of developmental levels and setting limits
for maladaptive behavior, such as acting out. Very few behaviors are to be accepted
unconditionally in any circumstance. Dependency is unlikely an outcome for most situations.
Concepts tested

Question 1298
A client who is the victim of domestic violence states to the nurse, "If only I could change to be
how my partner wants me to be. I know things would be different." Which would be
the best response by the nurse?
A "Are you doing anything to provoke your partner into beating you?"
B "Maybe if you understood your partner better, you could stop the violence."
C "The violence is temporarily caused by stress in your relationship. Don't give up hope."
D "The violence shown to you is not because of what you did or did not do."

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Question Explanation
Correct Answer is D
Rationale: Only the perpetrator (batterer) has the ability to stop the violence. A change in the
client's behavior will not cause the abuser to become less violent or nonviolent. In most cases,
this client will need to leave the environment or home. The other responses are not appropriate,
correct, or therapeutic.
Concepts tested

Question 1299
A client who was recently diagnosed with colorectal cancer is crying in their hospital room. The
client is scheduled to have surgery tomorrow for placement of a new colostomy. Which action by
the nurse would be most effective in helping this client cope?
A Encourage the client to verbalize their feelings or fears about the upcoming surgery
B Explain to the client that leakage and odors from the colostomy can be easily prevented
C Reassure the client that the colostomy will be hidden under clothing and not noticeable
D Provide information to the client about colorectal cancer support groups in the community

Question Explanation
Correct Answer is A
Rationale: The diagnosis of cancer can have a significant, emotional impact on a client. It would
be most effective for the nurse to first explore the client's feelings and thoughts about the illness
and planned interventions by encouraging the client to verbalize and actively listening to what
the client says. The nurse should not assume that the reason the client is upset is because of the
surgery and/or colostomy itself. Making statements about managing the colostomy post-surgery
and recommending cancer support groups are premature and provide false reassurance that
ignores the client's current emotional needs.
Concepts tested

Question 1300
The nurse is caring for clients in an inpatient mental health unit. In order to develop a therapeutic
milieu, the nurse should include which intervention in the client's plan of care?
A Offer a businesslike atmosphere where clients can work on individual goals
B Discourage expressions of anger to avoid disrupting other clients
C Form a group forum in which clients decide on unit rules, regulations, and policies
D Provide a testing ground for new patterns of behavior while clients take responsibility for their
own actions

Question Explanation
Correct Answer is D
Rationale: A therapeutic milieu is purposeful and planned to provide safety and a testing ground
for new patterns of behavior while holding clients responsible for their actions. The other
approaches are part of various types of therapy.
Concepts tested

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Question 1301
The nurse is taking a health history from a Native American client. It is critical for the nurse to
remember that eye contact with such clients may be interpreted as which behavior?
A Expected
B Professional
C Rude
D Enjoyable

Question Explanation
Correct Answer is C
Rationale: Native Americans tend to consider direct eye contact to be impolite or aggressive
among strangers. The nurse should not misinterpret the lack of direct eye contact as a clinical
symptom.
Concepts tested

Question 1302
The nurse is caring for a client who is withdrawn. Which nursing intervention would
be most effective to help the client develop relationship and interpersonal skills?
A Assist the client to analyze the meaning of the withdrawn behavior
B Schedule the client multiple experiences to interact with groups of clients
C Inform the client that other clients have similar problems
D Offer the client frequent opportunities to interact with one person

Question Explanation
Correct Answer is D
Rationale: A withdrawn client is uncomfortable in social interaction. The nurse-client or a one-
on-one relationship is a corrective relationship in which the client learns tolerance and skills for
relationships.
Concepts tested

Question 1303
A client with stage I, non-small cell lung cancer is scheduled for a lobe resection. The client tells
the nurse, "I would rather have chemotherapy than surgery." Which response by the nurse
is most appropriate?
A "Surgery is the treatment of choice for your type of lung cancer."
B "Did you have bad experiences with previous surgeries?"
C "Tell me what you know about the treatment options available."
D "Are you afraid that the surgery will be very painful?"

Question Explanation
Correct Answer is C
Rationale: The client's statement indicates that the client seems to have concerns about the
surgery. In this situation, it is most appropriate to further explore the client's understanding with
an open-ended response by the nurse that will elicit the most information from the client.
Although the answer "Surgery is the treatment of choice…" is accurate, it is a closed-ended

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response that will discourage the client from sharing their concerns about surgery. The remaining
two answers indicate that the nurse has jumped to conclusions about the client's reasons for not
wanting surgery and are not therapeutic or appropriate.
Concepts tested

Question 1304
During a counseling session, a partner verbalizes concern because the client frequently
daydreams about moving to Arizona to get away from the pollution and crowding in southern
California. Which approach should the nurse use to explain what is occurring?
A Detaching or dissociating in this way postpones painful feelings
B Converting or transferring a mental conflict to a physical symptom can lead to conflict within
the partnership
C Such fantasies can gratify unconscious wishes or prepare for anticipated future events
D Isolating the feelings in this way reduces conflict within the client and with others

Question Explanation
Correct Answer is C
Rationale: Fantasy, or imagined events such as daydreaming, can be used to express unconscious
conflicts or to gratify unconscious wishes. The other options cannot be applied to this situation
with the information provided.
Concepts tested

Question 1305
A client states, "People think I'm no good, you know what I mean?" Which response by the nurse
would be the most therapeutic?
A "We can discuss possible reasons you create this impression on people."
B "People often take their own feelings of inadequacy out on others."
C "I think you are good. Now, there is one person who likes you."
D "I am not sure what you mean. Tell me more about that."

Question Explanation
Correct Answer is D
Rationale: Asking the client to explain in more detail allows the nurse to gain insight into why
the client feels this way. Therapeutic communication techniques elicit more information from the
client, especially when delivered in an open, nonjudgmental fashion. By seeking more
information, the nurse is applying the first step of the nursing process which is assessment.
Concepts tested

Question 1306
The nurse is working to establish a therapeutic relationship with a client. Which approach would
be most effective in establishing a therapeutic relationship?
A Wait for the client to approach
B Implement active listening
C Share a personal story
D Ask yes or no questions

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Question Explanation
Correct Answer is B
Rationale: Establishing therapeutic relationships is done through making appropriate eye
contact, using open ended questions, displaying positive non-verbal cues and utilizing active
listening strategies. All other options are counterproductive to establishing a therapeutic
relationship.
Concepts tested

Question 1307
The hospital staff requests that parents who have a Greek heritage remove the amulet from
around their infant's neck. The parents refuse. The nurse should understand the parents may be
concerned about which factor?
A Fright from spiritual beings
B Evil eye or envy of others
C Mental development delays
D Balance in body systems

Question Explanation
Correct Answer is B
Rationale: In the Greek heritage the matiasma, "bad eye" or "evil eye, " results from the envy or
admiration of others. The belief is that the eye is able to harm a wide variety of things, including
inanimate objects and that children are particularly susceptible to attacks. Persons of Greek
heritage employ a variety of preventive mechanisms to thwart the effects of envy. One of these is
the protective charm in the form of an amulet that consists of blessed wood or incense.
Concepts tested

Question 1308
Nurses in direct care positions are more satisfied when opportunities exist for autonomy and
control. The nurse manager becomes the facilitator rather than the decision maker of the
schedule for unit needs when self-scheduling exists. Peer pressure and team work are the driving
forces during self-schedule approaches.
A Seek an explanation for the death and come to an acceptable conclusion
B Plan for another pregnancy within two years and maintain physical health
C Discuss feelings with each other and use grief support resources
D Focus on the other children and move through the loss quickly

Question Explanation
Correct Answer is C
Rationale: To communicate in a therapeutic manner, the nurse should help the couple begin the
grieving process by suggesting that the couple communicate with each other and seek out grief
support resources. To ignore the loss or focus on "why" the death occurred when there often isn't
an identifiable cause or to suggest to plan for another pregnancy are nontherapeutic and
inappropriate suggestions.
Concepts tested

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Question 1309
The nurse is assessing a client during a visit to a community mental health center. The client
discloses that "I have been thinking about ending my life." Which statement would be the nurse's
best response to this information?
A "Have you thought about how you would do it?"
B "We will help you deal with those thoughts."
C "Do you want to discuss this with your pastor?"
D "Is your life so terrible that you want to end it?"

Question Explanation
Correct Answer is A
Rationale: Most experts believe that people who commit suicide don't want to die; they just want
to stop hurting. When a client tells you s/he is thinking about death or suicide, you must evaluate
the immediate danger the person is in. The correct option provides an opening to discuss the
plan, the means (pills, gun, etc.), time set for doing it, and intent to commit suicide. Clients who
have formulated a suicide plan are closer to suicidal behavior than those who have vague,
nonspecific thoughts.
Concepts tested

Question 1310
The nurse in an inpatient psychiatric unit is assessing a client admitted for acute psychosis
related to schizophrenia. Which client statement supports the assessment finding of disordered
thoughts?
A "I'm a little confused. What time is it?"
B "I can't find my "Mesmer" shoes. Have you seen them?"
C "I'm fine. It's my daughter who has the problem."
D "I'm so angry about this. Wait until my partner hears about this."

Question Explanation
Correct Answer is B
Rationale: A neologism is a word that is self-invented by a person and not readily understood by
another person. The use of neologisms is often associated with a thought disorder. The other
statements reflect appropriate connections between the expressed thoughts. Thought disorders
are associated with schizophrenia, delusions and hallucinations of psychosis.
Concepts tested

Question 1311
The visiting nurse is caring for a 55-year-old female client who had a right radical mastectomy
several months ago. Which client statement is most indicative of the possibility that the client is
not coping well with an altered body image?
A "I guess it's time for me to quit wearing a bikini at my age anyway."
B "It really isn't much of a problem for me, I never had large breasts anyway."
C "I plan to volunteer to work with others who have had a mastectomy."
D "I only look at myself in the mirror after I am fully dressed."

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Question Explanation
Correct Answer is D
Rationale: An inability to look at the incision or surgical site is most likely indicating that the
client is possibly experiencing denial or anger during the process of coping with a loss such as
the loss of a breast. Not being able to look at herself undressed can indicate that the client might
be experiencing negative feelings associated with an altered body image. The other statements
are more indicative of the client moving towards acceptance of the loss.
Concepts tested

Question 1312
The nurse is caring for a victim of domestic abuse. Which characteristic does the nurse recognize
as commonly being associated with the abuser?
A Alcohol addiction
B High tolerance for frustration
C Overconfidence
D Low self-esteem

Question Explanation
Correct Answer is D
Rationale: Abusers are often charming, jealous, manipulative, controlling, narcissistic,
inconsistent, critical, hypersensitive, vicious and cruel. Even though a lot of abusers seem
"tough" and "confident," they often suffer from low self-esteem. Alcohol can make someone
who is easily frustrated and angry more violent, but alcoholism does not cause abuse.
Concepts tested

Question 1313
The nurse is caring for a mother who has just delivered a stillborn infant. What would be
the most therapeutic nursing intervention?
A Reassuring the mother that she now has an angel in heaven watching over her
B Offering the mother the opportunity to hold, bathe and dress the infant
C Explaining to the mother that she is young and will have other children
D Notifying the hospital chaplain to come and pray with the mother

Question Explanation
Correct Answer is B
Rationale: The loss of an infant has special meaning for grieving parents. To help them
understand that the death is a reality and to facilitate their grieving, it is important to offer the
opportunity to hold the infant while dying or after the delivery and to provide a quiet, private
place for the parents with their child. Allow the parents to have as much time with their child as
they request. Differences in gender, cultural practices and religious beliefs will affect the parents'
grief response and the nurse needs to be alert for verbal and nonverbal cues.

Giving false reassurance, pointing out that future pregnancies are possible and arranging for a
chaplain's visit are nontherapeutic interventions that are insensitive to the mother's current,
emotional needs and are based on cultural bias and assumptions.
Concepts tested
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Question 1314
The nurse on a medical unit is implementing the Clinical Institute Withdrawal Assessment for
Alcohol (CIWA) tool for a client admitted for alcohol use disorder. Which finding most supports
the nurse's assessment that the client is experiencing acute withdrawal?
A A generalized shaking of the body accompanied by repetitive thoughts, expressed verbally
B An excited state accompanied by disorientation, hallucinations and tachycardia
C Single or multiple jerks caused by rapid contracting muscles with alternating relaxation
D Disorganized thinking, feelings of terror and non-purposeful behavior

Question Explanation
Correct Answer is B
Rationale: Delirium tremens is a severe form of alcohol withdrawal that involves sudden and
severe changes of the nervous system. The client initially presents with impaired cognition or
agitation. The other findings typically progress in the following order: confusion, disorientation,
agitation, hallucinations, diaphoresis, fever, tachycardia, hypertension and extreme tremors. The
other findings/behaviors are not typically seen with alcohol withdrawal.
Concepts tested

Question 1315
The nurse is caring for a client who has had a benzodiazepine dependency for the past several
years. The client is now in an outpatient detoxification program and the nurse is teaching the
client about detoxification. Which instruction should be a priority for the nurse to include in this
patient's plan of care?
A Avoid alcohol use during this time
B Rise slowly from a lying to standing position
C Expect mild physical symptoms
D Discontinue the drug by weaning

Question Explanation
Correct Answer is A
Rationale: Central nervous system depressants interact with alcohol. The client will gradually
reduce the dosage under the health care provider's direction. During this time, alcohol must be
avoided. The other options are correct. However, the question asks for a priority, which is the
correct answer.
Concepts tested

Question 1316
A client has been admitted to an inpatient behavioral health unit for severe depression and
suicidal threats. The client has been placed on suicide precautions. The nurse should be aware
that the danger of the client attempting suicide is greatest during what period of time?
A When the client's mood or energy level improves.
B After a visit from the client's estranged partner.
C During the night shift when staffing is limited.
D At the time of the client's greatest despair.

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Question Explanation
Correct Answer is A
Rationale: The risk for suicide is often increased when there is an improvement in mood and
energy level. This can occur when the client is being treated and receiving new or increased
doses of antidepressants. The medications can make the client feel less ambivalent and give the
client the energy to carry through with the threat for suicide.
Concepts tested

Question 1317
A client with schizophrenia is admitted to a mental health center with acute paranoia. The client
tells the nurse: "I am a government official being followed by spies." Upon further questioning,
the client states: "My warnings must be heeded to prevent nuclear war." Which action
is most appropriate for the nurse to take?
A Contact the government agency.
B Ask for more information about the spies.
C Confront the client's delusions.
D Listen quietly without comments.

Question Explanation
Correct Answer is D
Rationale: The client's comments demonstrate grandiose ideas or delusions of grandeur.
The most appropriate action is to calmly listen and avoid being pulled into the client's delusional
thinking. At some point, validation of the present situation will need to be done. Confrontation
would be an inappropriate action and non-therapeutic.
Concepts tested

Question 1318
A client who lives in an assisted living facility tells the nurse, "I am so depressed. Life isn't
worth living anymore." Which statement is the best response by the nurse?
A "Maybe you are just having a bad day today."
B "Have you thought about hurting yourself?"
C "Try to think of the many positive things in your life."
D "Did you tell any of this to your family?"

Question Explanation
Correct Answer is B
Rationale: It is most important to determine whether someone who voices thoughts about death
is considering suicide (i.e. suicidal ideation). Individuals may provide both behavioral and verbal
clues as to the intent of their acts. Behavioral clues include giving away prized possessions,
getting financial affairs in order, writing suicide notes and demonstrating a sudden lift in mood.
Verbal clues may be both direct and indirect. An example of a direct statement includes, "I want
to die." An example of an indirect statement includes, "I don't have anything worth living for
anymore". This client's statement indicates suicidal ideation and the client's safety is the highest
priority. The nurse should ask the client directly about thoughts or plans to harm themselves. The
other responses are not therapeutic and will not help identify if the client is at risk for suicide.
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The best statement by the nurse follows the nursing process by collecting more data about the
client's statement.
Concepts tested

Question 1319
The emergency room nurse is evaluating a client with injuries sustained from domestic partner
violence. The nurse should understand that after an acute battering incident, the batterer
is most likely to respond to the client's injuries by taking which action?
A Contact a close friend and ask for help with the incident.
B Minimize the episode with an underestimation of the injuries.
C Be very remorseful and enter a rehabilitation program.
D Seek medical help for the victim's injuries.

Question Explanation
Correct Answer is B
Rationale: Many batterers lack an understanding of the effects of their behavior on the person
who was battered. Batterers use excessive minimization. They typically are in a state of denial
about the situation, their behaviors or their intent. The other actions are not typically seen from
the batterer in a domestic/partner violence incident.
Concepts tested

Question 1320
A nurse enters the room of a postpartum mother and observes the baby lying at the edge of the
bed. The mother is sitting in a nearby chair. The mother says to the nurse, "take the baby out of
here. I do not want it." Which response by the nurse is best?
A "This is a common occurrence after birth, but you will come to accept the baby."
B "Many women have postpartum blues and need some time to love their baby."
C "What a beautiful baby! Her eyes are just like yours and so is her smile."
D "You seem upset. Tell me what the pregnancy and birth were like for you."

Question Explanation
Correct Answer is D
Rationale: A nonjudgmental, open-ended response facilitates dialogue between the client and the
nurse. The other three options ignore the situation and the needs of the mother. The nurse should
recognize that this client may be having postpartum depression. The best response by the nurse is
open-ended, allowing further discussion about the client's feelings and emotions.
Concepts tested

Question 1321
The parents of a 4 year-old boy have just been informed that their son has a congenital
neurologic disorder that is terminal. The nurse should anticipate the parents' reaction to fall into
which crisis phase?
A Pre-crisis phase
B Crisis phase
C Impact phase

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D Resolution phase

Question Explanation
Correct Answer is A
Rationale: A crisis is a sudden event in one’s life that disturbs homeostasis, during which usual
coping mechanisms cannot resolve the problem. The development of a crisis situation follows a
relatively predictable course. Stages in a crisis go from the pre-crisis phase (phase 1) , to the
impact phase (phase 2), then the crisis phase (phase 3), and finally the resolution phase (phase 4).
The time frame of recent bad news places the parents in phase 1. In this phase, an individual is
exposed to a precipitating stressor, resulting in increased anxiety and employment of previous
problem-solving techniques.
Concepts tested

Question 1322
During the change-of shift-report, the nurse reports that one of the clients is of the Catholic
religion and was admitted for the delivery of her ninth child. Which comment made by the nurse
indicates a bias against the client?
A "I'm wondering who is taking care of the other children."
B "The client's spouse is requesting to stay overnight with her."
C "All those people tend to indulge in large families."
D "I'm surprised that the client insists on a natural birth."

Question Explanation
Correct Answer is C
Rationale: A bias is a tendency, inclination, or prejudice toward or against something or
someone. The nurse's comment indicates the bias that people of Catholic faith tend to have large
families due to the religion's position on birth control. The other comments are not indicative of a
bias by the nurse.
Concepts tested

Question 1323
The nurse in a behavioral health inpatient unit is observing a female client who has been
diagnosed with obsessive-compulsive disorder. Which behavior supports this diagnosis?
A The client verbalizes suspicions about thefts on the unit.
B The client prefers to interact with female staff members.
C The client exhibits repetitive, involuntary movements.
D The client is seen washing her hands every 15 minutes.

Question Explanation
Correct Answer is D
Rationale: Washing her hands every 15 minutes indicates compulsive behaviors seen with
obsessive compulsive disorder (OCD). OCD is characterized by repetitive, unwanted, intrusive
thoughts (obsessions) and irrational, excessive urges to perform certain actions (compulsions).
Affected individuals are often unable to stop the compulsive behaviors. The other behaviors are
not typically seen with OCD. Verbalizes suspicions reflect a paranoid thought process seen with

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delusional disorders, such as schizophrenia or schizoaffective disorder. Repetitive involuntary
movements are side effects seen with certain antipsychotic medications.
Concepts tested

Question 1324
The nurse on an inpatient hospital unit answers a call light and enters a client's room. The client
expresses anger stating they have been waiting for more than 5 minutes for a blanket. Which is
the best response from the nurse?
A "I see this is frustrating for you. I have a few minutes so let's talk."
B "I am surprised that you are upset. The request could have waited a few more minutes."
C "Let's talk. Why are you upset about this?"
D "I apologize for the delay. I was involved in an emergency."

Question Explanation
Correct Answer is A
Rationale: The best response from the nurse acknowledges the client's verbalized needs and
encourages an open conversation. To say "let's talk" and ask a "why" question is not a
therapeutic approach because it does not acknowledge or validate the client's feelings. To
apologize and not acknowledge the client's feelings is inappropriate. It is rude for the nurse to tell
a client their request could wait a few minutes, and this response does not acknowledge the
client's verbalized needs.
Concepts tested

Question 1325
The nurse is teaching a client about effective stress management techniques prior to a surgical
procedure. Which technique should the nurse recommend for this client?
A Imagery
B Deep breathing
C Distraction
D Biofeedback

Question Explanation
Correct Answer is B
Rationale: Deep breathing is a reliable and valid method for stress reduction and can be taught
and reinforced in a short period of time preoperatively. The other approaches require more time
and repetition over time for maximum effectiveness.
Concepts tested

Question 1326
The nurse is working with clients who are experiencing intimate partner violence. The nurse
should understand that intimate partner violence remains frequently undetected for which
reason?
A Little knowledge is known about batterers and battering relationships
B The expenses due to police and court costs are prohibitive
C Few people who have been battered seek medical care

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D There are typically many series of minor, vague complaints

Question Explanation
Correct Answer is D
Rationale: Signs of intimate partner violence may not be clearly manifested, or may be vague,
and often include a series of minor complaints such as headache, abdominal pain, insomnia,
muscle pain, and dizziness. These may be cover indications of violence that go undetected.
These complaints may be vague and reflect ambivalence or apprehension about the disclosure of
intimate partner violence.
Concepts tested

Question 1327
The nursing home case management team including the client's spouse, are discussing the plan of
care for a client with advanced dementia due to Alzheimer's disease. The client is exhibiting
disorientation, agitation and hallucinations that noticeably worsen in the evening. Which
intervention should the team recommend to be tried initially?
A Serve the client dinner in their room.
B Administer a psychotropic medication in the late afternoon.
C Initiate transfer of the client to the 'locked' dementia unit.
D Encourage the client's spouse to stay with the client in the evening.

Question Explanation
Correct Answer is D
Rationale: Behavioral problems occur in about 90% of patients with Alzheimer's disease (AD).
These problems include repetitiveness or asking the same question repeatedly, delusions,
hallucinations, agitation, aggression, altered sleeping patterns, wandering, hoarding, and resisting
care. When these behaviors become problematic, interventions must be planned carefully and
should start with the least restrictive or invasive interventions. Having a calming family member
stay with the client in the evening is a good, initial intervention to try. The other interventions are
more restrictive/invasive and should be reserved for when all other measures have been
exhausted.
Concepts tested

Question 1328
The nurse is caring for a client who is experiencing a panic attack. What intervention should the
nurse implement?
A Assist the client to describe the experience in detail
B Maintain safety for the client
C Develop a trusting relationship
D Teach the client to control behaviors

Question Explanation
Correct Answer is B
Rationale: Clients who display signs of severe anxiety or who are experiencing a panic attack
must be supervised closely. Clients may harm themselves or others during these episodes as

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perception is skewed and thinking is flawed. All other interventions will be futile and are
inappropriate until the client's anxiety has been reduced to a tolerable level.
Concepts tested

Question 1329
The nurse is working in an inpatient psychiatric setting and understands that touching clients
should be limited to a quick handshake for which reason?
A A handshake allows the use of therapeutic touch while maintaining boundaries.
B Touching a client, other than a handshake, can set off a violent episode.
C A handshake will not be misinterpreted as an invitation to more sexual behavior.
D Refraining from touching signals the termination of the nurse-client relationship.

Question Explanation
Correct Answer is A
Rationale: The therapeutic use of touch is a basic part of the nurse-client relationship. However,
in a psychiatric setting, the extent of physical contact should be limited to handshakes. Some
facilities may even have a no-touch policy, especially when working with clients who have a
history of sexual trauma. Even reassuring touching can be misinterpreted by the client.
Concepts tested

Question 1330
The nurse has been caring for the same client for 5 days. The client has been exhibiting
manipulative behaviors. The nurse becomes aware of feeling reluctant to interact and care for the
client. Which action should the nurse take?
A Report the feelings of reluctance to an objective peer or supervisor.
B Limit contact with the client to avoid reinforcement of the behaviors.
C Develop a behavior modification plan for the client.
D Talk with the client about the negative effects of their manipulative behaviors.

Question Explanation
Correct Answer is A
Rationale: The nurse who experiences stress in a professional relationship with a client can gain
objectivity through discussion with other professionals. The nurse may wish to have a peer
observe the nurse-client interactions with this client for a shift and then have a debriefing of
reactions that can influence the nurse-client relationship in positive and negative ways.
Concepts tested

Question 1331
A client is reported to have a dual diagnosis. The nurse should understand that this indicates a
substance use disorder as well as what other type of problem?
A Mental health diagnosis
B Cross addiction
C Disorder of any type
D Medical problem

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Question Explanation
Correct Answer is A
Rationale: A dual diagnosis is the concurrent presence of a major psychiatric disorder and a
substance use disorder.
Concepts tested

Question 1332
A Latino couple confides in the nurse about their concern with staff giving their 9-month-old
infant the "evil eye." What should the nurse communicate to the other staff members who are
involved in the care of this family?
A Talk very slowly while speaking to the infant
B Look only at the parents and not the infant
C Avoid touching the infant above the waist
D Touch the infant while performing a visual assessment

Question Explanation
Correct Answer is D
Rationale: In some Spanish-speaking cultures, there is a belief that an "evil eye" is cast when
looking at a person without touching them. The spell is believed to be broken by touching the
person while looking at or assessing them. The nurse should communicate this belief to other
staff members and instruct them to be sure to touch the child while looking or assessing them to
ease the parents' concern.
Concepts tested

Question 1333
A client with chronic pain asks the nurse, "What is your opinion about acupuncture to help with
chronic pain?" The nurse responds, "I think some of those complementary treatments can be
scary." The nurse's response is an example of what perspective?
A Ethnocentrism
B Cultural insensitivity
A Discrimination
D Prejudice

Question Explanation
Correct Answer is A
Rationale: Ethnocentrism is the universal unconscious tendency of human beings to think that
their ways of thinking, acting, and believing are the only right, proper and natural ways. It can be
a major barrier to the provision of culturally conscious care. Ethnocentrism perpetuates an
attitude that beliefs that differ greatly from one's own are strange, bizarre or unenlightened, and
therefore wrong. At a more complex level, ethnocentric people regard others as inferior or
immoral and believe their own ideas are intrinsically good, right, necessary, and desirable, while
remaining unaware of their own value judgments.
Concepts tested

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Question 1334
The nurse is teaching a childbirth education class and is discussing postpartum depression.
Which statement, made by a class member, indicates the need for additional teaching?
A "I may experience postpartum depression up to a year after delivery."
B "It's common for women with postpartum depression to have delusions about the infant."
C "I will make an effort to talk with someone about my feelings if I start to feel overwhelmed."
D "Women with postpartum depression have feelings of guilt and worthlessness."

Question Explanation
Correct Answer is B
Rationale: Postpartum depression symptoms include sleep and appetite disturbances,
uncontrolled crying, with feelings of guilt and/or worthlessness. Although postpartum depression
typically occurs within the first three months after delivery, it can occur up to a year later. A new
mother who has symptoms of postpartum depression should take steps to get help right away.
Delusions are associated with postpartum psychosis, not depression.
Concepts tested

Question 1335
The nurse asks a client with a history of alcohol use disorder about recent drinking behavior. The
client states, "I didn't hurt anyone. I just like to have a good time and drinking helps me to relax."
The client is using which defense mechanism?
A Denial
B Rationalization
C Intellectualization
D Projection

Question Explanation
Correct Answer is B
Rationale: Rationalization is justifying illogical or unreasonable ideas, actions or feelings by the
development of acceptable explanations for unacceptable actions. Both the teller and the listener
find the rationalizations more satisfactory than the reality. Intellectualization is the use of
reasoning in response to confrontation with unconscious conflicts and accompanying stressful
emotions. Projection is the assignment of one's own feelings or thoughts to others.
Concepts tested

Question 1336
A client is admitted to the hospital with a history of confusion. The client has difficulty
remembering recent events and becomes disoriented when away from the home. Which
statement would provide the best reality orientation for this client?
A "Hello. My name is Elaine Jones and I am your nurse for today."
B "How are you today? Remember, you're in the hospital."
C "Good morning. Do you remember where you are?"
D "Good morning. You're in the hospital. I am your nurse Elaine Jones."

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Question Explanation
Correct Answer is D
Rationale: As cognitive ability declines, the nurse should provide a calm, predictable
environment for the client. This response establishes time, location and the caregiver's name.
Concepts tested

Question 1337
A client who has been excessively drinking alcohol for five years states: "I drink when I get
upset about "things." I have been unemployed. I feel like life is not leading anywhere." The nurse
understands that the client is using alcohol as a way to deal with what issue?
A Recreational/social needs
B Feelings of anger
C Stressors in life
D Issues of guilt and disappointment

Question Explanation
Correct Answer is C
Rationale: Alcohol is used by some people to manage anxiety and stress. The overall intent with
this behavior is to decrease negative feelings and increase positive feelings. However, substance
abuse, no matter what form or substance, eventually has an outcome of increased negative
feelings.
Concepts tested

Question 1338
The nurse is caring for a client who reports the onset of symptoms associated with tardive
dyskinesia. Which finding would the nurse expect to observe?
A Fine motor tremors of the hands while eating
B Rapid, repetitive tongue movements
C Behavior changes related to judgment
D Involuntary yelling of random words

Question Explanation
Rationale: Tardive dyskinesia (TD) is a syndrome of involuntary movements that usually affects
the face, mouth, tongue, trunk and limbs. TD may occur years after treatment with a neuroleptic
agent and may be irreversible. Predisposing factors include older age, phenothiazine treatment,
history of smoking and history of diabetes mellitus.
Concepts tested

Question 1339
The nurse is counseling a postpartum client who has a history of a substance-abuse problem.
Which question is a priority when interviewing the client?
A When was the last time you used illegal substances?
B Do you feel that you have bonded with your infant?
C Have you attended any support groups related to substance abuse?
D How have you managed the stress of being a new mother?

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Question Explanation
Correct Answer is A
Rationale: While all of the questions are appropriate, it is essential to assess whether or not the
mother is still abusing illegal substances. This would pose a risk for the client and the newborn.
The other questions are appropriate to ask after assessing for recent substance abuse.
Concepts tested

Question 1340
An inpatient psychiatric client diagnosed with schizophrenia is observed talking to unseen people
and urinating on the floor. Which action by the nurse is appropriate to address the client
urinating on the floor?
A Toilet the client more frequently with supervision
B Withhold privileges each time the voiding occurs
C Require the client to mop the floor after each incident
D Restrict the client's fluids throughout the day

Question Explanation
Correct Answer is A
Rationale: With a client that has altered thought processes, the appropriate nursing approach to
change behaviors is to take an active role in attending to the physical needs of the client. The
other options are incorrect approaches.
Concepts tested

Question 1341
The spouse of a client appears distressed about the client's impending death. Which intervention
is a priority for the nurse?
A Recommend an easy-to-read book on grief
B Assess the family's patterns for dealing with death
C Leave the client and spouse alone for privacy
D Explain the stages of death and dying to the family

Question Explanation
Correct Answer is B
Rationale: When a new problem is identified, it is important for the nurse to first collect accurate
information. This is crucial to ensure that the client and the family's needs are adequately
identified in order to plan and implement nursing care. Once the situation has been assessed and
a plan has been established, the nurse can focus on teaching or referral to other resources.
Concepts tested

Question 1342
The nurse is caring for a 14-year-old adolescent who attempted suicide. Which
stressor is most likely to occur during adolescence and contribute to the risk of suicide?
A The ending of a long-term romantic relationship
B A challenging academic environment

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C Peer pressure and social isolation
D Financial strain and increased financial responsibilities

Question Explanation
Correct Answer is C
Rationale: During adolescence, an important benchmark is to achieve a sense of identity and
peer acceptance. Peer pressure is a common occurrence during adolescence. Social isolation can
be self-imposed or can occur as the result of the inability to express feelings to peers or family
members. A challenging academic environment, financial responsibilities, or the end of a
romantic relationship are not stressors commonly associated with an adolescent attempting
suicide.
Concepts tested

Question 1343
The nurse is providing care for a client who is diagnosed with schizophrenia and treated with
clozapine. The client reports that his leg has developed an involuntary movement and he can feel
his heart beating. Which other assessment findings should the nurse gather before calling the
health care provider (HCP)?
A Vital signs including oral temperature
B Glasgow Coma Scale (GCS) to measure level of consciousness
C Bowel sounds in all four abdominal quadrants
D Total urinary output for the last 24 hours

Question Explanation
Correct Answer is A
Rationale: Clients taking clozapine and other medications that have a direct effect on the central
nervous system (CNS) are at risk for developing Neuroleptic Malignant Syndrome (NMS). NMS
is a generalized syndrome that includes hyperthermia, hypertension, tachycardia, slowed reflexes
and involuntary movements. This is an emergency and the nurse should notify the health care
provider. Bowel sounds, level of consciousness and urinary output are not warranted for this
focused assessment.
Concepts tested

Question 1344
The client tells the nurse that they are fearful of the planned surgery because of evil thoughts
from a close family member. What is the best response by the nurse?
A Explore the client's feelings
B Request a language translator
C Ignore the superstitious feelings
D Notify the health care provider

Question Explanation
Correct Answer is A
Rationale: Therapeutic communications are based on attentive listening to expressed feelings. If
the nurse is not familiar with the cultural beliefs of a client, the nurse's acceptance of feelings

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should be followed by further questions about the client's feelings to gain insight into the client's
culturally-determined belief system. The other responses are not therapeutic or appropriate in
this situation.
Concepts tested

Question 1345
The nurse and client discuss the progress that has been made toward the client's goal of quitting
smoking. This is a typical step in which phase of the therapeutic relationship?
A Orientation
B Termination
C Working
D Pre-interaction

Question Explanation
Correct Answer is B
Rationale: During the termination phase, the nurse and client will discuss progress towards the
goal and feelings about the termination of the therapeutic relationship. In the orientation phase,
the nurse and client will become acquainted and discuss roles and goals. In the working phase,
the nurse and client strategically work towards the set goals and discuss any concerns that may
arise.
Concepts tested

Question 1346
The nurse is caring for a client who is the victim of domestic violence. The client states, "If I just
could follow directions, this would not have happened." This statement indicates the client is
experiencing which feeling?
A Helplessness
B Rejection
C Fear
D Self-blame

Question Explanation
Correct Answer is D
Rationale: Intimate partner violence is defined as physical, sexual, stalking, and psychological
aggression by a current or former partner. The nurse is often the first health care worker in
contact with these victims. Victims of domestic violence may be immobilized by a variety of
affective responses with one being self-blame. The nurse's responsibility is to make a safety plan
with the victim and follow any facility policies or procedures concerning victims. However, the
victim has a right to self-determination without judgment.
Concepts tested

Question 1347
The nurse on the mental health unit is assigned to a client diagnosed with post-traumatic stress
disorder (PTSD). What priority interventions shall the nurse include in the client's plan of
care? Select all that apply.

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A Medicate the client with a sedative while they experience flashbacks
B Discuss the coping strategies that the client is using in response to the trauma
C Stay with the client during periods of flashbacks and nightmares
D Place the client in a secluded area away from others
E Encourage the client to talk about the trauma at their own pace
F Assign the same staff to the client as often as possible

Question Explanation
Correct Answer is B, C, E, F
Rationale: Trauma-related disorders, such as PTSD, can be described as the client's reaction to an
extremely distressing experience, such as natural or man-made disasters, combat, serious
accidents, witnessing the violent death of others, or being the victim of torture, terrorism, rape, or
other crimes that cause severe emotional shock and have long-lasting psychological
effects. Interventions that are considered trauma-informed highlight the importance of respect for
the client, collaboration and connection, providing information about the connections between
trauma and other health concerns, instilling hope, and empowering the trauma survivor to guide
and direct their recovery plan. A PTSD client may be suspicious of others in their environment.
It is a priority to facilitate building a trusting relationship. The presence of a trusted individual
may reassure the client and calm their fears for their personal safety. Debriefing or talking about
the traumatic event is the first step in the client's progression toward resolution. The long-term
resolution of the client's post-traumatic response is largely dependent on the effectiveness of the
client's coping strategies. Interventions, such as seclusion, may be retraumatizing to a client with
a history of trauma and are only indicated if the client exhibits behavior that presents an
imminent risk of harm to themselves or others. Administering a sedative without a clear, clinical
indication is considered a chemical restraint. This should never be used for the convenience of
the staff or as a punishment. The nurse should first try other measures to decrease agitation, such
as talking down (verbal intervention).
Concepts tested

Question 1348
The nurse is caring for a client who is diagnosed with autism. The client begins eating his meal
with his utensils, but places them on the table and begins to use his hands. Which response by the
nurse would be best?
A "You can't have any more food until you use the spoon."
B "Well I guess fingers sometimes work better than spoons."
C "Use the spoon to eat your food."
D "I believe you know better than to eat with your hands."

Question Explanation
Correct Answer is C
Rationale: This response identifies an expectation and instruction for the client. Since the client
has demonstrated that he can use his utensils, he should be expected to maintain this level of
independence. The other options are not therapeutic approaches for this client.
Concepts tested
NCLEX: Psychosocial Integrity

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Question 1349
The nurse is performing the initial assessment of a client in the emergency department. Which
statement by the client most strongly suggests domestic or partner violence?
A "No one else in the family is as accident-prone as I am."
B "I have only been married for two months."
C "I have tried leaving home but have always gone back."
D "I am determined to make things work out."

Question Explanation
Correct Answer is C
Rationale: Intimate partner violence may occur as a pattern or frequently. Violence is part of a
cycle of abuse. After the incident, the honeymoon phase occurs, and the abuser demonstrates
love and vows to change. The victim may feel responsible for the violent attack and may
consider reconciliation. The victim may leave the abuser and return frequently before a decision
to leave permanently may occur.
Concepts tested

Question 1350
The nurse is caring for clients in an assisted living facility. A client enters the day room wearing
a sheer nightgown. Which nursing action is the most therapeutic in response to the client's attire?
A Ask the client's daughter to address the client's attire on her next visit
B Quietly point out how the other clients are dressed on the unit
C Tactfully explain appropriate clothing for the unit
D Assist the client to her room and help her select appropriate attire

Question Explanation
Correct Answer is D
Rationale: This action assists the client to maintain self-esteem while modifying her behavior. By
pointing out the other clients' attire, the client could feel ashamed and self-conscious. Explaining
appropriate attire does not directly address the situation as effectively as assisting the client. The
action needed should be direct and timely but avoid embarrassment for the client.
Concepts tested

Question 1351
The nurse is caring for a client who is experiencing alcohol withdrawal. The client is
experiencing tremors and nausea. The client's vital signs are within normal limits, but the client
is sweating profusely. Which nursing intervention is a priority for this client?
A Update the client regularly on their progress
B Ask the family to leave the bedside to provide privacy
C Assess the client's vital signs every 6 hours
D Monitor for agitation or hallucinations

Question Explanation
Correct Answer is D

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Rationale: During alcohol withdrawal, the client may experience many clinical manifestations.
Six to eight hours after alcohol cessation, the client may experience tremors, nausea, and
agitation. After eight to ten hours, the client may experience increasing perceptual changes, such
as hallucinations, unconsciousness, seizures, or delirium. This is a medical emergency and the
nurse should anticipate administration of lorazepam or chlordiazepoxide. After twelve to twenty-
four hours, the client may experience tonic-clonic seizures and diazepam may be administered.
Monitoring the client for delirium tremens (DTs) is a nursing priority. DTs are a medical
emergency and if left untreated have a significant risk of death. Vital signs and monitoring for
clinical manifestations of DTs should be done more often than every 6 hours. During this time,
regularly updating the client on their progress may cause frustration with the client. Additionally,
if the client wants the family at the bedside, privacy is not needed.
Concepts tested

Question 1352
The nurse is interviewing a young client who expresses hopelessness. Which of the following
questions is a priority for the nurse to ask?
A "Does anything help relieve these symptoms?"
B "How long have you felt like this?"
C "Have you thought about suicide?"
D "Have you spoken to anyone about this feeling?"

Question Explanation
Correct Answer is C
Rationale: One in ten young adults experiences a period of major depression, and suicide is a
leading cause of death in the United States. It is a priority for the nurse to assess if the client is
planning to harm themselves. This should be done with a direct question that, if positive ("yes"),
should be followed with additional questions to determine if the client has a plan to carry out
suicide. The other questions are also helpful but are not the priority at this time.
Concepts tested

Question 1353
The nurse is caring for a client who was admitted to the psychiatric unit with a diagnosis of
bipolar disorder. The client constantly tries to help the housekeeping staff and demands constant
attention. Which activity is most appropriate for this client?
A Table tennis
B Reading
C Checkers
D Cards

Question Explanation
Correct Answer is A
Rationale: The client is exhibiting the need for an outlet of physical energy. Table tennis allows
for physical activity with limited attention requirements. The other options could over-tax the
client's level of self-control because the client needs to be physically active.
Concepts tested

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Question 1354
The nurse is caring for a client diagnosed with bipolar disorder. The client is expected to transfer
to a residential facility. A social worker from the facility calls to obtain information about the
client. Which action is appropriate concerning this request?
A "I can never give information out over the telephone."
B "I will need to obtain the client's written consent before releasing information."
C "You must contact the health care provider's office to receive referral information."
D "I can only acknowledge the client is currently being treated at this facility."

Question Explanation
Correct Answer is B
Rationale: In order to release information, the nurse should obtain the client's written consent.
The client has the right to privacy and protection of confidential information. The other actions
are inappropriate or incorrect approaches to this request.
Concepts tested

Question 1355
The nurse is caring for a client who was admitted two days ago to the psychiatric unit for major
depression. The client continues to be withdrawn and does not interact with staff or other clients.
Which action by the nurse would be most appropriate to encourage the client to increase
interactions with others?
A "Come play a board game with me and another staff member."
B "Come with me, so you can paint a picture to help you feel better."
C "It is important for you to participate in group activities."
D "Our team here thinks it's good for you to spend time with others."

Question Explanation
Correct Answer is A
Rationale: By inviting the client directly to participate in a game with just a couple of other
people provides clear, direct, and positive behavioral expectations of the client that can gradually
engage the client in small group interactions. By focusing on one activity, the client may have
lessened anxiety when compared to an unstructured discussion. By stating what the "team
thinks," the client may feel embarrassed or targeted. While it is important for the client to
interact more with others, group activities may be too stressful at this time. Painting, while it
may be therapeutic to lessen anxiety, does not promote interaction.
Concepts tested

Question 1356
The client is diagnosed with depression. Which therapeutic communication skill is most likely to
encourage the client to express feelings?
A Direct confrontation
B Active listening
C Projective identification
D Reality orientation

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Question Explanation
Correct Answer is B
Rationale: The use of therapeutic communication skills, such as silence and active listening,
encourages verbalization of feelings. Reality orientation is used with clients who may have
cognitive impairment. Direct confrontation is usually not used except in cases where a risk of
physical harm to the client or others is anticipated. Projective identification is used to project the
bad object into (not onto) another person, so it becomes a part of that person. The person then
identifies with that other person and hence has means for control.
Concepts tested

Question 1357
The nurse is assessing the newborn of a mother who tested positive for heroin. Which assessment
finding should the nurse anticipate for this infant?
A Large for gestational age
B Central nervous system depression
C Lethargy with excessive sleepiness
D Irritability

Question Explanation
Correct Answer is D
Rationale: Neonatal abstinence syndrome (NAS) is characterized by irritability, continual crying,
decreased sleep, fever, diarrhea, and seizures. Initial treatment is supportive with the newborn
being swaddled to decrease sensory stimulation and offered small frequent feedings. These
newborns are usually born small for gestational age and require hypercaloric formula.
Concepts tested

Question 1358
A client of Latino descent is diagnosed with ovarian cancer. The client is refusing radiation and
chemotherapy, describing them both as "hot." What action should the nurse take next?
A Document the situation and client response in the notes
B Ask the client to describe her concerns about "hot" treatments
C Talk with the client's family about the situation
D Report the situation to the health care provider

Question Explanation
Correct Answer is B
Rationale: In Latino culture, it is often believed that disease is caused by an imbalance between
hot and cold principles. Treatment is often based on this principle as well, with some treatments
having negative connotations. The correct response is the best choice as it is client/culture-
centered and encourages the client to describe concerns. The other answer choices may also be
done, but it is most important to solicit the client's concerns first.
Concepts tested

Question 1359
Which client behavior would indicate that the nurse-client relationship has progressed from the
orientation phase to the working phase?
Page | 557
A Identifies painful feelings and expresses a desire to discuss them
B Considers regressive behaviors as a positive defense mechanism
C Expresses a desire to be cared for and nurtured
D Reestablishes a relationship with an estranged family member

Question Explanation
Correct Answer is A
Rationale: The working phase of the nurse-client relationship refers to the period of time when
the client is willing to collaborate with the nurse in making positive changes and achieving goals.
By identifying painful feelings and demonstrating a willingness to speak about them, the client
has progressed to the working phase of the nurse-client relationship. The other behaviors are not
indicative of the client's readiness to make positive changes or do not pertain to the nurse-
client relationship.
Concepts tested

Question 1360
A client diagnosed with schizophrenia is observed mumbling to self and speaking to the
television. The nursing staff is unable to understand what the client is attempting to
communicate. At this time, what is the most desirable outcome for this client's behaviors?
A Interprets accurately the events and behaviors of others
B Expresses feelings appropriately through verbal interactions
C Engages in meaningful and understandable verbal communication
D Demonstrates improved social relationships within the unit

Question Explanation
Correct Answer is C
Rationale: The client is exhibiting disorganized thinking and difficulty with verbal
communication. As the client engages in the therapeutic process, including medication
management and milieu therapy, the expected outcome is improved communication. The other
choices are important but improved communication is necessary before one can express feelings
and relate to others. The correct answer choice also specifically addresses the behavior
described.
Concepts tested

Question 1361
To establish trust in a nurse-client relationship, which qualities are most important for the nurse
to exhibit?
A Empathy and understanding
B Honesty and consistency
C Genuineness and kindness
D Confidence and optimism

Question Explanation
Correct Answer is B

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Rationale: All of the qualities listed are important. Honesty and consistency is the best option
because the client will be able to depend on the nurse regardless of the situation, foster
appropriate and clear boundaries, and demonstrate the professionalism of the nurse.
Concepts tested

Question 1362
A client diagnosed with schizophrenia is paranoid. During the visiting hour, the client alertly
watches the activities of other clients, visitors, and staff. The client's behavior most likely
indicates which associated problem?
A Altered sensory perception
B Feelings of increased anxiety
C Impaired verbal communication
D Social isolation

Question Explanation
Correct Answer is B
Rationale: Paranoid thinking and behavior is often exacerbated by anxiety. The visiting hour is a
time of increased activity and the presence of other people not known to the client. These factors
could increase both anxiety and paranoia, causing hypervigilance and being overly alert to
surroundings. While a client with schizophrenia may also have impaired verbal communication,
altered sensory perception, and be socially isolated, anxiety is the most likely cause of the
behavior.
Concepts tested

Question 1363
A client with paranoid delusions stares at a nurse over a period of several minutes. The client
suddenly pushes a chair, walks up to the nurse, and shouts, "You think you're so perfect, pure,
and good!" What is the appropriate response for the nurse to make?
A "I will not speak to you when you are shouting."
B "Is that why you've been staring at me?"
C "Perfect? I don't quite understand."
D "You seem angry right now."

Question Explanation
Correct Answer is D
Rationale: The nurse recognizes the underlying emotion with a matter-of-fact attitude. The nurse
should avoid telling the client how the nurse feels. A general rule for interactions between clients
with a psychiatric diagnosis and staff members is to focus on feelings first when giving
responses to behaviors.
Concepts tested

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BASIC CARE AND
COMFORT
Question 1364
The nurse is performing the Weber assessment test on a client who reports hearing loss in the left
ear. Which finding would indicate to the nurse the client is experiencing conductive hearing
loss?
A The client hears the sound vibrate from the top of the head in the affected ear.
B The client hears the sound by air conduction longer than feeling bone conduction.
C The client feels the bone conduction longer than hearing the sound conduction.
D The client pushes on the tragus while repeating back what is whispered.

Question Explanation
Correct Answer is A
Rationale: For the Weber test, the tuning fork is placed on the bridge of the forehead, nose, or
teeth. In a normal test, the sound is heard equally in both ears. With unilateral conductive loss,
sound is heard in the affected ear. With unilateral sensorineural loss, sound is heard in the normal
or better-hearing side. In a Rinne test, the tuning fork is placed on the mastoid bone behind the
ear until the client can no longer feel the vibration. The fork is then moved beside the ear. In a
normal test, air conduction is greater than bone conduction. The whisper test has the client repeat
what is heard while pushing on the tragus.
Concepts tested

Question 1365
The nurse is reviewing written education with a client. The nurse notes the client squinting and
moving the document close to their eyes. What assessment tool would be used to collect
additional information about this patient's problem?
A Snellen chart
B Jaeger test
C Confrontation test
D Ishihara cards

Question Explanation
Correct Answer is B
Rationale: The Snellen chart is used to assess far vision; the Jaeger test is used for near vision.
Confrontation tests assess visual field and peripheral field deficits. Ishihara cards assess for the
ability to differentiate color.
Concepts tested

Question 1366

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The nurse is assessing a client who had a cerebrovascular accident for complications. Which
finding observed by the nurse would indicate the client is experiencing Broca’s aphasia?
A The client is unable to comprehend what others are saying.
B The client speaks in nonsensical sentences.
C The client has difficulty forming words.
D The client demonstrates the inability to understand written words.

Question Explanation
Correct Answer is C
Rationale: Patients with a stroke in the brain’s left hemisphere are more likely to have language
deficits. Damage to the Wernicke area may lead to difficulty understanding verbal
communication, called receptive aphasia. Damage to the Broca area causes problems with
speaking or finding words, called expressive aphasia. The client with Broca’s aphasia has slow
speech, difficulty in choosing words, and difficulty forming words. This leads to frustration as
the client’s comprehension is intact. Wernicke’s aphasia is a loss of comprehension. Fluency
remains but is nonsensical. Anomic aphasia leads to the inability to identify written words.
Concepts tested

Question 1367
The nurse is assessing the client with a hearing deficit for pre-existing knowledge of hearing aid
care. Which of the following statements by the client demonstrates correct care?
A “I clean my hearing aids with a disinfectant cleanser weekly.”
B “I open the battery door at night.”
C “I use a paper clip to clean the microphone port.”
D “A whistling sound means I need to have my hearing aid checked.”

Question Explanation
Correct Answer is B
Rationale: If the patient uses a hearing aid, check the batteries routinely and clean the earpieces
or ear mold daily with mild soap and water. A whistling sound that is audible when the hearing
aid is held in the hand with the power on and the volume high indicates that the battery is
functioning properly. The microphone port should be cleaned with a hearing aid brush and pick.
The shell and molds of the hearing aid should be cleaned with a chemical-free damp cloth.
Concepts tested

Question 1368
The nurse is assessing a client for proper use of a prosthetic leg. Which of the following actions
by the client is correct?
A The client applies a stump sock over the residual limb.
B The client lubricates the prosthetic knee joint.
C The client pads all areas of the socket that irritate the skin.
D The client washes the liner weekly.

Question Explanation

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Correct Answer is A
Rationale: A stump sock is designed to redistribute pressure and wick moisture away from the
skin. Prosthetics require no maintenance from the wearer outside of cleaning. Adjustments to the
socket to prevent injury should be done by a therapist, prosthetist, or provider. Liners are washed
and changed daily to prevent infection.
Concepts tested

Question 1369
The nurse is assessing a client with left-sided weakness while using a cane for ambulation.
Which observation by the nurse would indicate correct use of the cane?
A The client holds the cane in the left hand.
B The client advances the stronger leg at the same time with the cane.
C The client advances the stronger leg with the cane.
D The client holds the cane in the right hand.

Question Explanation
Correct Answer is D
Rationale: When walking with a cane, a client should hold the cane in the hand opposite the side
that needs support. The patient stands with weight evenly distributed between the feet and the
cane. The cane is held on the client’s stronger side. When the client is ready to walk, the client
advances the cane one step ahead of the good leg. Then, the client supports their weight on the
good leg and cane and moves the weaker leg forward. Once the weaker leg is advanced, then
placing weight on the cane and weaker leg, the client moves the good leg forward.
Concepts tested

Question 1370
The nurse is caring for a client experiencing left-sided homonymous hemianopsia after a
cerebrovascular accident. The client has been leaving the left side of the meal plate untouched.
Which of the following interventions should be implemented to improve intake?
A Assist the client by feeding them the remaining food.
B Provide the client with modified utensils for the left limb.
C Encourage the client to perform visual scanning of the environment.
D Move all food into the functioning visual field.

Question Explanation
Correct Answer is C
Rationale: Homonymous hemianopsia is a condition in which a person sees only one side ―
right or left ― of the visual field of each eye. The condition results from a problem in brain
function rather than a disorder of the eyes themselves. The most common cause is a stroke.
Clients may bump into or fail to notice objects, including food on a plate. This is a problem with
vision and not will weakness or paralysis, therefore the client does not need assistance being fed.
Treatment includes training the client to move the eyes purposefully and move the head and eyes
to the affected side. This is known as visually scanning the environment. Moving all food to the
unaffected side does not promote independence/autonomy.
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Concepts tested

Question 1371
The nurse is discussing the plan of care with an older adult client who wears hearing aids. The
nurse notes the client leaning forward and asks the nurse to repeat the noise. Which action should
the nurse take to assist the client?
A Provide written materials for any message that cannot be heard
B Decrease background noise
C Check hearing aids for function
D Position self so that lips can be seen by the client

Question Explanation
Correct Answer is B
Rationale: The priority action here is to reduce background noise, which is extremely distracting
to a client with hearing aids. The client should be able to see the lips of the speaker, facial
expressions, and hand movements. Hearing aids, if applicable, can be checked for dead batteries,
etc. Finally, any message that cannot be verbally communicated can be written/typed.
Concepts tested

Question 1372
The nurses on a medical unit are participating in a quality improvement project to promote
clients’ sleep and rest. Which of the following actions should be implemented?
A Plan admissions to the unit during daylight hours
B Silence the alarms in the nursing station
C Schedule afternoon and nighttime “quiet time” hours
D Turn off all lights in the clients’ rooms at night

Question Explanation
Correct Answer is C
Rationale: In this hospital, unfamiliar noises, such as people walking by or entering and leaving
the room and the sounds of elevator doors, bring complaints from patients in health care
facilities. Many health care facilities have made attempts to transform their patient care areas
into quieter settings that facilitate rest and sleep. Attention to design features with a focus on
eliminating environmental noise, providing patients with private rooms, and formal quiet times
on units all are aimed at creating an environment that is conducive to good sleep. Alarms are a
safety feature and should not be silenced. Admissions are nearly impossible to schedule as
emergencies happen 24/7. Turning off lights may increase the risk of falls and injuries.
Concepts tested

Question 1373
The nurse is planning care for a client with a history of sleep-wake disturbances who reports a
preferred bedtime at 10 pm. The nurse notes that the vital signs are scheduled for 11 pm. Which
action would be appropriate for the nurse to take?
A Take the client’s vital signs at 10 pm
B Ask the client to try to stay awake until 11 pm

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C Wake the client for 11 pm vital signs
D Attempt to take the 11 pm vitals without waking the client

Question Explanation
Correct Answer is A
Rationale: Whenever possible, provide care during periods when the patient is normally awake.
When this is not feasible, avoid waking the patient during REM sleep, when rapid eye
movements can be observed. Because a patient’s need for sleep is important, examine priorities
for nursing care. For example, consider whether checking a vital sign or carrying out a particular
nursing measure is more important than the patient’s sleep. It is safe to assess a client’s vital
signs 1 hour before the scheduled time in this situation.
Concepts tested

Question 1374
The nurse is assisting a client with denture care. Which of the following actions is appropriate?
A Use toothpaste when brushing the dentures
B Leave the dentures to air dry
C Rinse the dentures in hot water
D Line the sink with a towel when cleaning

Question Explanation
Correct Answer is D
Rationale: Dentures should be soaked in and brushed with a nonabrasive denture cleanser. Hot
water may warp the plastic used to make the denture. Similarly, leaving them to air dry may
cause warping. Lining the sink may prevent damage to the dentures if they are accidentally
dropped.
Concepts tested

Question 1375
The nurse is caring for a client with myopia who wears eyeglasses. The client is on supplemental
oxygen via nasal cannula. Which of the following actions is appropriate?
A Encourage the client to keep the glasses wrapped in a napkin when not in use
B Check the skin behind the ears for breakdown
C Place the glasses with the lenses down when the client removes them
D Ask the family to take the glasses home for safe keeping

Question Explanation
Correct Answer is B
Rationale: Eyeglasses are expensive items and should be protected from damage and loss.
Wrapping the glasses in a napkin increases the likelihood that they will be thrown away. Lenses
should be up to prevent scratching. Myopia is near-sightedness and therefore the client may need
them to ambulate and perform activities of daily living (ADLs). Glasses, along with oxygen
tubing, can contribute to skin breakdown, so the skin behind the ears should be assessed
regularly.
Concepts tested

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Question 1376
The nurse is evaluating the client’s use of a walker with four wheels. Which of the following
findings requires intervention?
A The client uses the chair arms for support when rising from a seated position.
B The client pushes the walker forward and then steps in between the back legs of the walker.
C The client applies body weight to the walker for support.
D The client stands upright and looks forward when ambulating.

Question Explanation
Correct Answer is C
Rationale: Walkers also are available with wheels on all four legs. Patients who require a larger
base of support and do not rely on the walker to bear weight can use these. If full body weight is
applied to this type of walker, it could roll away, resulting in a fall. Wheeled walkers are best for
patients who need minimal weight bearing from the walker. All other actions are correct.
Concepts tested

Question 1377
The nurse is evaluating the client’s denture care practices. Which of the following actions
requires intervention?
A The client uses a toothbrush to clean the dentures.
B The client uses regular toothpaste when brushing the dentures.
C The client stores the dentures in a covered container.
D The client uses denture adhesive before placing them in the mouth.

Question Explanation
Correct Answer is B
Rationale: Dentures should be cleaned using denture cleanser. Toothpaste may be too abrasive
for the plastics in the dentures. All other practices are expected.
Concepts tested

Question 1378
The nurse is evaluating a client’s understanding of the teaching on crutch walking. Which of the
following statements indicates an understanding of the teaching?
A “I should put my weight on the pads under my arms.”
B “I will keep my crutches close to my feet when walking.”
C “I should be done with my crutches before I need to replace any parts.”
D “I will go up the stairs with my good leg and crutches first.”

Question Explanation
Correct Answer is D
Rationale: The top of the crutches should be about 2 finger width below the armpit. Weight
should be placed on the hand grips. Crutches should be routinely checked for wear and damage.
Rubber crutch tips will need to be replaced when they are worn or cracked. Clients should be

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taught to ascend up the steps with the crutches and “good” leg first. Crutches should be at least
12 inches away from the feet to prevent falling.
Concepts tested

Question 1379
The nurse is assessing the client with a sigmoid colostomy. The client reports frequent soft stools
from the stoma. What statement by the nurse is appropriate?
A “Loose and watery stools are expected with this type of ostomy.”
B “Foods like applesauce and bananas can help with diarrhea.”
C “Wait to empty your pouch until it is 3/4 of the way full.”
D “Reduce your fluid intake until the diarrhea subsides.”

Question Explanation
Correct Answer is B
Rationale: Diarrhea may occasionally occur in a client with a sigmoid colostomy, however, the
typical stool is firmer or more like a paste compared to a higher ostomy placement. Foods such
as applesauce and bananas can help with diarrhea. Ostomy pouches should be emptied once they
are half full to prevent leakage. Fluid intake should be encouraged to prevent dehydration.
Concepts tested

Question 1380
The nurse is caring for a client who has been receiving broad-spectrum antibiotics. The client has
developed frequent, watery diarrhea and a fever. Which prescription should the nurse obtain
first?
A a stool specimen
B oral probiotics
C a fecal managment system
D oral antipyretic

Question Explanation
Correct Answer is A
Rationale: Clostridium difficile is diagnosed through toxin testing of stool. Prompt diagnosis is
required so treatment can begin. Probiotics, antipyretics, and a rectal tube, now known as a fecal
management system, are acceptable interventions for antibiotic-associated diarrhea but are not
the priority.
Concepts tested

Question 1381
The nurse is caring for a client with chronic pain who was prescribed oxycodone extended
release for pain management. The client is concerned about developing constipation. Which
response by the nurse is appropriate?
A “Only take the medication when your pain is severe.”
B “Increase your intake of dairy products.”
C “We will ask your provider to order a daily stimulant laxative.”
D “You can use a bulk forming laxative to help relieve your constipation.”

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Question Explanation
Correct Answer is D
Rationale: Opioids are a common cause of medication-induced constipation and can result in
significant distress for the patient. Increasing fluid and fiber in the diet are ways to prevent
constipation. Psyllium, a form of insoluble fiber, is considered a bulk-forming laxative. Daily
stimulant laxatives are avoided if possible due to significant side effects and rebound
constipation. Dairy is constipating. Clients should be encouraged to increase their intake of fruits
and vegetables. Extended-release opiates are scheduled and should not be taken in an as-needed
fashion.
Concepts tested

Question 1382
A nurse is preparing to perform a right eye irrigation. What action is correct?
A Direct the solution to flow from the inner to outer canthus
B Don sterile gloves before beginning the procedure
C Position the client on the left side
D Ask the client to look to the right

Question Explanation
Correct Answer is A
Rationale: Eye irrigation is performed to remove secretions or foreign bodies or to wash the eye
after chemical injury. The head should be tilted slightly toward the affected side and the irrigant
instills to flush from inner to outer canthus. Nonsterile gloves are used. The client should fix
their gaze straight ahead.
Concepts tested

Question 1383
The nurse is preparing to perform continuous bladder irrigation (CBI) for a client who had
prostate surgery. Which action is correct for the nurse to take?
A Deflate the catheter balloon
B Place the client in supine position
C Purge the air from the tubing prior to connecting to the catheter
D Clamp the tubing above the access port

Question Explanation
Correct Answer is C
Rationale: When providing continuous bladder irrigation, purge the air from the tubing to ensure
that no air enters the system, similar to IV tubing. The client should be in semifowlers for CBI.
The catheter balloon should not be deflated, or the catheter may dislodge. When performing
intermittent irrigation, the catheter may be clamped below the access port.
Concepts tested

Question 1384
A nurse is caring for a client who has chronic venous insufficiency and is prescribed elastic
compression stockings. Which action would be appropriate for the nurse to take?
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A Remove the stockings every two hours
B Position the stockings from the client’s ankle to the thigh
C Rub a small amount of lotion onto the client’s legs before applying stockings
D Apply the elastic stockings before the client gets out of bed in the morning

Question Explanation
Correct Answer is D
Rationale: When applying elastic compression stockings, the nurse should apply the stockings
before the client puts their feet in a dependent position (such as walking or sitting up with their
feet dangling). This decreases the edema and eases the application of elastic stockings. An
assessment of the area should take place at least once a shift. The nurse is assessing the color,
temperature, and integrity of the skin. Elastic stockings are applied from the client’s toes to the
thigh. Lotion should be avoided before applying compression stockings.
Concepts tested

Question 1385
A nurse is caring for a client who has right-sided paralysis from a stroke. Which intervention
should the nurse implement to prevent footdrop?
A Place a sandbag to maintain right plantar flexion
B Position soft pillows against the bottom of the feet
C Apply a protective boot to the right ankle
D Splint the right lower extremity to maintain proper alignment

Question Explanation
Correct Answer is C
Rationale: Footdrop occurs when the foot is permanently fixed in the plantar flexion position. To
prevent foot drop, the nurse should apply a protective boot on the affected foot aligning the
ankle. The nurse should avoid positioning the client with extended right plantar flexion. Pillows
do not provide adequate support. The nurse should avoid splinting the entire extremity, which
could limit the mobility of the extremity.

Concepts tested

Question 1386
A nurse is preparing to transfer a client who has been on bed rest to a chair. Which action should
the nurse take first?
A Place a transfer belt on the client
B Position the bed at an appropriate height
C Assist the client to a seated position
D Obtain orthostatic vital signs

Question Explanation
Correct Answer is D
Rationale: A client who has been on bed rest is at risk for orthostatic blood pressure due to the
decrease of venous return from muscle contraction. Before moving a client who has been on bed

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rest, the nurse should assess orthostatic blood pressure first. Then, the nurse will position the bed
at an appropriate height, assist the client to a seated position, and then place the transfer belt on
the client.
Concepts tested

Question 1387
The nurse is placing a client into the supine position. Which action should the nurse take to
maintain proper body alignment for this client?
A Place a folded blanket from the femur to the popliteal space
B Position a pillow under the shoulder with arm flexed
C Lift lower extremities off the bed with folded blankets
D Use pillows under the upper extremities with hands down

Question Explanation
Correct Answer is A
Rationale: When placing the client in the supine position, the nurse should place a trochanter
roll, a folded blanket, under the client’s femur extending to the popliteal place. The trochanter
roll will prevent the external rotation of the hip. Positioning a pillow under the shoulder and
lifting feet or upper extremities are used to decrease pressure on bony prominences but do not
maintain proper alignment.
Concepts tested

Question 1388
The nurse is educating a client with newly diagnosed gout about dietary restrictions. Which
statement made by the client would indicate to the nurse that further teaching is required?
A “I will limit the amount of fruit juices I drink.”
B “I should avoid carbonated beverages.”
C “I will need to avoid alcohol.”
D “I should choose shellfish over red meat.”

Question Explanation
Correct Answer is D
Rationale: The client with gout should be instructed to avoid foods that are high in purine, which
includes organ meats, seafood, fructose, and all alcohol.
Concepts tested

Question 1389
The nurse is teaching a client about nutritional requirements to promote wound healing. Which
dietary choice by the client indicates effective teaching?
A baked fish and spinach
B buttered pasta and fruit cup
C grilled cheese sandwich and fried potatoes
D ham sandwich and green salad

Question Explanation

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Correct Answer is A
Rationale: To promote wound healing, the nurse should instruct the client to choose foods that
are high in protein, carbohydrates, and vitamin C and low in fat. Baked fish is a complete
protein, and spinach is a good source of vitamin C. Green salad, grilled cheese, and buttered
pasta lack protein. Ham sandwiches and fried potatoes are high in fat.
Concepts tested

Question 1390
The nurse has educated a client who is newly diagnosed with hypertension about dietary
restrictions. The client, who is visually impaired, has requested a written copy of the education.
Which action should the nurse take?
A Use pictures on the instructions
B Provide the instructions in a large print
C Use simple sentences on the instructions
D Provide the instructions at low reading level

Question Explanation
Correct Answer is B
Rationale: The client, who is visually impaired, that requests a written copy of teaching would
benefit from the instructions being in large print. Clients who are health illiterate, or who have
decreased reading levels, would benefit from pictures and simple sentences on the instructions.
Concepts tested

Question 1391
The nurse is assisting a client newly diagnosed with diabetes type I with meal planning
exchanges. Which food choice made by the client would be appropriate?
A beef patty on bread, French fries, ½ cup of watermelon, and diet soda
B broiled fish, one cup of rice, green beans, and ice water
C one cup of cooked pasta with grilled chicken, broccoli, and olive oil, one cup of strawberries,
and unsweetened iced tea
D two cups of lettuce, tomatoes, and cucumbers with ranch dressing and sugar free gelatin with
peaches

Question Explanation
Correct Answer is C
Rationale: Diabetic meal planning exchange lists are an easy way for clients to adequately
choose appropriate foods. With the exchange list, the client will choose a number of helpings of
food from the list for each meal and snack. The client will choose a starch, fruit, vegetable, meat,
fats, and free foods. The meal should include a food from each list.
Concepts tested

Question 1392
The nurse is assisting a client who has hypothyroidism with meal planning. Which food should
the nurse recommend the client choose?

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A white rice
B poached eggs
C wheat bread
D baked chicken

Question Explanation
Correct Answer is C
Rationale: The client with hypothyroidism is at high risk for constipation and should be
instructed to eat foods that are high in fiber, such as wheat bread, beans, and broccoli. White rice,
poached eggs, and baked chicken are not good sources of fiber and could increase constipation.
Concepts tested

Question 1393
The nurse is assisting a client who has a history of pancreatitis with meal planning. Which food
choice made by the client would require further teaching?
A grilled chicken
B cheeseburger
C vegetable soup
D pasta

Question Explanation
Correct Answer is B
Rationale: The nurse should instruct the client to avoid eating foods high in fat, such as cheese
and beef, which can stimulate the pancreas. Foods that are low in fat, such as grilled chicken or
vegetable soup or foods that are high in carbohydrates, such as pasta, are less stimulating to the
pancreas.
Concepts tested

Question 1394
A nurse is performing hourly assessments on a postoperative client with an indwelling catheter.
The nurse notes 20 milliliters of urine in the drainage bag since the last assessment. Which action
does the nurse perform first?
A Prepare to administer a prescribed fluid bolus
B Notify the healthcare provider of the output
C Perform a bladder scan
D Check the catheter tubing for any kinks

Question Explanation
Correct Answer is D
Rationale: The nurse should first ensure the tubing is free of kinks. Urinary catheter tubing that is
kinked, or twisted, can prevent the flow of urine into the drainage bag. A fluid bolus is indicated
when there are signs of dehydration. The nurse needs to perform additional assessments prior to
performing interventions. A bladder scan is indicated when urinary output is decreased and
bladder distention is noted. The nurse must first ensure the catheter is functioning properly. The

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healthcare provider should be notified when urinary output is less than 30 ml/hr. However, the
nurse must first perform additional assessments before information the provider of the findings.
Concepts tested

Question 1395
A nurse is assessing the daily intake and output for a client. The nurse notes that the client’s total
fluid intake was 2,000 mL and the client's output was 1,300 mL of urine. Which action should
the nurse take?
A Document the findings
B Notify the healthcare provider
C Advise the client to increase oral fluid intake
D Perform a straight urinary catheterization

Question Explanation
Correct Answer is A
Rationale: The client’s fluid balance is expected. The excretion of urine makes up approximately
half of the daily fluid output. The rest of the fluid loss is via the skin, lungs, and gastrointestinal
system. The healthcare provider should be notified when there is a significant imbalance of
intake and output. Additional assessments are required to determine an imbalance. Increasing
oral fluid intake is not indicated for this client. The urinary output is normal. Urinary
catheterization is not indicated. The client is not showing signs of urinary retention.
Concepts tested

Question 1396
A nurse is reviewing laboratory data for a client with colon cancer who is receiving
chemotherapy. Which finding indicates the client is developing malnutrition?
A White blood cell count of 4,000/mm³
B Hemoglobin level of 10.5 g/dL
C Albumin level of 3.1 g/dL
D Glucose level of 195 mg/dL

Question Explanation
Correct Answer is C
Rationale: Albumin levels help to determine adequate protein levels and caloric intake. Low
albumin levels are indicative of malnutrition. The normal serum albumin level is 4 to 6 g/dL. A
low white blood cell (WBC) count is an expected finding for a client receiving chemotherapy.
However, a low WBC count is indicative of a risk of infection, not malnutrition. Low
hemoglobin levels are an expected finding for a client receiving chemotherapy. However, a low
hemoglobin level indicates anemia, not malnutrition. Chemotherapy can cause hyperglycemia.
However, a high serum glucose level is not indicative of malnutrition.
Concepts tested

Question 1397
A nurse is providing care to a client with malnutrition due to chronic alcohol use. The nurse
knows that the client’s malnutrition is due to which pathophysiologic factor?

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A Damage of the intestinal mucosa
B Blockage of the bile ducts
C Increased pressure in the portal vein
D Enlargement of esophageal veins

Question Explanation
Correct Answer is A
Rationale: Alcohol has a toxic effect on the intestinal mucosa. Nutrient absorption occurs in the
gastrointestinal system, specifically the small intestine. Fibrotic liver tissue due to alcohol use
blocks the bile ducts. Blocked bile ducts result in increased bilirubin levels, not malnutrition.
Chronic alcohol use can lead to cirrhosis, which increases the pressure of the portal vein and
leads to fluid accumulation in the abdomen. However, this mechanism does not explain
malnutrition. Chronic alcohol use causes enlargement of esophageal veins. However, the main
concern of esophageal varices is bleeding, not malnutrition.
Concepts tested

Question 1398
A nurse is providing care to a client with dysphagia. The client coughs frequently during meals
and refuses food after a few bites. Which action will best promote adequate nutrition in the
client?
A Position the client in a high-Fowler’s position
B Encourage the client to select their food preferences
C Provide liquid nutritional supplements
D Request a speech-language pathologist consult

Question Explanation
Correct Answer is D
Rationale: A speech-language pathologist can evaluate the client’s ability to swallow and
recommend an appropriate food consistency to promote nutrition and prevent aspiration.
Positioning the client in a high-Fowler’s position prevents aspiration of food into the lungs.
However, this intervention does not address the client’s difficulty eating. Encouraging the client
to select their food preferences promotes independence in eating. This intervention does not
resolve the client’s difficulty eating. Liquid nutritional supplements are indicated when a client
does not receive enough nutrients. However, the client’s difficulty eating needs to be assessed
first.
Concepts tested

Question 1399
A nurse is assessing a client with history of hypertension who is taking prescribed nifedipine.
The client reports experiencing anorexia, nausea, and dysgeusia. Which action will the nurse take
to promote adequate nutrition in the client?
A Educate the client on the importance of a low-sodium diet
B Request a prescription for an anti-emetic from the healthcare provider
C Advise the client to eat small meals throughout the day
D Instruct the client to take the medication with grapefruit juice

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Question Explanation
Correct Answer is B
Rationale: Nausea, dysgeusia, and anorexia are side effects of nifedipine. Requesting a
prescription for an anti-emetic from the healthcare provider will help address the client’s
gastrointestinal symptoms. A low-sodium diet will help manage the client’s hypertension.
However, it does not address the client’s concerns. Encouraging the client to eat small meals
throughout the day does not address the gastrointestinal concerns. Grapefruit juice causes a drug-
food interaction with nifedipine. Grapefruit can increase the serum levels and effects of
nifedipine.
Concepts tested

Question 1400
A nurse is performing an intake assessment on a client who is homeless. Which statement by the
nurse best assesses the client’s hygiene practices?
A “Tell me about your bathing habits.”
B “When was the last time you showered?”
C “How do you obtain supplies to bathe?”
D “Let me know when you’d like to shower.”

Question Explanation
Correct Answer is A
Rationale: The nurse should allow the client to verbalize their bathing habits. Clients who are
homeless often do not have the means to perform frequent hygiene practices. Asking about the
last time they showered or how they obtain supplies may make the client feel uncomfortable and
offended. Allowing the client to choose their bathing time promotes independence. However,
this does not assess hygiene practices.
Concepts tested

Question 1401
A nurse is assessing a client with a history of left hemiplegia. The nurse notes the client’s hair is
disheveled and the fingernails appear unclean. Which statement by the nurse best addresses the
client’s hygiene?
A “When was the last time you combed your hair?”
B “Tell me how often you perform your personal hygiene.”
C “Does your condition interfere with your hygiene routine?”
D “It is important to clean underneath your fingernails when you bathe.”

Question Explanation
Correct Answer is C
Rationale: Asking the client if their condition interferes with their hygiene can accurately assess
for any barriers to performing a routine. Assessing interfering factors can help provide the client
with assistance as needed. Asking the client when they last combed their hair does not provide
sensitive client care. Assessing the frequency of personal hygiene does not address the client’s
mobility deficit. The client has hemiplegia and may have difficulty performing their hygiene

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routine. Educating the client on skin care is important. However, this does not take the client’s
mobility deficit into consideration.
Concepts tested

Question 1402
A nurse is preparing bathing supplies for a client during the morning shift. The client refuses to
shower, stating they want to sleep instead. How should the nurse respond to the client’s request?
A “You can bathe during the evening shift.”
B “Is there a time of day when you prefer to bathe?”
C “Bathing will make you sleep more comfortably.”
D “Why don’t you want to bathe in the morning?”

Question Explanation
Correct Answer is B
Rationale: Assessing the client’s bathing routine allows the client to maintain their personal
preferences. Allowing the client to choose a specific time of the day may encourage hygiene
practices. Telling the client they can bathe during the evening shift does not allow the client to
make a choice in their hygiene practices. Giving advice on bathing does not specifically address
the client’s refusal to perform hygiene. “Why” questions are a barrier to therapeutic
communication. The nurse should assess the client’s hygiene preferences first.
Concepts tested

Question 1403
A nurse is performing a skin assessment on an older client. The nurse notes dryness to the skin
and body odor upon inspection. Which statement by the nurse best addresses the client’s
hygiene?
A “When is the last time you bathed?”
B “Wearing deodorant prevents body odor.”
C “It is important to bathe every day.”
D “What kind of bathing products do you use?”

Question Explanation
Correct Answer is D
Rationale: Asking the client what kind of bathing products they use helps to determine if the skin
dryness and body odor are related to their hygiene routine. Asking the client about the last time
they bathed and telling them deodorant prevents body odor does not promote sensitive care and
might be offensive to the client. Assuming the client does not bathe daily does not promote
sensitive care. The nurse should assess the client’s bathing habits and hygiene routines.
Concepts tested

Question 1404
A nurse is preparing to perform an intermittent closed catheter irrigation on a client. Which
action should the nurse perform prior to beginning the procedure?
A Cleanse the access port on the urinary catheter
B Detach the drainage bag from the urinary catheter

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C Pour tap water into the irrigation basin
D Prepare a sterile field close to the client

Question Explanation
Correct Answer is A
Rationale: Catheter irrigations are performed through the access port to minimize exposure to
infectious organisms. The nurse should clean the access port prior to attaching the irrigation
syringe. The catheter should not be detached from the drainage bag as it can increase the risk of
microorganism entry. Catheter irrigations should be performed with a sterile solution. Tap water
can introduce microorganisms into the bladder. Closed catheter irrigation requires an aseptic
technique.
Concepts tested

Question 1405
A nurse is providing perineal care to a client with urinary incontinence. Which action should the
nurse perform to promote skin integrity?
A Cleanse the skin with hot water
B Apply a moisture barrier cream
C Cover the area with talc-based powder
D Place a towel between the client’s thighs

Question Explanation
Correct Answer is B
Rationale: Moisture barrier creams protect the skin from breakdown in clients who have frequent
incontinence. Constant moisture can create maceration of the skin. Perineal care should be
performed with tepid, not hot, water. Hot water can cause burns to the skin. Powder should not
be applied to the area, as it can cause abrasiveness and further skin breakdown. Placing a towel
between the thighs will further expose the skin to moisture. The skin should be kept dry.
Concepts tested

Question 1406
A nurse is providing care to a client with urinary incontinence who has an abrasion to the left
inner thigh. Which action should the nurse perform to maintain skin integrity?
A Apply antimicrobial ointment to the abrasion
B Insert an indwelling urinary catheter
C Spray the abrasion with an alcohol-free barrier film
D Place a gauze dressing on the client’s thigh

Question Explanation
Correct Answer is C
Rationale: An alcohol-free barrier film will protect the abrasion from constant moisture as a
result of incontinence. The nurse should protect the skin to prevent breakdown. An antimicrobial
ointment will protect the abrasion from bacteria. However, incontinence causes constant
moisture, and the abrasion should be kept dry. Urinary catheters should not be inserted for the
purpose of incontinence. The nurse should use other methods to keep the skin and abrasion dry.

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Placing a gauze dressing on the client’s thigh will cover the abrasion but will not protect it from
constant moisture.
Concepts tested

Question 1407
A nurse is providing hygiene care to a client with urinary incontinence. Which skin breakdown
prevention strategy should the nurse implement?
A Initiating a turning schedule
B Providing the client with disposable briefs
C Cleansing the perineal area frequently with soap
D Applying moisture barrier ointments

Question Explanation
Correct Answer is D
Rationale: Moisture barrier ointments help maintain the skin’s integrity by repelling urine and
preventing maceration of the skin. A turning schedule will help prevent pressure ulcer formation.
However, it will not prevent breakdown due to incontinence. Disposable briefs will not prevent
the skin from having constant moisture due to incontinence. The nurse should apply products
that repel moisture. Cleansing the perineal area with soap is not recommended. Soap may irritate
the skin.
Concepts tested

Question 1408
A nurse is preparing to perform Crede’s maneuver on a client who is unable to void. How should
the nurse perform this procedure?
A Exert manual pressure over the suprapubic area
B Ask the client to inhale deeply and bear down forcefully
C Massage the area above the navel
D Instruct the client to lean forward while sitting on the toilet

Question Explanation
Correct Answer is A
Rationale: Crede’s maneuver requires manual compression at the level of the bladder. Manual
compression aids in pushing urine out of the bladder. Asking the client to inhale and bear down
is characteristic of the Valsalva maneuver. The bladder is located below the area of the navel, not
above. Leaning forward while sitting on the toilet will help the bladder empty once urination
begins. However, this does not exert enough pressure as Crede’s maneuver does.
Concepts tested

Question 1409
A nurse is instructing a client who is unable to void on techniques to assist with urine
elimination. The nurse instructs the client to squeeze the abdominal muscles and bear down
forcefully. Which technique is the nurse promoting?
A Double voiding
B Valsalva maneuver

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C Kegel exercises
D Crede’s maneuver

Question Explanation
Correct Answer is B
Rationale: Squeezing the abdominal muscles while bearing down is characteristic of the Valsalva
maneuver. The Valsalva maneuver increases the pressure within the bladder to facilitate urine
elimination. Double voiding is characterized by attempting further urination after emptying the
bladder completely. Kegel exercises involve tightening of the pelvic muscles to prevent urinary
incontinence. Crede’s maneuver involves applying direct manual pressure over the level of the
bladder.
Concepts tested

Question 1410
A nurse is instructing a client with urinary retention how to perform double voiding to promote
urination. The nurse will instruct the client to do which action after initiating voiding?
A Hold the urine midstream, then finish emptying the bladder
B Massage the bladder for 5 minutes after voiding, then void again
C Wait 30 seconds after voiding, then attempt to void again
D Lean forward while voiding, then stand upright to finish emptying the bladder

Question Explanation
Correct Answer is C
Rationale: Double voiding is characterized by bladder emptying, followed by a period of rest and
a subsequent attempt to further empty the bladder. Initiating voiding, holding the urine, and
emptying the bladder is characteristic of Kegel exercises which involve tightening the pelvic
muscles. Massaging the bladder stimulates urination. However, the client should only wait a few
seconds before attempting to void again. Leaning forward while voiding compresses the bladder
and promotes urination. However, this does not describe double voiding.
Concepts tested

Question 1411
A nurse is assessing a client who is on a bladder-retraining program. Which clinical finding
indicates the training program is effective?
A The client has no incontinence episodes for 3 days.
B The client is able to verbalize the need to void.
C The client voids 300 milliliters in one episode of urination.
D The client denies bladder discomfort when voiding.

Question Explanation
Correct Answer is A
Rationale: The goal of a bladder-retraining program is to increase the bladder’s ability to hold
urine for a prolonged period of time. No incontinence episodes indicate the training was
successful. The client’s need to void will be unchanged. A bladder-retraining program

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encourages clients to suppress urination. Voiding 300 milliliters in one episode is not the goal of
a bladder-retraining program. Bladder discomfort is unrelated to the goal of bladder-retraining.
Concepts tested

Question 1412
A nurse is evaluating the effectiveness of urinary habit training for a client with functional
incontinence. Which finding indicates the program was successful?
A The client’s voiding episodes increase in frequency.
B The client urinates at scheduled intervals.
C The client verbalizes a decrease in bladder spasms.
D The client’s bladder distention is decreased.

Question Explanation
Correct Answer is B
Rationale: The goal of bladder training for clients with functional incontinence involves
establishing predictable patterns of urination. The ability of the client to urinate at scheduled
intervals indicates the training was successful. Increased episodes of voiding is not the goal of
bladder training for functional incontinence. Bladder spasms and bladder distention are not
associated with functional incontinence or a urinary habit training program.
Concepts tested

Question 1413
A nurse is assessing a client post-nasogastric tube removal for a paralytic ileus. Which finding
indicates the treatment has restored bowel function?
A Absence of abdominal pain upon palpation
B Abdominal resonance heard upon percussion
C Bowel sounds are normoactive upon auscultation
D Abdomen is rounded upon inspection

Question Explanation
Correct Answer is C
Rationale: A paralytic ileus is characterized by decreased peristalsis, constipation, and the
inability to evacuate the bowels. A nasogastric tube decompresses the bowel and restores
function. Normoactive bowel sounds indicate peristalsis is present. Absence of abdominal pain
upon palpation is a normal finding. However, this does not evaluate the return of bowel function.
Resonance is not an expected abdominal sound upon percussion. The normal abdominal
percussion sound is tympany. A rounded abdomen is a normal finding. However, this does not
evaluate whether there is bowel activity present.
Concepts tested

Question 1414
A nurse is assessing a client who has a prescription for strict bedrest. Which finding indicates the
client is developing complications from immobility?
A Bronchovesicular breath sounds are auscultated
B Achilles deep tendon reflexes are brisk

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C Bowel sounds are hyperactive
D Non-blanchable redness noted to the heels

Question Explanation
Correct Answer is D
Rationale: Immobility leads to increased pressure on bony prominences. The heels are highly
susceptible to pressure injuries. Non-blanchable redness to the heels is indicative of a stage 1
pressure injury. Brisk deep tendon reflexes are a normal finding. Hyperactive bowel sounds are
not an expected finding with prolonged immobility. Immobility causes decreased peristalsis,
evidenced by hypoactive bowel sounds. Bronchovesicular breaths sounds are a normal finding.
Immobility can lead to decreased chest expansion and accumulation of respiratory secretions.
Concepts tested

Question 1415
A nurse is assessing a client with multiple sclerosis who is on bed rest. Which respiratory finding
indicates the client is developing complications from immobility?
A Oxygen saturation of 92%
B Inspiratory to expiratory ratio of 1:2
C Decreased cough response
D Bronchial lung sounds auscultated

Question Explanation
Correct Answer is C
Rationale: Immobility causes the respiratory muscles to weaken, leading to a decreased ability to
cough up secretions. A decreased cough response is indicative of weakened respiratory muscles.
An oxygen saturation of 92% is a normal finding. The normal oxygen saturation is ≥ 92%. An
inspiratory to expiratory (I:E) ratio of 1:2 is a normal finding. Expiration should be longer than
inspiration. Bronchial lung sounds are a normal finding. This indicates adequate airflow through
the lungs.
Concepts tested

Question 1416
A nurse is assessing a client with paraplegia. Which condition indicates a complication from
immobility?
A Increased basic metabolic rate
B Recurrent migraines
C Decreased cardiac workload
D Frequent urinary tract infections

Question Explanation
Correct Answer is D
Rationale: Immobility causes urinary stasis. Retention of urine can lead to bacteria multiplication
and frequent urinary tract infections. An increased basic metabolic rate is not an expected
finding. Immobility causes a decrease in metabolic rate and nutrient metabolism. Migraines are
not directly associated with immobility. Neurological symptoms include emotional and

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behavioral changes. A decreased cardiac workload does not result from immobility. Immobility
leads to decreased cardiac output, causing an increase in the workload of the heart.
Concepts tested

Question 1417
A nurse is performing a musculoskeletal assessment on a client. Which action should the nurse
take to assess dorsiflexion of the ankle?
A Ask the client to raise the toes toward the knee
B Instruct the client to point the toes toward the ground
C Advise the client to turn the sole of the foot toward the opposite leg
D Tell the client to turn the sole of the foot away from the opposite leg

Question Explanation
Correct Answer is A
Rationale: Dorsiflexion of the ankle assesses the ability of the foot to flex upward. This action is
performed by raising the toes toward the knee. Pointing the toes toward the ground assesses for
plantar flexion. Turning the sole of the foot toward the opposite leg assesses inversion of the
ankle. Turning the sole of the foot away from the opposite leg assesses eversion of the ankle.
Concepts tested

Question 1418
A nurse is assessing a client for hip flexion contractures. Which test will the nurse use to perform
this assessment?
A Lasegue test
B Thomas test
C McMurray test
D Phalen test

Question Explanation
Correct Answer is B
Rationale: The Thomas test assesses the presence of a flexion contracture of the hip. The client
should be supine, with one leg extended and the other with a flexed knee. When the knee is
brought to the chest, the opposite leg will rise if a flexion contracture is present. The Lasegue test
is used to check for lumbar disc herniation and nerve irritation. The McMurray test is used to
assess for a meniscus cartilage injury to the knee. The Phalen test is used to evaluate carpal
tunnel syndrome.
Concepts tested

Question 1419
A nurse is performing a physical assessment on a toddler. Which activity will the nurse use to
assess for fine motor skills?
A Hopping up and down
B Throwing a ball
C Clapping hands
D Matching shapes and sizes

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Question Explanation
Correct Answer is D
Rationale: Matching shapes is an activity used to assess for fine motor skills. A developmental
milestone for a toddler is being able to match shapes such as circles, triangles, and squares. The
abilities to throw a ball, clap hands, and hop up and down assess for gross motor skills.
Concepts tested

Question 1420
A nurse is performing a skin assessment on a client who is immobile. Which area of the skin
would be a priority for the nurse to inspect for pressure injuries?
A Below the breasts
B Under the calves
C Behind the head
D In the groin

Question Explanation
Correct Answer is C
Rationale: Bony prominences are high-risk areas for pressure injuries. Areas where the bone is
close to the surface, such as the occipital area of the scalp, can cause increased pressure to the
skin and decreased circulation to the underlying tissues. Below the breasts and in the groin are
skin fold areas. Skin folds are high-risk areas for irritation and infection. The skin below the
calves is not a high-risk area for pressure injuries.
Concepts tested

Question 1421
A nurse is assisting an unlicensed assistive personnel (UAP) with morning care for a client with
decreased mobility. Which action should the nurse take to decrease friction and shearing?
A Pull the client towards the head of the bed
B Place bilateral heel protectors
C Apply moisturizer to the skin
D Lift the client up in bed

Question Explanation
Correct Answer is D
Rationale: Friction and shearing cause skin tissue layers to pull apart. Friction and shearing can
be due to bedsheets dragging or rubbing against the skin. Lifting, rather than pulling, a client
decreases the risk of shearing. Pulling the client towards the head of the bed causes friction and
shearing against the bedsheets. Applying bilateral heel protectors will prevent skin breakdown
due to pressure, not friction or shearing. Applying moisturizer to the skin maintains integrity and
prevents dryness. However, this does not prevent friction or shearing.
Concepts tested

Question 1422

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A nurse is providing care to a client who is immobile. Which intervention will best protect the
client from developing skin breakdown?
A Reposition the client every 2 hours
B Assist the client with passive range of motion twice per shift
C Provide the client with at least 2,500 mL of water daily
D Inspect the client’s skin frequently

Question Explanation
Correct Answer is A
Rationale: Repositioning a client every 2 hours is an independent nursing action that best
prevents skin breakdown. Repositioning the client offloads pressure from bony prominences and
promotes circulation. Assisting the client with passive range of motion (ROM) twice per shift
will prevent muscle atrophy. However, infrequent ROM exercises do not protect the skin from
breakdown. Adequate hydration is important to maintain skin turgor and elasticity. However, this
intervention is not enough to offload pressure and prevent skin breakdown. Inspecting the
client’s skin frequently alerts the nurse to any concerns. However, this does not prevent skin
breakdown.
Concepts tested

Question 1423
A nurse is providing care to a client with a history of Guillain-Barre syndrome. Which action
should the nurse perform to promote cardiovascular function?
A Place a specialty mattress on the client’s bed
B Assist the client to ambulate with crutches
C Elevate the head of the bed
D Perform passive range of motion exercises

Question Explanation
Correct Answer is D
Rationale: Clients with Guillain-Barre syndrome experience muscle weakness in the extremities.
Range of motion (ROM) exercises promote circulation to the extremities and maintain
cardiovascular function. A specialty mattress will decrease the risk of skin breakdown in a client
who is immobile. This action does not promote cardiovascular function. Ambulation with
crutches is not a safe intervention for a client with Guillain-Barre syndrome. Elevating the head
of the bed helps promote lung expansion and respiratory function.
Concepts tested

Question 1424
The nurse is turning and repositioning a client who is immobile. Which of the following actions
by the nurse is appropriate?
A Turn the client while the bed is in the lowest position
B Stand at the foot of the bed while completing the turn
C Remove pillows prior to turning
D Put up all four of the bed’s side rails during the turn

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Question Explanation
Correct Answer is C
Rationale: Removing the pillows or other support devices ensures that there are no obstacles that
would make the turn more difficult. After the client has been repositioned, the support devices
and pillows should be reapplied. The nurse should stand at the center of the client while
completing the turn. The bed should be raised to a comfortable working height for the nurse and
the returned to the lowest position after the turn has been completed. The side rails should be put
down during the turn while the nurse is at the side of the bed. This allows the nurse to use proper
body mechanics while repositioning the client.
Concepts tested

Question 1425
The nurse is preparing to transfer a client who is immobile from the bed to a stretcher. Which of
the following actions by the nurse is most appropriate?
A Raise the head of the bed to a comfortable angle
B Instruct the client to hold a staff member’s hand during the transfer
C Ensure the bed is in the lowest position
D Gather additional staff members to perform the transfer

Question Explanation
Correct Answer is D
Rationale: To safely perform a lateral transfer, the nurse should gather additional personnel. The
bed should be raised to a comfortable working height, while the head of the bed is lowered to the
lowest angle tolerated by the client. The client should cross their arms over their chest during the
transfer.
Concepts tested

Question 1426
The nurse is assisting an unlicensed assistive personnel (UAP) with a bed bath of a client who
has skeletal traction of the lower extremity. Which action by the UAP requires immediate
intervention by the nurse?
A Removing the traction weights
B Cleaning the pin sites
C Encouraging the client to use a trapeze
D Placing a pillow under the client’s heel

Question Explanation
Correct Answer is A
Rationale: The weights of traction devices should not be removed until the provider discontinues
the prescription completely. Cleaning of the pin sites, asking the client to use a trapeze, and
placing a pillow under the client’s heels are all appropriate actions to prevent complications.
Concepts tested

Question 1427
The nurse is caring for a client who recently had a cast applied to the right lower extremity.
Which of the actions by the nurse is appropriate?
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A Place the leg in a dependent position every two hours
B Apply a warm compress above the cast site
C Assess capillary refill of the toes every four hours
D Clean inside the cast with cotton swabs

Question Explanation
Correct Answer is C
Rationale: Assessment of the neurovascular status of the extremities should be done on a very
frequent basis after a new cast, brace, or splint is applied. The affected extremity should be
elevated rather than dependent. No objects, including cotton swabs, should be placed inside the
cast. Cold compresses would be more beneficial than warm compresses.
Concepts tested

Question 1428
The nurse is caring for a client who had an external fixator device placed on the tibia four hours
ago. Which action by the nurse is appropriate?
A Submerging the extremity in a chlorohexidine bath
B Cleansing each pin site individually
C Applying compression stockings over the device
D Instructing the client to do weight bearing activity

Question Explanation
Correct Answer is B
Rationale: An external fixation device should have each of the pins cleaned on a regular basis
and assessed for signs of inflammation or infection. The extremity should not be submerged, and
compression stockings are not appropriate. Weight-bearing activities can be performed based on
the provider’s instruction once the swelling has subsided, but in this case, the client should not be
weight-bearing since they only had the procedure four hours ago.
Concepts tested

Question 1429
The nurse is educating a client about how to reposition safely using a trapeze. Which statement
should the nurse include in the teaching?
A “Remove the trapeze each time you reposition yourself.”
B “Don’t use the trapeze for lateral turns.”
C “A nurse should be present each time you use the trapeze.”
D “Pull up on the trapeze with your hands.”

Question Explanation
Correct Answer is D
Rationale: A trapeze is a device that hangs over the bed and can be used by the client to
reposition. The client uses their hands to grasp the bar and it can be used with or without staff
assistance. The trapeze should remain in place and can be used for all types of repositioning.
Concepts tested

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Question 1430
The nurse is assisting a staff member to reposition a client up in the bed. Which instructions
should the nurse make to the client?
A “Grab my arm while we pull you up.”
B “Place your chin on your chest while we move you.”
C “Keep your legs straight when we pull you up.”
D “We will raise the head of the bed before we move you.”

Question Explanation
Correct Answer is B
Rationale: The client should cross their arms over the chest and lift the head so that their chin
touches their chest. The nurse should lower the head of the bed rather than raise it. The client
should be instructed to bend their knees with their feet flat on the bed and then push when being
pulled up.
Concepts tested

Question 1431
The nurse is educating a client on how to transfer from the bed to the chair with a caregiver’s
assistance. Which of the following statements by the nurse is appropriate?
A “You should avoid wearing shoes during transfers.”
B “Take deep breaths if you begin to feel weak or dizzy.”
C “We will place a gait belt around your waist.”
D “Hold on to the side rails of the bed while we move.”

Question Explanation
Correct Answer is C
Rationale: When transferring a client from the bed to the chair the nurse will place a gait belt on
the client to ensure safe handling. The client should wear non-skid footwear, and should alert the
nurse to discontinue transferring if they begin to feel weak or dizzy. Grasping the side rails of the
bed is not recommended because the client may struggle to let go of the bed while trying to
transfer.
Concepts tested

Question 1432
The nurse is caring for a client who has no mobility of the lower extremities. Which action by
the nurse is most appropriate to maintain the client’s proper body alignment while in the lateral
position?
A Placing trochanter rolls beside the client’s hips
B Using a foot boot on the superior extremity
C Placing a pillow between the client’s knees
D Raising the head of the bed to 45 degrees

Question Explanation
Correct Answer is C

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Rationale: The lateral position can cause internal rotation and adduction of the femur, so the
nurse should place a pillow between the client’s legs to avoid stress on the hips. Foot boots
should be used while the client is supine to prevent foot drop, and trochanter rolls are also used
in the supine position. The head of the bed should not be elevated.
Concepts tested

Question 1433
The nurse is caring for a client who had a total hip arthroplasty two days ago. Which action by
the nurse is appropriate to maintain the client’s correct body alignment?
A Placing an abduction pillow between the legs.
B Crossing the client’s legs at the ankles.
C Raising the head of the bed to 90 degrees.
D Turning the client onto the affected side.

Question Explanation
Correct Answer is A
Rationale: An abduction pillow should be placed between the clients legs to prevent dislocation
of the hip prosthesis. The client’s legs should never be crossed, and turning the client into the
lateral position with the affected leg down is not recommended.
Concepts tested

Question 1434
The nurse is observing an unlicensed assistive personnel (UAP) who is providing perineal care
for a female client. Which of the following techniques, if observed by the nurse, would indicate
that the UAP is performing perineal care correctly?
A Using a circular motion from anal to pubic area
B Washing from side to side within the labia
C Washing from the pubic area toward the anal area
D Rinsing with a large amount of water

Question Explanation
Correct Answer is C
Rationale: Perineal care is important to prevent infection. The correct technique for performing
perineal care for a female client is to wash from the pubic area toward the anal area. Using a
circular motion causes friction which could cause injury. Washing within the labia side to side
causes friction and could cause injury. Rinsing with large amounts of water could cause
overhydration.
Concepts tested

Question 1435
The nurse is assisting a client with impaired sensation perform hygiene care. Which action by the
client would require the nurse to intervene?
A The client uses a mirror to inspect the bottoms of his feet.
B The client washes his feet with lukewarm water.
C The client applies a single layer of lotion to his feet.

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D The client cuts the toenails with clippers.

Question Explanation
Correct Answer is D
Rationale: The client with impaired sensation to the lower extremities, such as with diabetes or
peripheral vascular disease, foot care is required to prevent injury. The client should inspect their
feet with a mirror, wash with lukewarm water, and apply a single layer of lotion to prevent
injury. Cutting toenails could result in an injury and the nurse should intervene.
Concepts tested

Question 1436
The charge nurse is assisting a client to remove the soft contacts from the eyes. Which action by
the client would require the nurse to intervene?
A Slides the lens from the cornea to the white of the eye before removing it
B Lifts each lens directly from the cornea by pinching with forefinger and thumb
C Pulls the upper eyelid down, compressing the lens between the thumb and forefinger
D Applies sterile normal saline drops to the lens, then pulls down with upper lid

Question Explanation
Correct Answer is A
Rationale: When removing contacts from the eyes, the client should avoid sliding the lens from
the cornea to the sclera before removing it. This could cause friction against the cornea, resulting
in injury. The client should be instructed to either lift the lens directly from the cornea by
pinching or pulling the upper eyelid down, compressing the lens between the thumb and
forefinger. The client could apply sterile normal saline drops and then pull down with the upper
lid.
Concepts tested

Question 1437
The nurse is caring for a client with a femoral fracture who has a prescription for Buck’s skin
traction and notes that the client’s foot is against the footboard of the bed. Which of the
following actions would be most appropriate for the nurse to take?
A Wedge a pillow between the client’s foot and the footboard
B Readjust the traction weights and pull ropes
C Remove the skin traction
D Reposition the client to the center of the bed

Question Explanation
Correct Answer is D
Rationale: Buck’s skin traction is prescribed to create skin and skeletal traction that uses a pully
system of weights to realign and reduce a fracture. The client who is in Buck’s skin traction with
their foot against the footboard needs to be repositioned to the center of the bed. The nurse
should not remove the skin traction or readjust the weights and pull ropes. Placing a pillow
between the client’s foot and footboard could affect the alignment of the weights.
Concepts tested

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Question 1438
The nurse is preparing to reposition a client who is postoperative on day one after a right hip
arthroplasty. Which of the following actions should the nurse take?
A Keep the client’s hip in abduction at all times
B Flex the client’s hip at a 90-degree angle
C Move the client towards the unaffected side
D Place the client’s legs together

Question Explanation
Correct Answer is A
Rationale: A client who is postoperative hip arthroplasty should be positioned with the hips
abducted at all times, which prevents dislocation of the hip. The client should be moved towards
the affected side to prevent dislocation. Placing the client’s legs together and flexing the hip
could cause hip dislocation.
Concepts tested

Question 1439
The nurse is planning care for a client who is postoperative intermaxillary fixation for a
mandibula fracture. Which of the following should be the priority of the nurse to place at the
client’s bedside?
A Nasogastric tube
B Wire cutters
C Toomey syringes
D Tongue depressor

Question Explanation
Correct Answer is B
Rationale: The client who is postoperative intermaxillary fixation will have wires to keep the
jawbone aligned. If a client experiences respiratory distress, the nurse will need to cut the wires
to access the airway. A nasogastric tube is used to decompress the stomach, Toomey syringes are
used to irrigate the mouth, and a tongue depressor retracts the cheeks, but these are not a priority.
Concepts tested

Question 1440
The nurse is planning care for a client who is 3 days postoperative on a left above-the-knee
amputation. Which of the following actions should the nurse take to prevent hip contractures?
A Elevate the stump on a pillow.
B Have the client sit up to the chair during the day.
C Position the client prone several times a day.
D Encourage the client to perform flexion exercises.

Question Explanation
Correct Answer is C

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Rationale: When planning care for a client following a postoperative left above-the-knee
amputation, the nurse should implement interventions to prevent hip contractures. The nurse
should position the client prone several times a day for 30 minutes. Sitting in a chair all day,
elevating the stump on a pillow, and encouraging the client to perform flexion exercises
increases the client’s risk for developing hip contracture and should be avoided.
Concepts tested

Question 1441
The nurse is educating a client with osteoporosis about appropriate exercises. Which of the
following statements made by the client would indicate teaching was effective?
A “I will start riding a bicycle.”
B “I am going to join a yoga class.”
C “I will start taking brisk walks every day.”
D “I am going to take a water aerobics class.”

Question Explanation
Correct Answer is C
Rationale: Clients with osteoporosis should be educated on exercises that promote weight-
bearing activities, such as walking, hiking, and tennis. Weight-bearing activities promote bone
development. Yoga, water aerobics, and bike riding are appropriate cardio exercises but are not
weight-bearing.
Concepts tested

Question 1442
The nurse is teaching a client about crutch walking. Which of the following statements made by
the client would indicate the need for more teaching?
A “I will keep my elbows slightly flexed when walking with the crutches.”
B “I will put both crutches on the unaffected side if I am going to sit down.”
C "I will avoid applying pressure under my arms when I use my crutches."
D “I will advance my affected leg using the crutches when walking upstairs.”

Question Explanation
Correct Answer is D
Rationale: When climbing the stairs, the client is taught to step up with the unaffected leg while
putting weight on the crutch handles. The elbows should be flexed at a 20-30 degree angle to
avoid pressure under the arm and prevent damage to the axillary nerve. Placing both crutches on
the unaffected side is the correct technique when sitting down.
Concepts tested

Question 1443
The nurse is assessing a client with a femoral fracture who has a prescription for Buck’s skin
traction. Which finding would require the nurse to intervene?
A The weights are equal on both sides.
B The weights are sitting against the foot of the bed.
C The head of the bed is elevated.

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D The ropes are positioned in the center of the wheel grooves.

Question Explanation
Correct Answer is B
Rationale: Buck’s skin traction is prescribed to create skin and skeletal traction that uses a pully
system of weights to realign and reduce a fracture. When assessing the skin traction, the nurse
should evaluate that the weights are equal on both sides and hang freely away from the bed. The
ropes should be positioned in the center of the wheel grooves. The head of the bed can be
elevated to provide countertraction.
Concepts tested

Question 1444
The nurse is teaching the partner of a client who had a stroke and has dysphagia about how to
prevent complications while eating. Which statement by the client’s partner indicates the need
for further teaching?
A “Food should be placed on the unaffected side of the mouth.”
B “We will avoid milk products during meals.”
C “The head should be tilted back when swallowing.”
D “Crushed ice can be used to stimulate the swallow reflex.”

Question Explanation
Correct Answer is C
Rationale: Dysphagia, which is common with clients who have had a stroke, is difficulty with
swallowing. A client with dysphagia needs to take precautions when eating to prevent aspiration
of food and drink, which could result in pneumonia. The nurse will teach the client and partner to
place food on the unaffected side of the mouth, tuck the chin to the chest to assist with
swallowing, and monitor for coughing while eating. Crushed ice can be used to stimulate the
swallow reflex. The nurse should instruct to avoid milk products during meals, which can
increase salivation.
Concepts tested

Question 1445
The nurse is caring for a client who had a right-sided stroke and has homonymous hemianopsia.
Which action should the nurse take during meals?
A Offer to feed the client
B Set up the meal tray on the client’s right field of vision
C Cut up food into bite-sized pieces
D Encourage the client to use their left hand

Question Explanation
Correct Answer is B
Rationale: Homonymous hemianopsia occurs when the client has blindness in the same half of
each visual field, resulting in the client ignoring areas that would be in the visual field. Clients
with homonymous hemianopsia may not eat the food on one side of the tray because they do not
see it. The nurse should set up the meal tray on the side of the client’s field of vision. The nurse

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should only cut up the client’s food if the client requests it. The client with a right-sided stroke
may have difficulty using the left hand. The nurse should encourage the client to feed
themselves.
Concepts tested

Question 1446
The clinic nurse is reviewing the dietary history of an adolescent female client. The client states,
“I have been counting my calories, as I do not want to gain weight.” Which statement would be
appropriate for the nurse to make?
A “Monitoring your calories now will help you stay a healthy weight into adulthood.”
B “You should be fine as long as long as you eat at least three meals a day.”
C “You do not look like you are overweight.”
D “Let’s talk about the types of foods you eat during the day.”

Question Explanation
Correct Answer is D
Rationale: Adolescence is a period of rapid physical, emotional, social, and sexual maturation,
where the rate of growth can vary among individuals. Nutrient needs for adolescence are
increased during this period of growth. Weight consciousness is often an issue among
adolescents, especially female clients. When assessing the dietary history of an adolescent
female client who reports counting calories, the nurse should explore the types of foods the client
eats. This will evaluate if the client is meeting the nutritional requirements.
Concepts tested

Question 1447
The clinic nurse is reviewing the health history for a client during an annual physical exam. The
nurse notes that the client has had an increase in body mass index (BMI) measurement. Which
question would be appropriate for the nurse to ask?
A “Have you experienced any changes in your life that are stressful?”
B “Has there been a reason for you to eat more food?”
C “Are you happy with how you look?”
D “What types of food do you like to eat?”

Question Explanation
Correct Answer is A
Rationale: Obesity is defined as a bodyweight greater than 20% or a BMI of 30 or more. There
are different theories on the cause of obesity, and there are psychological factors that can
increase the risk of obesity. Clients may use food to satisfy emotional needs or deal with stress or
have a family environment that uses food as a social requirement. For a client who has had
weight gain, the nurse should first focus on factors that could cause the weight gain, such as
stressful situations. Asking the client the reason, types of food preferred, or their personal
impression of themselves are not therapeutic and could result in the client not being willing to
explore dietary modifications
Concepts tested

Question 1448
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The nurse is teaching about the prescribed therapeutic diet for a client with renal disease. Which
statement by the client would indicate teaching was effective?
A “I will increase my fluid intake.”
B “I will eat foods rich in potassium.”
C “I will limit my protein intake.”
D “I will use salt just when I am cooking.”

Question Explanation
Correct Answer is C
Rationale: The renal therapeutic diet is prescribed for clients with renal disease and is to reduce
the workload on kidneys. The client should be taught to decrease fluid and potassium intake. The
client should be instructed that sodium intake is restricted and avoid excess use, such as with
cooking. The client will be told to eat limited protein.
Concepts tested

Question 1449
The nurse is assisting with feeding a client who has alterations in cognition. Which action should
the nurse take?
A Cut up the food into many small pieces
B Provide one food at a time from the tray
C Stroke the client’s lips to promote chewing
D Tie a bib over the client's clothes for protection

Question Explanation
Correct Answer is B
Rationale: The client with alterations in cognition would be provided one food at a time from the
tray, as offering all foods may be overwhelming. Clients should be provided with a napkin, not a
bib, to promote self-esteem. To prevent confusion, the food should be provided in its original
form. The nurse should be assessing the client's need for assistance and be aware of cues the
client will give. To promote chewing and swallowing, the nurse should stroke the underside of
the client’s chin
Concepts tested

Question 1450
The nurse is caring for a client with nutritional deficiencies who has a prescription for calorie
counts. Which action should the nurse take?
A Record the portion size of the food the client consumed
B Create a list of the food the client consumed during the day
C Identify the foods from different food groups that the client consumed
D Determine the amount of nutrients from the foods the client consumed

Question Explanation
Correct Answer is A
Rationale: There are different methods the nurse can implement to assess the dietary intake of a
client. A 24-hour recall method focuses on a list of all food and beverages consumed during the

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day and is not accurate since it relies on memory. A food frequency record identifies the types of
foods the client eats to look for patterns and deficits. A calorie count is a precise collection of
what a client consumes by documenting the amount of food eaten.
Concepts tested

Question 1451
The nurse is planning care for a client who is on bed rest. When assessing hygiene care practices,
which question would be the priority for the nurse to ask?
A “How often do you bathe at home?”
B “What type of hygiene products do you use?”
C “When do you prefer to take a bath?”
D “Are you willing to have a bath in bed?”

Question Explanation
Correct Answer is C
Rationale: When planning hygiene care for a client, the priority for the nurse to assess is when
the client prefers to take a bath. Clients may prefer before breakfast or before bed. The client
may also have a request to perform hygiene before interventions or visiting with family. Hygiene
products, location of the bath, and the frequency of bathing are important but not the priority to
plan care.
Concepts tested

Question 1452
The nurse is caring for a client who is on bed rest. The client states, “My hair is so long and
keeps getting in the way.” Which statement should the nurse make?
A "Do you have any preference on how you like to wear your hair?"
B “Can your family help you with your hair?”
C “I can wash your hair later if I have time.”
D “Long hair can be difficult to manage in your condition.”

Question Explanation
Correct Answer is A
Rationale: When caring for a client, assisting the client with their hair is part of the hygiene care.
The nurse should identify the client’s usual hair and scalp practices, along with styling
preferences. If the client expresses a request, the nurse should provide options and not assume
the client’s family will provide assistance.
Concepts tested

Question 1453
The nurse is performing oral care for a client who is unresponsive. Which action would be
appropriate for the nurse to take?
A Use a stiff toothbrush to clean the client’s teeth
B Insert fingers inside client’s cheek to keep mouth open
C Place client in left lateral position
D Apply petroleum jelly to the client’s lips

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Question Explanation
Correct Answer is C
Rationale: Placing the client on his side helps fluid run out of his mouth by gravity, thus
preventing aspiration and choking. The nurse should use a soft toothbrush, not a stiff one, to
avoid injury to the gingivae. The nurse should use a bite block or an oral airway, not a thumb or
index finger, to keep the client's mouth open. The nurse should apply a water-soluble lubricant to
the client's lips after oral care.
Concepts tested

Question 1454
The nurse is preparing to assist a client with a chronic respiratory disorder perform hygiene care.
The client states, “I won’t be able to help you; I just can’t do it anymore.” Which statement
should the nurse make?
A “I understand, and I will do it for you.”
B “Even if it is hard, try to do what you can.”
C “You can take your time as long as you participate.”
D “Let us work together, so I can assess your ability.”

Question Explanation
Correct Answer is D
Rationale: A client’s perception of functioning can affect how the client perceives their overall
health. When a client reports being unable to perform functions, the nurse should collect
objective data related to the client’s ability. Telling the client to participate or doing it for the
client is helpful but does not fully assess the client’s ability and validate the client’s perception of
functioning.
Concepts tested

Question 1455
A hospice nurse is caring for a client with terminal pancreatic cancer who is receiving end-of-life
care. The client states, “I do not want to eat or be fed.” Which statement should the nurse make?
A “I understand your choice and will inform the healthcare provider.”
B “Choosing not to eat is a very painful way to die.”
C “We can discuss this option further, and then you can make your decision.”
D “You can try clear liquids instead of solid foods.”

Question Explanation
Correct Answer is A
Rationale: The client has the right to make decisions about their end-of-life care. If the client
decides to not receive care, such as eating, the nurse should respect the client’s rights and report
to the healthcare provider. The other options do not respect the client’s decision.
Concepts tested

Question 1456

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A nurse is caring for a client with stage IV cervical cancer who is receiving prescribed
chemotherapy. The client states, “I don’t want any more chemotherapy, but my children insist I
keep going.” Which statement should the nurse make?
A “Your children just want you alive as long as possible.”
B “I would keep fighting if I were you.”
C “I can discuss the process with you to stop treatment.”
D “You need to think about the outcome of your decision.”

Question Explanation
Correct Answer is C
Rationale: A client has the right to make decisions about their care. The role of the nurse is to
support the client in these decisions and provide the client with appropriate information. If a
client expresses they do not want to continue treatment, then the nurse should provide the client
with information related to the decision. Giving the client personal opinions or requesting they
discuss it with family first or take time to think about it does not address the client’s concern.
Concepts tested

Question 1457
The nurse is collecting the lifestyle history of a client with risk factors for heart disease. The
client states, “I don’t have time to exercise.” Which statement would be appropriate for the nurse
to make?
A “You should be exercising to prevent heart disease.”
B “There are some everyday activities that you can do to lower your risk”
C “You will need to prioritize exercise in your schedule.”
D “Any type of activity will be sufficient.”

Question Explanation
Correct Answer is B
Rationale: Clients with risk factors for heart disease should be assessed for their level of
exercise. Routine exercise can decrease the risk of developing heart disease. The nurse should
assess the client for any type of activity, including recreational and occupational activities.
Everyday activities can also decrease the risk of developing heart disease.
Concepts tested

Question 1458
The nurse is teaching a client about implementing a new exercise program. Which statement by
the client would indicate to the nurse that further teaching is required?
A “I will perform a cool down before I finish exercising.”
B “I will stop exercising if my heart rate gets above the target rate.”
C “I should exercise every day to build up my tolerance.”
D “I should include different types of activities during the exercise session.”

Question Explanation
Correct Answer is C

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Rationale: When teaching a client about implementing a new exercise program, the nurse should
instruct the client to exercise 2 to 3 days a week but not back-to-back days. The client should rest
one day between days exercised. The client should be advised to perform a 10-minute cooldown,
stop exercising if the heart rate is above the target rate, and include a combination of activities
during the exercise.
Concepts tested

Question 1459
A nurse is about to transfer a client who has a weak left leg to a chair. Which action by the nurse
demonstrates the correct transfer technique?
A Align knees with the client’s knees
B Place the client’s left leg slightly in front of the right leg
C Position the chair to the left side of the bed
D Grasp the client under the axilla

Question Explanation
Correct Answer is A
Rationale: When transferring a client to a chair, the nurse should position the chair on the client’s
strong side, place the strong leg slightly in front of the weak leg, and then align the knees up with
the client’s knees. Using a gait belt, the nurse will lift while the client bears weight on the good
leg and pivots into the chair.
Concepts tested

Question 1460
A nurse is observing the unlicensed assistive personnel (UAP) who is using a mechanical lift
with a hammock sling to transfer a client from the bed to a chair. Which action by the UAP
would require the nurse to intervene?
A The UAP places the sling under the client from shoulders to the knee.
B The UAP places the bed in the lowest position during the transfer.
C The UAP locks the hydraulic valve before attaching the sling to the lift.
D The UAP raises the head of the bed to a sitting position before transfer

Question Explanation
Correct Answer is B
Rationale: When observing the UAP perform a transfer with a mechanical lift, the nurse should
intervene to prevent injury to the UAP and client. When using a mechanical lift, the bed should
be raised to the highest level to properly position the lift under the client’s bed. The UAP should
place the sling under the client from shoulders to the knee which distributes the client’s weight
evenly on the sling. The hydraulic valve should be locked before attaching the sling to prevent
accidental movement. The bed should be placed in a sitting position to ensure the client is in a
sitting position during the transfer.
Concepts tested

Question 1461
The nurse is assessing a client who is immobile. Which finding would indicate to the nurse that
the client is experiencing systemic effects of impaired physical mobility?
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A Diminished breath sounds
B Hypertension
C Polyuria
D Hyperactive bowel sounds

Question Explanation
Correct Answer is A
Rationale: Body systems require movement to function effectively. An immobile client should
be assessed for manifestations of systemic effects. Respiratory changes include diminished
breath sounds due to the inability to take deep breaths. Venous return is dependent on muscle
contraction, and immobility will lead to hypotension. Urine flows by gravitational forces, so
when the client is immobile, urine stasis will occur resulting in oliguria. Joint contractures will
develop from a lack of movement of tendons. The GI tract will have a decrease in perfusion,
resulting in hypoactive bowel sounds from a decrease in peristalsis.
Concepts tested

Question 1462
A nurse is performing active range-of-motion exercises for a client who is immobile. Which
body movement should indicate to the nurse that the client has full range of motion of the
shoulder?
A Adducting the arm so that it lies 90° angle to the client’s side
B Circumducting the shoulder in a 180° half circle
C Abducting the arm to a 90° angle from the side of the body
D Flexing the shoulder by raising the arm from a side position to a 180° angle

Question Explanation
Correct Answer is D
Rationale: To assess the range of motion of a client’s shoulder, the nurse will flex the shoulder
by raising the arm from a side position to a 180° angle with the fingers pointing directly upward.
The shoulder can circumduct a full 360° circle
Concepts tested

Question 1463
The nurse is planning care for a group of assigned clients. For which client should the nurse
implement the sequential compression device?
A The client who is postoperative day two from abdominal surgery
B The client who had a stroke with paralysis of the left leg
C The client with pneumonia who sits up to the chair for meals
D The client with a gastrointestinal infection who uses a bedside commode

Question Explanation
Correct Answer is B
Rationale: A sequential compression device is used to promote venous return, which will
decrease the risk of developing a deep vein thrombosis. The nurse should implement the
sequential compression device for the client who has impaired mobility resulting in the inability

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to ambulate. The client who had a stroke with paralysis of the left leg is the highest risk for
developing a DVT. The client who is postoperative 2 days, the client with pneumonia, and the
client with gastrointestinal infection are ambulatory.
Concepts tested

Question 1464
The nurse is collecting the health history of a client who is taking prescribed oral tetracycline.
Which of the following statements by the client indicates a need for further teaching?
A “I will wait several hours after taking the tetracycline to take my prescribed iron
supplement.”
B “I can take probiotics to reduce the change of some side effects.”
C “I will take my medication with milk to prevent nausea.”
D “I will stay out of the sun while I take this medication.”

Question Explanation
Correct Answer is C
Rationale: Tetracycline is most effective when taken on an empty stomach. Clients should take
the medication 1 hour before meals or two hours after meals. It is important not to take it with
dairy products, antacids, or iron supplements. The combination of tetracycline with metallic ions
such as aluminum, calcium, iron, or magnesium inhibits absorption. If the patient has consumed
dairy products or antacids, it is necessary to withhold tetracycline for two hours. Tetracycline
increases the risk of sunburn and photosensitivity. Probiotics have been shown to prevent
antibiotic associated diarrhea.
Concepts tested

Question 1465
The nurse is educating a client with kidney disease about a renal diet. Which of the following
menu choices by the client indicates an understanding of the dietary restrictions?
A Spinach salad with grilled salmon, dried cranberries, pecans, parmesan cheese, and vinaigrette
dressing and iced tea
B Ham and cheese sandwich on wheat bread with a side salad and milk
C Nachos with chicken, tomato salsa, cheese, and avocado slices and diet cola
D Chicken salad with lettuce on pita bread with apple slices and cucumber water

Question Explanation
Correct Answer is D
Rationale: A renal diet is one that is low in sodium, phosphorous, and protein. It is prescribed to
reduce the workload on the kidneys. Potassium and fluid restrictions are dependent on the
client’s individual kidney function. All of the menu choices, other than the chicken salad on pita
bread, are high in sodium, phosphorus, and/or protein.
Concepts tested

Question 1466
The nurse is evaluating the client’s understanding of the prescribed low sodium diet. Which of
the following menu selections would demonstrate adherence to the diet recommendations?
A Scrambled egg sandwich with ham and orange juice
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B Beef and vegetable soup with crackers and grilled cheese
C Salmon, broccoli, sweet potato fries, and canned pears
D Tuna casserole with beet and goat cheese salad

Question Explanation
Correct Answer is C
Rationale: Foods that have increased amounts of sodium include processed foods (canned or
boxed), dairy products, and those that have salt added (cured, for instance). Clients on a sodium-
restricted diet are not required to omit all salt but are instructed to reduce salt, usually to 2,000
mg/day as in the DASH diet. Tuna casserole is made with canned tuna and canned soup.
Crackers and bread contain large amounts of sodium as well. Goat cheese is considered dairy and
is a high source of sodium.
Concepts tested

Question 1467
The nurse is evaluating a client’s understanding of a carbohydrate-consistent diet. Which of the
following menu selections demonstrates an understanding of the diet recommendations?
A Bacon, scrambled eggs with cheese, avocado slices, and black coffee
B Grilled chicken thigh, small baked potato with butter and sour cream, and side salad with
ranch dressing
C Baked chicken tenders with green beans and cauliflower
D Burrito with ground beef, rice, cheese, salsa, sour cream, and black beans and Mexican corn

Question Explanation
Correct Answer is B
Rationale: The focus of the carbohydrate-consistent diet is eating the same amount of
carbohydrates every day and at each meal, to keep glucose levels stable. High-fiber and heart-
healthy fats are encouraged; sodium and saturated fats are limited. Carbohydrate-consistent diets
are not to be confused with high protein, low carbohydrate, or ketogenic diets. On average,
people with diabetes should aim to get about half of their calories from carbohydrates (preferably
starches and fiber). All of these examples of breakfast options contain almost no carbs, whereas
the burrito is high in carbohydrates. The meal with the chicken tenders is also too low in
carbohydrates.
Concepts tested

Question 1468
The nurse is caring for a client with a history of heart failure who is diagnosed with septic shock
and receiving fluid resuscitation. What findings would indicate to the nurse that the client has
developed a complication from this treatment?
A Increase in urine output
B Rise in blood pressure
C Shortness of breath
D Elevation in heart rate

Question Explanation

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Correct Answer is C
Rationale: The client experiencing shock requires large-volume fluid replacement. This can lead
to fluid overload and exacerbation of heart failure. Symptoms include shortness of breath and
crackles, swelling, and cramping. The treatment is for shock, so a rise in blood pressure and
increase in urine output are intended outcomes and are not useful in determining heart failure. An
elevated heart rate is a manifestation of shock and is also not useful in identifying heart failure in
this client.
Concepts tested

Question 1469
The nurse is caring for a client with liver failure who is receiving prescribed furosemide. What
finding would indicate to the nurse that the client has developed a complication from this
treatment?
A Decreased urine output
B Change in mental status
C Reduced abdominal circumference
D Shortness of breath

Question Explanation
Correct Answer is A
Rationale: A furosemide overdose can be relative and produce severe dehydration, low blood
volume, low potassium, and severe electrolyte depletion. Urine output will decrease due to fluid
volume deficit. Change in mental status may result from hepatic encephalopathy due to liver
failure. Reduced abdominal circumference is an intended effect of the therapy. Shortness of
breath is caused by fluid volume excess related to liver failure.
Concepts tested

Question 1470
The nurse is caring for a client diagnosed with gastroenteritis who is febrile and having frequent
diarrhea. Which of the following findings best indicates that the client requires intravenous
fluids?
A Heart rate of 105
B Blood urea nitrogen level of 23 mg/dL
C Diarrhea 5 times in 24 hours
D Serum lactate level of 1.8 mmol/L

Question Explanation
Correct Answer is B
Rationale: The client's BUN is elevated indicating dehydration. A client who is severely
dehydrated will have a high BUN due to the lack of fluid volume to excrete waste products. A
heart rate of 105 can occur with fever but does not necessarily indicate volume loss. The serum
lactate is less than 2, indicating the client is not in shock and therefore may not require fluids.
Concepts tested

Question 1471
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The nurse is providing education to a client on a 1200 calories per day weight reduction diet. The
client will be reading labels to count calories. Which of the following statements by the client is
a correct interpretation of a food label?
A “The label says that 4 chicken nuggets are 210 calories. If I eat 6 nuggets, that will be 315
calories.”
B “Drinks in smaller containers are single servings. If the bottle says a serving is 200 calories,
that means the whole bottle is 200 calories”.
C “The soup can says that there are two servings per can and that there are 300 calories. That
means that there are 150 calories in each serving.”
D “The serving size that is recommended on the label is based on how much I should eat to
maintain good health.”

Question Explanation
Correct Answer is A
Rationale: By law, serving sizes must be based on the amount of food people typically consume,
rather than how much they should consume. When eating more than the listed serving, the
number of calories will have to be calculated for an accurate count. The calories listed on a food
label are for a single serving, which isn’t always the entire package. Food labels have been
updated for easier interpretation.
Concepts tested

Question 1472
The nurse is conducting a calorie count for a hospitalized client diagnosed with diabetes. The
recommended carbohydrate intake for the client is 50 grams per meal. The client also needs 20
grams of protein and 30 grams of fat. How many calories can the nurse expect the client to eat
per meal?
A 400
B 650
C 500
D 550

Question Explanation
Correct Answer is D
Rationale: Food diaries and calorie counts require documentation of actual intake for a specified
period of time. The grams of carbohydrate, protein, and fat for each food item eaten can be added
and multiplied by the appropriate calorie level (4, 4, and 9 calories per gram, respectively).
Concepts tested

Question 1473
The nurse is caring for an older adult client who has dementia. The client can feed themself but
has been experiencing weight loss. Which of the following actions is appropriate?
A Recommend placement of a feeding tube
B Ask the provider to prescribe a high fat diet
C Initiate a calorie count
D Monitor the client’s blood sugars

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Question Explanation
Correct Answer is C
Rationale: Weight loss is a frequent complication of dementia and occurs in clients at all stages,
even in the early stages. Malnutrition (namely, undernutrition) contributes to declining general
health status, to the frequency and severity of complications, especially infections, and to a faster
loss of independence. These states of malnutrition can be prevented or improved through early
identification and intervention. Evaluation of food intake, aka a calorie count, is part of the
nutritional evaluation. While diet changes and a feeding tube may eventually be appropriate,
assessment (collection of further data) must occur before intervening.
Concepts tested

Question 1474
A nurse is providing care to a client who weighs 176 pounds and is 5 feet 8 inches tall. What is
the client’s body mass index?
A 24.8
B 29.9
C 26.7
D 25.1

Question Explanation
Correct Answer is C
Rationale: The correct body mass index (BMI) for this client is 26.7. The BMI formula for
measurements in pounds and inches is as follows: (weight (lbs) / height (in) / height (in)) x 703.
Using the client’s measurements, the formula is as follows: (176 / 68 / 68) x 703 = 26.7.
Concepts tested

Question 1475
A nurse is providing care to a client who weighs 70 kilograms and is 5 feet 3 inches tall. Which
body mass index category is consistent with the client’s measurements?
A Underweight
B Normal
C Obese
D Overweight

Question Explanation
Correct Answer is D
Rationale: The client is overweight according to the body mass index (BMI). The client’s weight
needs to be converted to pounds for accurate calculations. 70 kilograms x 2.2 = 154 pounds. The
BMI formula is as follows: (weight (lbs) / height (in) / height (in)) x 703. Using the client’s
measurements, the formula is as follows: (154 / 63 / 63) x 703 = 27.2. The client’s BMI is
classified under the overweight category. BMIs of less than 18.5 are considered underweight.
BMIs of 18.5 – 24.9 are considered normal, and BMI’s over 30.0 are considered obese.
Concepts tested

Question 1476
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A nurse is providing care to a client hospitalized for an acute gastrointestinal illness. The client’s
usual weight is 160 lbs. The client currently weighs 151 lb. Which percentage is consistent with
the client’s weight loss?
A 6.5%
B 5.6%
C 4.5%
D 3.6%

Question Explanation
Correct Answer is B
Rationale: The client’s percentage of weight loss is 5.6%. The percentage weight change
calculation is as follows: ((usual weight – present weight) / usual weight) x 100. Using the
client’s weight, the formula is as follows: ((160 – 151) / 160) x 100 = 5.6%. The other
percentages are inconsistent with the client’s weight loss.
Concepts tested

Question 1477
A nurse is assessing a male client who is 5 feet 10 inches tall. What is the client’s ideal body
weight in pounds according to the Hamwi method?
A 150
B 156
C 160
D 166

Question Explanation
Correct Answer is D
Rationale: The client’s ideal body weight according to the Hamwi method is 166 pounds. For
male clients, the formula is as follows: 106 pounds for the first 5 feet of height + 6 pounds for
each additional inch. Using the client’s sex and height, the formula is as follows: (106 + (6 x 10))
= 166. The other weights are not consistent with the client’s information.
Concepts tested

Question 1478
A nurse is reviewing a laboratory report for a client with protein malnutrition. Which value is
consistent with the client’s condition?
A Albumin level of 2.9 g/dL
B Hemoglobin level of 11.5 g/dL
C Glucose level of 275 mg/dL
D Amylase level of 125 U/L

Question Explanation
Correct Answer is A
Rationale: An albumin level of 2.9 g/dL indicates a protein deficiency. Albumin is a protein
found in the blood that helps maintain and repair tissues. The normal albumin level is 3.5 to 5.0
g/dL. Hemoglobin is a protein that carries oxygen throughout the body. Low hemoglobin levels

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are indicative of anemia, not malnutrition. A glucose level of 275 mg/dL is above normal. This
value is not consistent with malnutrition. An amylase level of 125 U/L is a normal finding.
Amylase is an enzyme used to assess pancreatic function. It does not directly assess protein
malnutrition.
Concepts tested

Question 1479
A nurse is assessing a client with a suspected eating disorder. Which clinical manifestation is
indicative of malnutrition?
A Diaphoretic skin
B White patches on the tongue
C Enlarged lymph nodes
D Brittle hair

Question Explanation
Correct Answer is D
Rationale: Brittle hair is a sign of inadequate nutrition. The hair and skin may become dry and
have rough patches. Diaphoresis is not an expected finding with malnutrition. The skin tends to
be dry from lack of nutrients and hydration. White patches on the tongue are not associated with
malnutrition. Enlarged lymph nodes are indicative of an immune disorder, not malnutrition.
Concepts tested

Question 1480
A nurse is providing care to a client who is being weaned off nutritional support. What action
should the nurse take in monitoring the client’s nutrition?
A Assign a calorie count for each meal
B Calculate intake versus estimated caloric needs
C Record the client’s food intake
D Request high-protein foods for the client

Question Explanation
Correct Answer is C
Rationale: The nurse’s role in monitoring the client’s nutrition is to document the intake. The
nurse will record the percentage of food eaten at every meal. Assigning calories for each meal
will be prescribed by the healthcare provider or the registered dietician. Calculating intake versus
estimated caloric needs is a task performed by a dietician. Requesting high-protein foods for the
client is not a nursing task. The client’s diet is determined in collaboration with the healthcare
provider and dietician.
Concepts tested

Question 1481
A nurse is assessing a client with a prescription to advance diet as tolerated. The client is
currently drinking clear liquids. Which clinical manifestation indicates the client’s diet can be
advanced?
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A The client verbalizes feeling full.
B The client has consumed 45% of the meal.
C The last bowel movement was 3 days ago.
D The abdomen is soft and rounded.

Question Explanation
Correct Answer is D
Rationale: A rounded, soft abdomen is a normal finding, indicating the diet can be advanced. The
nurse assesses for abdominal distention, which is an indication that the diet is not being tolerated
well. Feelings of fullness indicate the diet is not being tolerated completely. The diet should be
advanced until the client verbalizes the absence of fullness. Consuming 45% of the meal is not
enough to advance a diet. Diets should be advanced when the client consumes at least 50 to 75%
of the meal. Lack of bowel movement indicates decreased peristalsis. Advancing the diet may
cause further constipation.
Concepts tested

Question 1482
A nurse is assisting a client who is visually impaired with their meal. Which intervention should
the nurse perform to promote the client’s independence in eating?
A Explain the location of items on the tray
B Feed the client small bites at a time
C Leave the tray within reach
D Place a napkin on the client’s chest

Question Explanation
Correct Answer is A
Rationale: Clients who are visually impaired benefit from knowing where items are on the tray.
This promotes independence by making it easier for the client to recognize where the food items
are located. Feeding the client does not promote independence. Leaving the tray within reach
does not allow a client who is visually impaired to safely perform independent feeding. The
client needs to know where food items are. Placing a napkin on the client’s chest does not
promote independence with eating.
Concepts tested

Question 1483
A nurse is setting a meal tray for a client who has a history of dementia. Which intervention will
the nurse implement to promote the client’s independence in eating?
A Leave the room while the client eats their meal
B Wait for the client to request their meal
C Feed the client while sitting at eye level
D Encourage the client to select their food preferences

Question Explanation
Correct Answer is D

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Rationale: Allowing the client to decide their food preferences promotes independence with their
nutrition. Leaving the room while a client with dementia eats their meal is not a safe
intervention. Clients with dementia require supervision while eating. A client with dementia
needs clear instructions when eating. Waiting for the client to request their meal will not ensure
adequate nutrition. Sitting at the client’s eye level while feeding increases the client’s comfort
during meals. However, it does not specifically promote independence.
Concepts tested

Question 1484
A nurse is assisting a client with their meal. The client has decreased fine motor movement in
both hands. Which action will the nurse perform to help promote the client’s independence in
eating?
A Feed the client small bites at a time
B Open the lid of the food containers
C Provide utensils with modified handles
D Ensure the food tray is compartmentalized

Question Explanation
Correct Answer is C
Rationale: Utensils with modified handles facilitate a client’s grasp. Being able to use utensils
when eating promotes independence. Feeding the client directly does not promote independence.
The nurse should allow the client to feed themselves whenever possible. The nurse should open
the lid of containers only if the client asks them to do so. Compartments on a food tray are
appropriate for a client who is visually impaired and requires guidance of food placement. This
action does not apply to a client with fine motor movement deficits.
Concepts tested

Question 1485
A nurse is assisting a client who has a history of arthritis with their breakfast. Which intervention
by the nurse will help encourage the client to eat independently?
A Request finger foods with the client’s meals
B Allow the client to choose their own food preferences
C Cut the client’s food into small pieces
D Ensure hot beverages are allowed to cool before drinking

Question Explanation
Correct Answer is A
Rationale: Clients with arthritis may have a hard time grasping utensils or opening food
container lids. Finger foods will allow the client to feed themselves more easily. Allowing the
client to choose their own food preferences is applicable to every client. The main focus for this
particular client is providing foods that are adequate for the client’s history of arthritis. Cutting
the client’s food into small pieces is not an intervention that promotes independence in a client
with arthritis. Small bites are indicated for a client with dysphagia. Ensuring hot beverages are
allowed to cool is a safety intervention, not an intervention that promotes independence.
Concepts tested
Page | 607
Question 1486
A nurse is assessing the dinner food tray of a client with a history of hypertension. Which food
item on the tray will the nurse replace?
A Mashed potatoes
B Skim cottage cheese
C Swiss chard
D Canned soup

Question Explanation
Correct Answer is D
Rationale: Canned soup has a high sodium content. Sodium attracts fluid, which increases
systemic volume and blood pressure. Mashed potatoes and Swiss chard are rich in potassium and
part of a recommended diet for clients with hypertension. Fat-free (skim) cottage cheese is rich
in calcium, a recommended food mineral for clients with hypertension.
Concepts tested

Question 1487
The nurse is educating a client with renal failure who has hyperkalemia about diet modifications.
Which of the following statements by the client indicates teaching was effective?
A “I will choose citrus fruits instead of bananas.”
B “I should substitute cauliflower for potatoes.”
C “Lima beans provide a good source of nutrients.”
D “Broccoli is a good green vegetable to eat.”

Question Explanation
Correct Answer is B
Rationale: Clients with renal failure will require a potassium restricted diet. The nurse should
teach the client to avoid foods that are high in potassium, such as citrus fruits, bananas, broccoli,
potatoes, and lima beans.
Concepts tested

Question 1488
A nurse is taking care of an Asian American client who states they have a “yin” illness. The
client requests “yang” foods to help alleviate the physical symptoms of the disease. Which food
will the nurse request for the client?
A Beef broth
B Iced tea
C Watermelon
D Tomatoes

Question Explanation
Correct Answer is A
Rationale: Asian Americans believe in the balance of yin-yang nutrition to alleviate their
illnesses. Yang foods are believed to bring warmth to the body and include foods such as meat

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broths, coffee, fried foods, and spices. Yin foods provide the opposite effect and include cold
beverages, fruits, and vegetables such as iced tea, watermelon, and tomatoes.
Concepts tested

Question 1489
A nurse is recording food preferences for a client who practices Islam. The nurse expects the
client to request the restriction of which food item?
A Milk
B Fish
C Eggs
D Pork

Question Explanation
Correct Answer is D
Rationale: Pork and pork products are restricted in the Islamic religion. The nurse should expect
the client to request pork products not be served. Milk, fish, and eggs can be consumed and are
not foods restricted for clients who practice Islam.
Concepts tested

Question 1490
A nurse is providing care to a client with pernicious anemia. The nurse knows that which
nutritional supplement will likely be prescribed for this client?
A Vitamin C
B Iron
C Vitamin B12
D Folate

Question Explanation
Correct Answer is C
Rationale: The most common form of vitamin B12 deficiency is pernicious anemia. Vitamin B12
is not able to be absorbed due to a lack of intrinsic factor. Clients with pernicious anemia require
supplementation or increased natural sources of Vitamin B12. Vitamin C helps to facilitate the
absorption of iron. However, it does not address the Vitamin B12 deficiency. The most common
form of anemia is iron deficiency. Iron supplements do not address the specific cause of
pernicious anemia. Folate helps to correct a Vitamin B9 deficiency, not B12.
Concepts tested

Question 1491
A nurse is providing care to several clients with gastrointestinal disorders. A client with which
diagnosis would benefit the most from nutritional supplementation?
A Chronic constipation
B Anorexia
C Acute gastritis
D Cholecystitis

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Question Explanation
Correct Answer is B
Rationale: Anorexia is a lack of appetite. Anorexia can cause a decrease in nutritional intake,
leading to protein and calorie deficits. A client with anorexia benefits the most from a nutritional
supplement. Chronic constipation causes irregular bowel habits and inadequate passage of stool.
The main goal for clients with chronic constipation is increased fluid and fiber intake. Acute
gastritis is inflammation of the gastric mucosa due to ingestion of irritating substances. The main
goal is to eat a bland diet to decrease the inflammation. Cholecystitis is inflammation of the
gallbladder. The treatment goal is to decrease fat intake.
Concepts tested

Question 1492
A nurse is planning care for a group of assigned clients on a medical surgical unit. Which client
should the nurse identify would benefit most from a nutritional supplement?
A A client who has been on a full liquid diet for 3 days
B A client who is on a clear liquid diet for acute diverticulitis
C A client who is 24 hours post-op from a cholecystectomy
D A client who experienced vomiting due to food poisoning

Question Explanation
Correct Answer is A
Rationale: A full liquid diet provides minimal options for adequate nutrient intake. A high-
protein, high-calorie supplement is recommended for clients who have been on a full liquid diet
for longer than 3 days. Acute diverticulitis is expected to resolve when bowel inflammation
decreases. The client’s risk for nutritional deficiencies during this time is low. A post-surgical
client has a low risk for nutritional deficiencies. A regular diet is commonly resumed shortly
after a cholecystectomy. Food poisoning is a condition that usually resolves within a few hours
to a few days. The main goal is to restore the fluid loss.
Concepts tested

Question 1493
A nurse is providing care to a client with a complex abdominal wound. Which type of nutritional
supplement will the client require to promote wound healing?
A Low-fat
B Low-sodium
C High-protein
D High-carbohydrate

Question Explanation
Correct Answer is C
Rationale: Protein breakdown is increased during acute stress conditions, such as wounds. High-
protein nutritional supplements replace lost protein and promote wound healing. A low-fat
supplement does not specifically promote wound healing. Intake of low-fat diets should be
encouraged for clients with cardiovascular disease. Low-sodium and high-carbohydrate intake
are not specifically indicated for a client with a complex wound. Low-sodium intake is

Page | 610
recommended to control fluid retention. High-carbohydrate intake increases blood glucose
levels, which can delay wound healing.
Concepts tested

Question 1494
The nurse is administering an enteral feeding via gastrostomy tube. Which of the following
assessments should the nurse complete first?
A Check the expiration date of the formula
B Connect the pump tubing to the client’s port
C Prime the pump tubing
D <span style="font-weight: 400;">Label the equipment with the date and time</span>
Label the equipment with the date and time

Question Explanation
Correcty Answer is A
Rationale: The nurse should check the expiration date of the formula first to ensure that the
contents are safe to administer. Once the nurse has checked the expiration date of the formula,
then the nurse would prime the pump tubing, connect the pump tubing to the client’s port, and
label the equipment with the date and time.
Concepts tested

Question 1495
The nurse is preparing to administer an enteral feeding through a nasogastric tube. Which of the
following actions by the nurse is appropriate?
A Remove the tube from the securement device
B Place the client in the supine position
C Withhold pain medications
D Aspirate gastric contents

Question Explanation
Correct Answer is D
Rationale: The nurse should aspirate gastric contents prior to initiating an enteral feeding to
confirm placement and do a visual assessment. The client should be sitting upright during and
immediately after feeding. Pain medications do not need to be withheld and the tube should not
be removed from the securement device.
Concepts tested

Question 1496
The nurse is preparing to administer enteral nutrition through a gastrostomy tube. Which of the
following actions should the nurse take?
A Flush the line with normal saline
B Lower the head of the bed
C Check the gastric residual
D Mix the client’s medications with the formula

Page | 611
Question Explanation
Correct Answer is C
Rationale: The nurse should check gastric residual prior to initiating a feeding to reduce the
client’s risk of aspiration. The head of the bed should be raised rather than lowered. Gastric tubes
should be flushed with water, and medications should be administered separately.

Concepts tested

Question 1497
The nurse is administering enteral nutrition through a nasogastric tube. Which of the following
assessment findings would indicate that the client is having difficulty with tube feeding?
A Hyperactive bowel sounds in all quadrants
B 100 milliliters of gastric residual prior to each feed
C Heart rate of 96 beats per minute
D Presence of nausea during the feeding

Question Explanation
Correct Answer is D
Rationale: Nausea and vomiting could indicate that the client is not tolerating enteral nutrition.
Hyperactive bowel sounds and a heart rate of 96 bpm are considered normal findings. Gastric
residual of 200 milliliters or more prior to feeding could indicate the client is not tolerating
feeding.
Concepts tested

Question 1498
The nurse is assessing a client who receives enteral nutrition through a gastrostomy tube. Which
of the following findings indicates that the client is experiencing gastrointestinal side effects
related to the feeding?
A Brisk turgor
B Brown stool
C Distended abdomen
D Decreased appetite

Question Explanation
Correct Answer is C
Rationale: The nurse should recognize that abdominal pain and distension are side effects of tube
feedings. Brisk turgor indicates that the client is hydrated. Brown stool is considered a normal
finding. The client may report a decrease in appetite when receiving enteral tube feeding.
Concepts tested

Question 1499
The nurse is evaluating a client’s nutritional status who is receiving prescribed enteral feedings
through a gastrostomy tube. Which of the following findings indicates that the client is
experiencing dehydration?
A Dry mucous membranes
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B Hypoactive bowel sounds
C Minimal gastric residual
D Abdominal distension

Question Explanation
Correct Answer is A
Rationale: The client who is experiencing dehydration will have dry mucous membranes, dry
skin, and skin tenting. Hypoactive bowel sounds and abdominal distension are abnormal findings
but do not indicate dehydration. Minimal gastric residual is a normal finding.
Concepts tested

Question 1500
The nurse is assessing a client who is receiving prescribed nutrition through a nasogastric tube.
Which of the following findings indicates that the nurse should discontinue the feeding
immediately?
A Hyperactive bowel sounds
B Persistent coughing
C Diarrhea
D Oliguria

Question Explanation
Correct Answer is B
Rationale: Coughing during enteral feeding administration may indicate that the client is
aspirating on the formula and the feeding should be discontinued immediately. Hyperactive
bowel sounds, diarrhea, and oliguria are all abnormal findings but do not require immediate
cessation of the feeding.
Concepts tested

Question 1501
The nurse is carig for a client who is receiving intermittent enteral nutrition and is experiencing
diarrhea. Which of the following actions by the nurse is appropriate?
A Place the client in the prone position
B Administer antiemetic medications
C Flush the tubing with water
D Replace the formula container

Question Explanation
Correct Answer is D
Rationale: The current delivery system may be contaminated, therefore the nurse should discard
the current formula and tubing and replace it with a new delivery set. Flushing the tubing and
administering antiemetic medications are not effective to treat diarrhea. The prone position is
contraindicated during enteral feedings.
Concepts tested

Question 1502

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The nurse is assessing a client with an indwelling urinary catheter who is postoperative
urethrocystoscopy. The nurse notes the client has had no urine output in the drainage bag in the
past two hours. Which action should the nurse take?
A Increase oral hydration
B Perform closed system irrigation
C Assess for pitting edema
D Reposition the urinary drainage bag

Question Explanation
Correct Answer is B
Rationale: An urethrocystoscopy is the examination of the bladder and urinary tract with the use
of scope. Following the procedure, the nurse should monitor the client’s urine output. If the
client does not have urine output, the nurse should assess for any obstruction, such as blood
clots, in the catheter. Performing closed system catheter irrigation is an appropriate intervention
to relieve an obstruction. Increasing oral fluids, repositioning the drainage bag, andr assessing for
pitting edema do not address the issue of obstruction.
Concepts tested

Question 1503
The nurse is caring for a client who reports nausea and vomiting for the past four days and has a
prescription for strict intake and output. Which action would be appropriate for the nurse to take?
A Measure the client’s emesis volume
B Administer intravenous fluids
C Initiate a clear liquid diet
D Insert an indwelling catheter

Question Explanation
Correct Answer is A
Rationale: The nurse will evaluate the client’s intake and output by assessing the volume of
emesis. Administering intravenous fluids and initiating a clear liquid diet are appropriate
interventions for the client with nausea and vomiting but do not specifically address intake and
output monitoring. There are no indications for an indwelling urinary catheter.
Concepts tested

Question 1504
A nurse is performing a functional assessment on an older client. Which tool will the nurse use to
assess the client’s independence in activities of daily living?
A Katz Index
B Braden scale
C Romberg test
D Wells score

Question Explanation
Correct Answer is A

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Rationale: The Katz Index of Independence in Activities of Daily Living is a tool that assesses
the client’s ability to perform activities such as bathing, toileting, and dressing independently.
The tool is based on a point system, with higher scores indicating the client is independent with
activities of daily living. The Braden scale is used to assess the risk of skin breakdown. The
Romberg test is used to assess balance. The Wells score is used to assess the risk of deep vein
thrombosis.
Concepts tested

Question 1505
A nurse is assessing an older client’s ability to perform activities of daily living (ADLs). Which
action by the client indicates that they are able to perform ADLs independently?
A Selects their food preferences
B Places the bedpan underneath them
C Fastens the buttons on a shirt
D Informs the nurse they are ready to bathe

Question Explanation
Correct Answer is C
Rationale: The client’s ability to fasten buttons is indicative of being able to dress independently.
Putting on clothes, outer garments, and fasteners are examples of independent activities of daily
living (ADLs). The use of a bedpan or commode is an example of dependent toileting. Selecting
their own food preferences is an example of client independence. However, this is not enough to
assess the client’s ability to feed themselves. Readiness to bathe is not enough to assess the
client’s ability to bathe independently.
Concepts tested

Question 1506
A nurse is performing an admission assessment on a client. Which statement by the
nurse best assesses the client’s independence with activities of daily living?
A “Describe some of your favorite hobbies.”
B “Do you experience any pain while walking?”
C “How many meals do you eat daily?”
D “Tell me about your usual hygiene routine.”

Question Explanation
Correct Answer is D
Rationale: Bathing and toileting are important activities of daily living (ADLs) to assess in a
client. Asking the client to share their hygiene routine helps to determine any activities that may
require supervision or assistance. Asking the client about pain with physical activity is important
but does not assess independence with activity. Asking about the frequency of meals is an
important part of a nutritional assessment but it does not assess the client’s independence with
feeding. Assessing hobbies is an important part of assessing a client’s social activities but does
not address independence with ADLs.
Concepts tested

Question 1507
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A nurse is preparing to assist a client with dysphagia to perform morning care. Which activity
requires supervision by the nurse?
A Perineal care
B Bathing
C Oral hygiene
D Shaving

Question Explanation
Rationale: A client with dysphagia is at risk for aspiration. Oral hygiene should be supervised by
the nurse as the client may have trouble handling their own secretions. Perineal care, bathing,
and shaving should be able to be performed by the client independently. There is no indication
that the client has trouble with mobility or blood clotting.
Concepts tested

Question 1508
A nurse is performing a general survey on an older adult client. The nurse notes that the client
has decreased fine motor movement and verbalizes wearing slippers with all outfits. Which
adaptation should the nurse recommend to the client to promote appropriate dress wear?
A Non-slip socks
B Elastic shoelaces
C Velcro closure shirts
D Pull-on pants

Question Explanation
Correct Answer is B
Rationale: Elastic shoelaces do not require the client to tie them, which can be a difficult activity
to perform with decreased fine motor movement. This adaptation can encourage the client to
wear appropriate shoe wear. Non-slip socks can prevent falls in the older adult client but does
not address the difficulty with fine motor movements. Pull-on pants and Velcro closure shirts are
a good option for a client with decreased fine motor movement. However, the scenario suggests
difficulty with applying appropriate shoe wear.
Concepts tested

Question 1509
A nurse is providing discharge instructions on the importance of activity to a client with
generalized weakness. Which equipment should the nurse recommend to the client use to
promote independence with activities of daily living?
A Raised toilet seat
B Knee scooter
C Shower chair
D Half-circle cane

Question Explanation
Correct Answer is C

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Rationale: A shower chair can provide stability to a client with generalized weakness while they
bathe. This adaptive equipment encourages the client to perform hygiene on their own. A raised
toilet seat is appropriate for clients who are unable to bend their knees or are prescribed hip
precautions. A knee scooter is not appropriate for a client with generalized weakness. A knee
scooter is indicated for clients with injury to one of the lower extremities. A half-circle cane is
indicated for clients who require minimal support. This device is not appropriate for a client with
generalized weakness.
Concepts tested

Question 1510
A home health nurse is performing an environmental assessment in the home of a client with a
balance disorder. Which modification will promote client independence with activities of daily
living?
A Installation of handrails over the toilet
B Removal of throw rugs from the floor
C Purchase of a grabber tool for the kitchen
D Placement of wall lamps in the hallway

Question Explanation
Correct Answer is A
Rationale: Handrails support the weight of the client when standing from a sitting position.
Installation of handrails above the toilet promotes independent hygiene. Removing the throw
rugs from the floor prevents falling due to slipping. This intervention promotes safety, not
independence with activities of daily living. A grabber tool facilitates picking up objects for
clients who are unable to perform full range of motion activities. This tool is not specifically an
indication for a client with balance problems. Wall lamps provide good lighting for clients who
have visual impairment, not balance disorders.
Concepts tested

Question 1511
A nurse is providing discharge instructions on adaptive tools to a client with osteoarthritis. What
should the nurse recommend to the client to promote independence with activities of daily
living?
A Half-circle cane
B Handrails
C Non-slip shoe
D Universal cuff

Question Explanation
Correct Answer is D
Rationale: A universal cuff is applied to the palm and can be used to hold silverware or hygiene
products such as a comb or a toothbrush. This device is indicated for clients who have decreased
grip strength, which occurs with osteoarthritis due to joint stiffness. A half-circle cane helps to
improve gait. However, a half-circle handle requires grip strength which can be decreased with
osteoarthritis. Handrails help clients maintain balance but require grip strength, which is

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impaired with osteoarthritis. A non-slip shoe prevents falls. However, this is not specifically
indicated for a client with osteoarthritis.
Concepts tested

Question 1512
A nurse is performing postmortem care on a client pending organ recovery. Which action should
the nurse take to ensure proper care of the body?
A Maintain ventilatory support
B Remove invasive lines
C Raise the head of the bed
D Cleanse the body

Question Explanation
Correct Answer is A
Rationale: Ventilatory and cardiovascular support is necessary for perfusion of vital organs. The
nurse should ensure the client is ventilated until organ recovery has been completed. Removing
invasive lines eliminates vascular access that is necessary for maintaining cardiovascular
support. Raising the head of the bed prevents facial discoloration but is not a priority when organ
recovery is pending. Cleansing the body is important to prepare for viewing but does not
specifically address organ recovery.
Concepts tested

Question 1513
A nurse is performing postmortem care on a client. Which action should the nurse take to
prepare the body for viewing?
A Ensure the window blinds are open
B Maintain invasive lines
C Place a sheet over the entire body
D Change the bed linens

Question Explanation
Correct Answer is D
Rationale: Applying fresh linens, absorbent pads, and a fresh gown are all part of postmortem
care. Changing the bed linen ensures the area is clean. The light in the room should be dimmed
to provide a calm environment. Invasive lines should be removed unless the client is pending an
autopsy or organ recovery. The client’s head and arms should remain outside of the cover sheet
to provide an opportunity for the family to visit with the body.
Concepts tested

Question 1514
The nurse is developing the plan of care for a client who reports difficulty with sleep during the
hospitalization. Which intervention would be the most appropriate for the nurse to implement?
A Provide the client with earplugs
B Encourage the client to watch television with low lights
C Schedule nursing care at routine times

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D Limit the amount of visiting hours in the evening

Question Explanation
Correct Answer is C
Rationale: Clients who are hospitalized often report difficulty falling asleep or disruption in
sleep. To promote sleep for the hospitalized clients, the nurse should schedule nursing care at
routine times to prevent excessive disruptions of the client’s sleep. Providing ear plugs will not
promote sleep and could pose a safety issue with clients. Limiting visitors will not promote
sleep. The client should be instructed to turn off televisions and avoid activities right before
attempting to sleep.
Concepts tested

Question 1515
The nurse is reviewing the sleep habits of a client who reports difficulty with sleeping. Which
statement by the client would require follow-up by the nurse?
A "I turn the ceiling fan on at night to cool the room."
B "I try to limit the amount of carbonated cola beverages I drink at night."
C “I have been engaging in vigorous exercise during the day.”
D “I like to read when I first go to bed.”

Question Explanation
Correct Answer is D
Rationale: There are activities that could affect a client’s ability to fall asleep or the quality of
sleep. A client who reports activities such as watching TV, reading a book, or working on the
computer in bed should be instructed about stimulus control. Stimulus control focuses on using
the bedroom only for sex and sleep. Decreasing carbonated cola beverages, engaging in exercise
during the day, and controlling the sleeping environment can promote better rest and sleep.
Concepts tested

Question 1516
The nurse is caring for a client who reports daytime drowsiness. The client states, “My partner
says my snoring is getting louder, and it sometimes wakes me up.” The nurse should understand
the client is experiencing which disorder?
A Obstructive sleep apnea
B Narcolepsy
C Circadian rhythm disorder
D Insomnia

Question Explanation
Correct Answer is A
Rationale: There are common sleep disorders that can impact the quality and quantity of a
client’s sleep. The nurse should understand the manifestations of the disorders to distinguish
what the client could be experiencing. Insomnia is characterized by difficulty in falling asleep or
maintaining sleep and be caused by stress, pain, change in environment, and medications.
Narcolepsy is characterized by extreme drowsiness, falling asleep very easily in any situation or

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environment, and being difficult to arouse. Obstructive sleep apnea is a sleep-related breathing
disorder that occurs when the throat muscles relax and block the airway, resulting in periods of
apnea followed by excessive snoring that will wake the client up from sleep. Circadian rhythm
disorder, often called jet lag, is characterized by disruption and misalignment of the client’s
sleep-wake cycle.
Concepts tested

Question 1517
The nurse is collecting the health history of a client who reports a new job that requires working
at night. Which would be an appropriate response by the nurse to assess psychological effects of
insufficient sleep?
A “Do you have trouble concentrating?”
B “Have you been feeling anxious?”
C “How long is your commute home?”
D “How much sleep are you getting during the day.”

Question Explanation
Correct Answer is B
Rationale: There are variables that can cause physiological and psychosocial effects from
insufficient sleep. Shift work or working at night is a variable that can affect a client’s sleep.
Psychosocial effects of insufficient sleep include anxiety, personal conflict, loneliness, and
depression. Physiological effects include fatigue, drowsiness, and development of illness.
Concepts tested

Question 1518
The nurse is assisting a client who is postoperative abdominal surgery to the chair. The nurse
notes the client is guarding the abdomen and grimacing when ambulating. Which response would
be most appropriate for the nurse to make?
A “Would you like me to give you some pain medication?”
B “Let me know if you are still uncomfortable sitting.”
C “Do you feel better sitting in the chair?”
D “Can you describe the feeling you are experiencing?”

Question Explanation
Correct Answer is D
Rationale: The nurse should assess the client for non-verbal behaviors that could indicate pain,
such as guarding, grimacing, restlessness, and crying. If the nurse observes these behaviors, the
nurse should complete a pain assessment, which includes asking for subjective data. The nurse
should ask the client to describe the feeling, including the quality, location, and intensity of the
pain.
Concepts tested

Question 1519

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The nurse is developing the plan of care for a client with chronic back pain who is requesting the
use of nonpharmacological interventions. Which intervention would be most appropriate for this
client?
A Cutaneous stimulation
B Distraction
C Music therapy
D Meditation

Question Explanation
Correct Answer is B
Rationale: The use of nonpharmacological interventions can be used to complement the
conventional interventions for pain. These interventions are varied and are used to alleviate
specific types of pain. Distraction is used to decrease pain by having the client focus their
attention on something specific, like a puzzle or watching television, and is best used for mild
pain. Music therapy, similar to distraction, uses music to soothe or decrease pain by affecting
transmitters and is best with acute pain. Cutaneous stimulation, such as with a TENS unit,
provides electrical stimulation to the skin’s surface by affecting the gate control theory, which
will decrease the number of pain impulses sent to the brain. Cutaneous stimulation is best used
with chronic, localized pain. Meditation is a relaxation technique to decrease pain by reducing
muscle tension and requires the client to control breathing.
Concepts tested

Question 1520
The nurse is assessing the vital signs for a client at 0400. The nurse should expect which of the
following findings for a client who is experiencing stage IV non-rapid eye movement (NREM)
sleep?
A An increase in temperature
B Small muscle twitching
C A decrease in pulse rate
D Easily arousable

Question Explanation
Correct Answer is C
Rationale: Stage IV NREM sleep, which is the deepest depth of sleep, is characterized by a
decrease in pulse and respiratory rate and blood pressure, along with a decrease in temperature,
due to the slowing of the metabolism rate. The client will have relaxed muscles and will be
difficult to arouse from sleep.
Concepts tested

Question 1521
A nurse is assessing a client at the beginning of the night shift. The client states, “I’m not
sleeping well at night, so can you not come into my room so often?” Which response would be
appropriate for the nurse to make?
A “The schedule is based on what is prescribed by your healthcare provider.”
B “I can review your plan of care to combine my tasks.”

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C “I will not enter your room if you are sleeping.”
D “You can choose the times you prefer to sleep.”

Question Explanation
Correct Answer is B
Rationale: The nurse should review the plan of care for clients who report difficulty sleeping to
cluster tasks. Clustering tasks decreases the number of times a nurse would have to enter a room.
The other options do not address the client’s concerns about getting sleep or are not practical.
Concepts tested

Question 1522
A nurse is assessing the sleep habits of a client who has a history of depression and reports
insomnia. The client states, “I spend my time in bed during the day, but then I find it difficult to
fall to sleep.” Which response would be appropriate for the nurse to make?
A “Exercising 20 minutes before bed will make you tired.”
B “Consider reading a book to help you relax.”
C “Avoid eating anything 30 minutes before you go to bed.”
D “Only use the bed when you feel sleepy.”

Question Explanation
Correct Answer is D
Rationale: The client who reports difficulty falling asleep should be instructed to go to bed when
sleepy, adopt a regular pattern of bedtime routines, and make the room quiet and dark. The client
should be told to avoid reading, watching TV, and exercise before bed. The client should not go
to bed hungry but avoid a large meal.
Concepts tested

Question 1523
The nurse is discussing the purpose of acupuncture with a client who has an anxiety disorder.
Which of the following statements by the client indicates the need for further teaching?
A “I will be able to reduce the medication I take for my anxiety.”
B “I may feel sore after the session.”
C “It will be a gradual improvement in my symptoms.”
D “My therapist encouraged me to try complementary therapy.”

Question Explanation
Correct Answer is A
Rationale: Acupuncture can be used as a complementary therapy for many conditions, including
anxiety disorders. Clients will undergo many sessions and should expect to see a gradual
improvement in symptoms. Therapy for anxiety includes medications, cognitive behavioral
therapy, rest, and exercise as well. Clients may not be able to reduce the amount of medication
taken.
Concepts tested

Question 1524

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The nurse is caring for an older adult client who has begun Tai Chi. Which of the following
reports from the client indicates this therapy is having the intended effect?
A Better balance
B Improved lifting ability
C Less snoring at night
D Weight loss

Question Explanation
Correct Answer is A
Rationale: Tai Chi has many health benefits including improved balance and coordination,
improved gait, and reduced fear of falling. Tai Chi also improves blood flow, neuromuscular
function, and cognitive function as well as decreases stress reactivity. The goals of Tai Chi are
not to improve lifting or promote weight loss, although they may be incidental effects. Clients
will not have reduced snoring.
Concepts tested

Question 1525
The palliative care nurse is caring for a client with severe chronic obstructive pulmonary disease
who is taking prescribed morphine. Which of the following client reports indicates that the
medication is having the intended effect?
A Reduced dyspnea
B Increased appetite
C A more productive cough
D Reduced frequency of exacerbations

Question Explanation
Correct Answer is A
Rationale: The goals of palliative interventions are to enable early detection of exacerbations,
decrease patient and family/caregiver anxiety, reduce unscheduled visits to the emergency room,
prevent hospitalizations, and support advanced care planning. Dyspnea is the most reported
symptom of COPD. The desired outcomes of morphine use in clients with respiratory disease are
to reduce dyspnea, pain, and anxiety. While cachexia is a common problem with clients who
have COPD, it is not treated with morphine. A cough would be treated with expectorants and
antitussives. A reduced frequency in exacerbations would occur through early identification of
infection.
Concepts tested

Question 1526
The palliative care nurse is caring for a client with cancer who is at end of life. The client has
been prescribed a scopolamine patch. Which of the following findings indicates that the
intervention is having the intended effect?
A Decreased secretions
B Reduced restlessness
C Improved cognition
D Increased urination

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Question Explanation
Correct Answer is A
Rationale: End-stage secretions (commonly referred to as “death rattle”) are known to occur in
close proximity to death. These secretions are both salivary and pulmonary. Scopolamine is an
anticholinergic that helps to dry up secretions and improve comfort in the client. It has side
effects including increased restlessness, reduced cognition, and urinary retention.
Concepts tested

Question 1527
The nurse is caring for a client with degenerative disk disease who had a spinal cord stimulator
implanted. Which of the following findings indicates the device is having the intended effect?
A Improved pain control
B Increased sensation in the periphery
C Improved balance
D Increased bone density in the spinal column

Question Explanation
Correct Answer is A
Rationale: A spinal cord stimulator is an implanted device that sends low levels of electricity
directly into the spinal cord to relieve chronic pain. The implantable device offers a
nonpharmacological approach to various pain conditions. Stimulators have been used for the
treatment of both neuropathic and ischemic pain. Spinal cord stimulation can improve the overall
quality of life and sleep and reduce the need for pain medicines. It is typically used along with
other pain management treatments. Stimulators do not improve sensation or balance and do not
increase bone density.
Concepts tested

Question 1528
The nurse is caring for a client admitted for an ischemic cerebrovascular accident. The client has
been prescribed a low sodium, low cholesterol diet. Which of the following actions should be
performed first?
A Perform a bedside swallow evaluation
B Assess the client’s ability to feed themselves
C Ask the assistive personnel to set up the meal tray on the bedside table
D Ensure that the items on the tray align with the prescribed diet

Question Explanation
Correct Answer is A
Rationale: A swallow evaluation is used to identify dysphagia. Performing a swallow evaluation
is the nurse’s priority in this situation. The client with a CVA is at high risk for aspiration. All
other interventions are appropriate but preventing aspiration is the priority.
Concepts tested

Question 1529
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The nurse is assessing an older adult client who has missing teeth and inflamed gums. The client
reports jaw pain when eating. Which finding should the nurse assess for?
A Weight loss
B Cognitive decline
C Frequent upper respiratory infections
D Dyspepsia after meals

Question Explanation
Correct Answer is A
Rationale: Loss of teeth and periodontal disease may make chewing more difficult. Poor
dentition is causally related to weight loss in older adults. Periodontal disease is associated with
tooth loss, abscesses, stroke, cardiovascular disease, and lung infections. It is not associated with
dyspepsia, cognitive decline, or upper respiratory tract infections.
Concepts tested

Question 1530
The nurse is assessing a post-operative client who received general anesthesia. A regular diet has
been prescribed. Which of the following actions is the priority?
A Determine if the gag reflex has returned
B Ask the client if they are nauseated
C Auscultate bowel sounds
D Determine the client’s orientation status

Question Explanation
Correct Answer is A
Rationale: General anesthesia will suppress the client’s gag reflex. To reduce the risk of
aspiration, it is imperative to ensure that the gag reflex has returned. All other actions are
appropriate for the care of the post-operative patient, but prior to feeding, assessing gag reflex is
the priority.
Concepts tested

Question 1531
The nurse is collecting the dietary history from a client with hyperlipidemia and is taking
prescribed simvastatin. Which statement by the client would require follow up by the nurse?
A “I’m eating salmon on my salad at lunch.”
B “I’ve switched to vegan meat substitutes.”
C “I’ve cut back on the number of eggs I eat.”
D “I’m trying to eat more grapefruit.”

Question Explanation
Correct Answer is D
Rationale: Grapefruit contains a substance that strongly inhibits the metabolism of drugs
normally metabolized by the CYP3A4 enzyme. Grapefruit interacts with simvastatin, increasing
the drug levels in the blood. It should be avoided. All other strategies are appropriate, as salmon

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increases HDL, tofu is made of soy products, and reducing egg consumption lowers dietary
cholesterol.
Concepts tested

Question 1532
The nurse is collecting dietary history from a client who is taking prescribed phenelzine to treat
depression. Which statement by the client would require follow up?
A “I ate pastrami and cheese on rye bread for lunch.”
B “I ate grilled chicken and green beans for dinner.”
C “I ate a salad with low fat dressing for lunch.”
D “I ate pasta with red sauce for dinner.”

Question Explanation
Correct Answer is A
Rationale: Monoamine oxidase inhibitors (MAOIs) block monoamine oxidase, which is an
enzyme that breaks down excess tyramine in the body. Blocking this enzyme helps relieve
depression. If the client takes an MAOI and then eats high-tyramine foods, tyramine can quickly
reach dangerous levels. This can cause a serious spike in blood pressure and require emergency
treatment. Foods high in tyramine include aged cheeses, cured and smoked meats, pickled or
fermented foods, soy products, beer, and products made with yeast. Pastrami sandwiches contain
very high levels of tyramine.
Concepts tested

Question 1533
The nurse is planning care for a client who is a Jehovah's Witness and is scheduled for a
cholecystectomy. Which lab data should indicate to the nurse that the client will require
alternative therapy?
A Platelet count of 250,000 mcL
B Hemoglobin concentration of 8.2 g/dL
C White blood cell count of 22,000 mm
D Glucose concentration of 100 mg/dL

Question Explanation
Correct Answer is B
Rationale: When planning care for a client who is a Jehovah's Witness, the nurse should
understand the use of blood products is against the client’s beliefs. A client who is a Jehovah's
Witness and is scheduled for surgery is at an increased risk for anemia from blood loss. The
nurse should understand that the client with a hemoglobin concentration of 8.2 g/dL is anemic
and will require alternative therapy. Normal platelet count is 150,000 to 450,000 mcL. An
elevated white blood cell count of 22,000 mm is a normal finding with a client who has
cholecystitis. A glucose concentration of 100 mg/dL is in the normal range.
Concepts tested

Question 1534
The nurse is caring for a client with chronic pain and is receiving scheduled oral pain
medication. Which of the following would indicate to the nurse the need for alternative therapy?
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A The client reported a decrease in appetite.
B The client refused to participate in physical therapy.
C The client asked when the next dose of medication is due.
D The client requested assistance with hygiene care.

Question Explanation
Correct Answer is B
Rationale: A client with chronic pain who is taking scheduled prescribed oral pain medication
should be assessed for the need for alternative therapy. Clients who refuse to participate in
activities, such as physical therapy, may need alternative therapy to manage pain. A client who is
taking prescribed oral pain medication can report a decrease in appetite. Clients who are taking
scheduled pain medication may ask when the next dose is due to ensure that their pain will be
controlled. Clients with chronic pain may ask for assistance with hygiene care, especially when
in the hospital.
Concepts tested

Question 1535
The nurse is evaluating the nutritional status for a group of clients. Which client has an increased
risk for undernutrition?
A The client who is pregnant
B The client who is an athlete
C The client with diabetes type II
D The client with a stressful job

Question Explanation
Correct Answer is A
Rationale: Undernutrition is a depletion or inadequate nutritional intake to meet the day-to-day
needs for metabolic demands. Vulnerable populations, including infants, pregnant women, older
adults, and hospitalized clients are at risk for undernutrition. Diabetes type II is associated with
overnutrition. Athletes require increased nutritional intake but are not a vulnerable population.
Clients with stressful jobs are at risk for overnutrition.
Concepts tested

Question 1536
The nurse is collecting the health history of a client with chronic pain. Which statement by the
client would require the nurse to intervene?
A “I often have to take breaks when cleaning my house.”
B “My partner has been helping with the cooking.”
C “It takes a little longer for me to walk to the mailbox.”
D "I now use a shower chair when I perform hygiene care."

Question Explanation
Correct Answer is C

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Rationale: Chronic pain can impact a client’s ability to perform activities of daily living, such as
bathing. A client who is taking bed baths may be having difficulty with getting in and out of the
bath. Chronic pain could decrease the amount of time a client does an activity, which is normal.
Concepts tested

Question 1537
A home health nurse is assessing a client who has end-stage heart failure. Which statement by
the client would indicate to the nurse the need for palliative care?
A “I seem to be urinating more frequently at night.”
B “I am too tired to complete my hygiene care.”
C “I noticed a change in my appetite.”
D “I think my legs feel swollen.”

Question Explanation
Correct Answer is B
Rationale: Heart failure is a chronic condition when the heart is unable to pump blood adequately
to the body resulting in a decrease in perfusion. Expected findings associated with fluid retention
in the body, resulting in edema in the lower extremities, include decreased peristalsis, and
nocturia. When assessing if the heart failure is progressing to the need for palliative care, the
nurse should assess the impact of the condition on the client’s ability to perform activities of
daily living. Heart failure causes increased activity intolerance, but a client who reports he or she
is unable to complete hygiene care may require further support from palliative care. Reports of
appetite change, increased urination at night, and extremity swelling are expected findings with
heart failure.
Concepts tested

Question 1538
The hospice nurse is assessing a client with terminal lung cancer. The client reports a decrease in
appetite. Which statement by the nurse would be appropriate?
A “Are there any specific foods that you do prefer to eat?”
B “Would you like to talk about placing a feeding tube?”
C “Do you have a set time for meals?”
D “Is there someone that can help you eat?"

Question Explanation
Correct Answer is A
Rationale: It is expected that clients with terminal cancer will experience a decrease in appetite.
Medications and treatments can also affect a client’s appetite. When assessing the need for
further management, the nurse should first ask if there are any favorite foods the client prefers.
Encouraging the client to eat preferred foods could help with maintaining adequate nutrition.
Feeding tube placement is the intervention when the client is unable to take food and drink orally
and is often the last resort. Having a set time for meals does not influence appetite. Someone to
assist with eating is an intervention when the client is unable to feed themselves.
Concepts tested

Question 1539
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A nurse is performing a pain assessment for a client who is alert. The nurse should recognize that
which of the following measures is the most reliable indicator of pain?
A Vital signs
B Severity of condition
C Nonverbal behaviors
D Self-report

Question Explanation
Correct Answer is D
Rationale: Pain is a subjective experience, based on the perception of the client. The most
reliable indicator of pain is the client’s self-report. Vital signs and nonverbal behaviors could
indicate the client is in pain, but they are not as reliable as self-reporting. The severity of the
condition could be a factor in the amount or intensity of pain, but it is not a reliable indicator of
pain.
Concepts tested

Question 1540
The nurse is assessing a client who is non-verbal for pain. Which action would be most
appropriate for the nurse to take?
A Ask a family member for signs of pain
B Observe client behaviors
C Administer ordered analgesics on schedule
D Use the client’s previous admission assessment

Question Explanation
Correct Answer is B

Question 1541
The nurse is preparing to assess the pain of a 5-year-old client. Which pain assessment tool
would be most appropriate to use with this client?
A Numeric Pain Intensity Scale
B Simple Descriptive Pain Scale
C Faces Pain Scale
D Visual Analogue Scale

Question Explanation
Correct Answer is C
Rationale: Children two years and older can report pain and point to the location. For a 5-year-
old client, the nurse could use the Faces Pain Scale, which has drawings of faces that show
different pain intensities. The child will point to the face that shows how much they hurt. The
Simple Descriptive, Numeric, and Visual Analogue Scales are more appropriate for adult clients.
Concepts tested

Question 1542

Page | 629
The nurse is collecting the health history of an older adult client who states, “I have been
experiencing pain in my back.” Which would be the best statement by the nurse?
A “Did you do something to hurt your back?”
B “Back pain is common with aging.”
C “Can you show me where the pain is?”
D “You may need therapy to strengthen your back.”

Question Explanation
Correct Answer is C
Rationale: When a client reports pain, the nurse should further assess the pain by asking about
the intensity, aggravating and alleviating factors, location, and impact of activities of daily
living. The nurse should avoid identifying interventions before the pain is assessed. Pain is not a
normal part of aging. Asking if the client did something is accusing and nontherapeutic.
Concepts tested

Question 1543
A client on a medical-surgical unit is admitted with severe shortness of breath due to
community-acquired pneumonia. Which intervention by the nurse would best promote the
client's comfort?
A Monitor vital signs frequently
B Encourage visits from family
C Encourage incentive spirometry
D Keep conversations short

Question Explanation
Correct Answer is D
Rationale: Clients with pneumonia often suffer from shortness of breath due to impaired gas
exchange. Keeping conversations short will best promote the client's comfort by decreasing
demands on the client's breathing and oxygen consumption. Although encouraging the use of
incentive spirometry and monitoring of vital signs are important for clients with pneumonia, they
will not directly help with discomfort such as shortness of breath. While the presence of family is
supportive, demands on the client to interact with the visitors may worsen the client’s oxygen
demands and shortness of breath.
Concepts tested

Question 1544
A client with a new transverse colostomy is scheduled for discharge tomorrow. The client
repeatedly asks the nurse to empty the colostomy pouch. Which is the best response by the
nurse?
A "I will let the nurse assistant know to empty the pouch."
B "You should be emptying the pouch yourself."
C "Show me what you have learned about emptying your pouch."
D "Why are you afraid to empty your pouch?"

Question Explanation

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Correct Answer is C
Rationale: Adults learn best in a participatory and collaborative environment. They do not want
to be lectured or scolded (e.g., "you should be emptying the pouch yourself"). But anxiety about
discharge, as well as fatigue or pain, could have had an impact on the client's ability to be fully
engaged in any previous learning. The best response is to ask the client to return demonstrate
how to empty the pouch. The other responses are nontherapeutic and do not support the goal for
the client to learn to manage the colostomy at home.
Concepts tested

Question 1545
A postoperative client has a nasogastric tube in place and is on a nothing-by-mouth diet. Which
intervention by the nurse would provide the most comfort to the client?
A Provide mints to freshen the client's breath
B Swab the client's mouth with glycerin swabs
C Perform frequent oral care with a wet, soft sponge
D Allow the client to melt ice chips in their mouth

Question Explanation
Correct Answer is C
Rationale: Frequent oral care is important for a client with a nasogastric tube and/or on a
nothing-by-mouth (NPO) diet to maintain intact oral mucous membranes and promote comfort.
Glycerin and mints tend to further dry out the mucous membranes, have no cleansing or comfort
value, and thus should not be used. Since the client is NPO, ice chips are contraindicated and
should not be given unless the health care provider changes the diet order.
Concepts tested

Question 1546
A female client is newly diagnosed with urge incontinence. She reports to the nurse that she is
often incontinent of large amounts of urine and expresses a fear of falling when rushing to the
bathroom. Which interventions should the nurse include in the client’s plan of care? Select all
that apply.
A Limit foods that irritate the bladder
B Restrict fluid intake to 1 liter per day
C Assist with vaginal pessary insertion
D Try to void every couple of hours
E Perform pelvic floor muscle exercises

Question Explanation
Correct Answer is A, D, E
Rationale: Urge incontinence involves periodic, but frequent, leakage of urine. Treatment
involves treating the underlying cause, but in most cases, no cause can be found. Medication and
behavioral interventions are tried before surgery is considered. Behavioral changes include
bladder training with urge suppression, restricting foods that may irritate the bladder, such as
caffeine, and pelvic floor muscle exercises. A pessary is commonly used in the management of

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pelvic support defects, such as cystocele and rectocele, but not urge incontinence. Severely
restricting fluid intake to 1 liter per day is not required and can lead to dehydration.
Concepts tested

Question 1547
A client with newly diagnosed irritable bowel syndrome states to the nurse: "All this fiber I have
to eat now is making me full of gas! It makes me want to stop taking it." Which actions by the
nurse would be appropriate? Select all that apply.
A Remind client to reduce intake of gas-forming foods
B Instruct client to eat only three larger meals every day
C Teach client about a balanced and nutrient-rich diet
D Inquire about a history of lactose intolerance
E Instruct client to reduce fiber and then add it again slowly

Question Explanation
Correct Answer is A, D, E
Rationale: Adequate fiber intake is critical to controlling irritable bowel syndrome (IBS) but can
result in bloating and gas if added to the diet too quickly. Increasing fiber intake gradually by
two to three grams per day will help reduce the risk of gas and bloating. Some foods, as well as
lactose in dairy products, also contribute to gas formation. Eating a balanced, nutritious diet is
good self-care practice but does not address excessive gas production. Large meals can cause
cramping (and diarrhea), so eating four to five smaller meals a day is recommended.
Concepts tested

Question 1548
The nurse in a sleep disorder clinic is teaching a client with insomnia about techniques to
promote sleep. Which statements by the client indicate that the client understood the
teaching? Select all that apply.
A "I will decrease my caffeine intake during the day and avoid coffee in the evening."
B "I will avoid drinking alcoholic beverages too close to bedtime."
C "I will exercise a few hours before my bedtime to make me tired, so I can sleep."
D "I will keep a sleep log and track my sleep and awake hours daily."
E "I will start a set of bedtime rituals that I will consistently use to help me fall asleep."
F "If I awaken during the night, I will stay in bed until I fall back asleep."

Question Explanation
Correct Answer is A, B, D, E
Rationale: Nurses can provide essential information to clients regarding symptom relief for
insomnia. The client should use a sleep log, decrease caffeine intake overall and not drink
caffeinated beverages in the evening, and establish a bedtime routine. An increase in daily
exercise is recommended; however, exercise within six hours before bedtime interferes with
falling asleep and is not considered as helpful in promoting good sleep. If the client awakens
during the night, the client should get up and engage in a quiet, non-stimulating activity, such as
reading. Alcohol may speed the onset of sleep, but it tends to disrupt sleep later in the night.
Concepts tested

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Question 1549
A client is placed on a high-protein diet and asks the nurse to describe the role of protein in the
body. Which responses by the nurse describe the role of protein? Select all that apply.
A "Wound healing is poor with decreased levels of protein."
B "Protein plays a role in the body's immunity."
C "Protein is necessary for the formation of body structures, including bone, muscle, and red
blood cells."
D "You can determine your protein needs according to your body weight."
E "Protein should be at least 5% of your total daily intake of calories."

Question Explanation
Correct Answer is A, B, C, D
Rationale: Protein is a vital component of every living cell and is required for the formation of
all body structures, including genes, enzymes, muscle, bone matrix, skin, and blood. Protein is
critical for the structure, function, and regulation of the body's tissues and organs. The
Acceptable Macronutrient Distribution Range (AMDR) is a recommended percentage of energy
intake for carbohydrates, proteins, and fats. The AMDR for protein is 10 to 35%. With decreased
levels of protein, there is a decrease in immune cells. Wound healing is poor, and the body is
unable to fight off infection because of multiple immunologic malfunctions throughout the
body. Protein needs can be determined according to body weight or by using the value of grams
per day, which is reliable for most healthy people. As a general guideline, the recommended
daily intake of protein is 0.04 to 0.06 ounces (1 to 1.8 grams) per 2.2 pounds (1 kg) of body
weight.
Concepts tested

Question 1550
The nurse is reviewing a client's dietary history. The nurse understands that which factors will
influence the client's dietary intake? Select all that apply.
A Education
B Anthropometric measurements
C Culture
D Personal feelings
E Religion

Question Explanation
Correct Answer is A, C, D, E
Rationale: Dietary choices or restrictions are influenced by economics, culture, religion, and
personal feelings and meanings associated with food. The financial income of the client or the
client's household can directly impact the ability to purchase sufficient food and/or food of high
nutritional value. Diverse lifestyles and eating habits directly impact a person's nutritional health
and well-being. Religious restrictions and beliefs or cultural practices may affect the client's
acceptance of, response to, and compliance with dietary therapies. Health care providers (HCP)
need to understand a client's cultural values, beliefs, and practices to provide culturally

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acceptable care. Anthropometric measures are used to measure growth rate, body protein, and fat
stores. They do not directly influence dietary intake.
Concepts tested

Question 1551
The nurse explains a low cholesterol diet to a client diagnosed with heart disease. Which menu
selection by the client demonstrates that the client understands the teaching?
A Turkey chili made with kidney beans
B Shrimp and pasta
C Sausage with peppers and fried potatoes
D Fried chicken and macaroni and cheese

Question Explanation
Correct Answer is A
Rationale: Cholesterol is a fat-like substance found only in animal products. It is not an essential
nutrient. The body makes enough good cholesterol (HDL). The American Diabetes Association
(ADA) recommends limiting the total intake of dietary cholesterol to less than 300 mg/day. This
may help reduce risk factors, such as increased serum cholesterol levels, which are associated
with the development of coronary artery disease. Different foods lower cholesterol in various
ways. Some deliver soluble fiber, which binds cholesterol and its precursors in the digestive
system and drags them out of the body before they get into circulation. Some deliver
polyunsaturated fats, which directly lower bad cholesterol (LDL). Some contain plant sterols and
stanols, which block the body from absorbing cholesterol. Canned chicken, unsalted butter, and
scrambled eggs are all products derived from animals. Legumes are plant-based and are
especially rich in soluble fiber.
Concepts tested

Question 1552
The nurse is caring for a client who is receiving bolus enteral tube feedings. Which of the
following actions by the nurse demonstrate safe practice for this client? Select all that apply.
A Flushing the tube with 30 to 60 mL of water every hour
B Maintaining the head of the bed at 30 to 45° during feedings
C Aspirating and measuring the residual gastric contents before each feeding
D Verifying the initial placement of the tube by radiographic assessment
E Providing oral hygiene every 48 hours
F Connecting the tube to low intermittent wall suction 45
G Placing the patient in the supine position for 30 minutes after each feeding

Question Explanation
Correct Answer is A, B, C, D
Rationale: Safe care of clients receiving enteral feedings focuses on preventing regurgitation and
aspiration. This is done by verifying the initial placement of the tube via radiographic
assessment, maintaining the head of the bed above 30° during and for 30 minutes following the
feeding, and ensuring the patient is able to tolerate the volume and speed of the nutrition by
measuring residual volumes prior to feeding. Flushing the tube every hour is not indicated and

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could lead to fluid overload. Placing the client in a supine position is contraindicated after just
having received a bolus of tube feeding because it increases the risk of regurgitation and
aspiration. Oral care should be provided regularly and at least every shift. Connecting the tube to
suction is incorrect.
Concepts tested

Question 1553
A nurse is caring for a client who is receiving enteral nutrition. Before starting the next bolus
feeding, what action should the nurse take?
A Add food dye (color) to the tube feeding
B Elevate the head of the bed to 90°
C Verify correct tube placement
D Irrigate the feeding tube vigorously

Question Explanation
Correct Answer is C
Rationale: Before the nurse administers anything through a feeding tube, correct placement of
the tube should be verified. The recommended angle for the head of the bed (HOB) while
receiving tube feedings is 30° to 45°, not 90°. It is no longer considered best practice to add dye
or food coloring to tube feeding as a way to monitor for aspiration. Food coloring has been
associated with the development of diarrhea. Irrigation of the tube is not indicated at this time,
and it should not be done vigorously.
Concepts tested

Question 1554
The nurse is monitoring a client who is caring for their prosthetic limb. Which action by the
client demonstrates that the client correctly understands prosthetic limb care?
A The client uses baby powder in the prosthetic limb socket.
B The client adjusts the fit of the prosthetic limb using gauze and tape.
C The client dries the inside of the prosthetic socket after wiping it with soap and water.
D The client changes the residual leg sock/stocking once every two days.

Question Explanation
Correct Answer is C
Rationale: To decrease the risk of irritation and infections, prosthetic limbs should be maintained
by keeping the socket clean and dry. Cleaning prosthetic sockets involves using soap and water
daily. The client should change the residual leg sock at least daily and only use products
prescribed by the primary HCP. Using baby powder is not appropriate. Periodic adjustments of
the sizing or fit of a prosthetic limb are expected and should be done by a professional. Using
tape and/or gauze to self-adjust the fit of the prosthetic might cause skin irritation and
breakdown.
Concepts tested

Question 1555
The nurse is monitoring a UAP as they provide perineal care to a client who suffers from urinary
incontinence. What action by the UAP would require intervention by the nurse?
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A The UAP utilizes a clean washcloth to wipe from anterior to posterior.
B The UAP cleanses the urinary meatus and then the labia majora and minora.
C The UAP provides perineal care after each episode of incontinence.
D The UAP removes the towel under the client once care is complete.

Question Explanation
Correct Answer is B
Rationale: It is critical that the UAP provides appropriate care, which reduces the risk of
infection and loss of skin integrity. Perineal care should be performed by cleansing from anterior
to posterior and outside to inside. This should be done using a clean portion of the washcloth for
each wipe. Cleansing the urinary meatus and then the labia majora and minora increases the risk
of spreading microorganisms from the protective structures of the labia to the urinary meatus.
Concepts tested

Question 1556
The nurse is reviewing information with a client about their new ileostomy. Which statement by
the client suggests that they understand the teaching?
A "It is normal for the skin around my stoma to be irritated."
B "It is normal to empty my pouch every thirty minutes."
C "It is normal to take a laxative as needed for constipation."
D "It is normal for my stoma to remain red in color." Correct Answer

Question Explanation
Correct Answer is D
Rationale: An ileostomy, a type of colostomy, is the surgical creation of an opening of the colon
onto the surface of the abdomen. It is usually performed due to colon resection. The ileostomy
stoma will remain red in color because it is very vascular. If the client needs to empty the pouch
every thirty minutes, then that would be considered too frequent and should be investigated
further. The skin around the stoma should not be irritated. If irritation occurs, interventions to
protect the skin should be implemented. Stool from an ileostomy will be liquid to semi-liquid,
and a laxative should not be taken.
Concepts tested

Question 1557
The nurse is collecting data on a client who is complaining of drowsiness and an inability to
concentrate. Which statements by the client's spouse indicate the client might be suffering from
obstructive sleep apnea? Select all that apply.
A "He seems to snore less when he sleeps in a chair."
B "He snores really loud during the night. I have to sleep in the other bedroom."
C "He falls asleep anytime he sits down."
D "He says he feels short of breath when lying flat."
E "He is very irritable and tired even when he has slept 12 hours the night before."
F "He stops breathing sometimes at night."
G "His legs are usually swollen at the end of the day."

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Question Explanation
Correct Answer is A, B, C, E, F
Rationale: The most common clinical manifestation of obstructive sleep apnea (OSA) is daytime
sleepiness and the inability to maintain concentration. Often the client's family members will
state the client snores loudly and stops breathing while sleeping. Swelling in the lower
extremities and shortness of breath when lying supine (orthopnea) are related to heart failure, not
OSA.
Concepts tested

Question 1558
A nurse is participating in a care conference for a postoperative client who has been reporting
frequent, unrelieved acute pain. Which statements suggest that the nurse understands the
principles of effective pain management? Select all that apply.
A Clients from Eastern cultures usually require less pain medication.
B Pain exists when and where the client says it exists.
C Pain is an emotional response to tissue inflammation or damage.
D Pain can be treated with pharmacologic and/or nonpharmacologic therapies.
E Postoperative pain should only be assessed by the health care provider.
F Family members can influence a client’s response to pain.

Question Explanation
Correct Answer is B, D, F
Rationale: The nurse must understand the physiologic, affective, cognitive, behavioral, and
sociocultural dimensions of pain and pain management. Assessing/evaluating pain is an
important part of the nurse's responsibility in all nursing care circumstances, including
postoperative pain. Pain is subjective, highly individualized, and sometimes complex to treat.
Pain is a physiological process and sensation caused by a specific stimulus, e.g., inflammation or
tissue damage, that is transmitted to the CNS. It is a misconception that clients from Eastern
cultures need less pain medication. Families and caregivers influence the person’s response to
pain through their beliefs and behaviors. For example, a family member may discourage the use
of opioids due to a fear that the client will become addicted.
Concepts tested

Question 1559
The nurse observes a client using crutches. Which of the following actions by the client would
require the nurse to intervene? Select all that apply.
A The handgrips of the crutches are even with the client's hips.
B The client is using crutches that have a broken rubber tip.
C The client has a spare pair of crutches and rubber tips.
D While using a three-point gait, the client is bearing weight on both legs.
E The client is resting their axillae or armpits on top of the crutches.

Question Explanation
Correct Answer is B, D, E

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Rationale: When clients use crutches, their hands should rest on the handgrips of the crutches.
The client's weight should not be resting on their axillae as this could lead to damage to the
axillary nerve. Clients should check the integrity of their crutches, including the rubber tips. The
crutches should be in good working order and not broken or worn down. Clients should have a
spare pair of crutches, including rubber tips. A three-point crutch gait is used for people who
only have one weight-bearing leg.
Concepts tested

Question 1560
The nurse is providing care for a client with subluxation of the finger joints and deformity of the
hands due to rheumatoid arthritis. The client’s partner states that it is increasingly difficult for the
client to perform activities of daily living. Which assistive devices will the nurse teach the client
about and include in the plan of care? Select all that apply.
A Button hooks
B Crutches
C Rolling walker
D Raised toilet seat
E Built-up eating utensils
F Hand splints

Question Explanation
Correct Answer is A, E, F
Rationale: Due to the deformity of the hands, assistive devices should be targeted to help the
client with hand and finger movement and promote independence with activities of daily living.
Built-up eating utensils are easier to hold and will help the client feed themselves. Button hooks
can help the client with getting dressed without needing assistance with buttons. Hand splints
support the finger joints and may help to improve dexterity. A rolling walker, crutches, and a
raised toilet seat would be used in a client with lower-extremity impairment or non-weight-
bearing status and are not necessary for this particular client.
Concepts tested

Question 1561
The nurse in a health clinic is reviewing recommended nutritional therapy with a client who has
a history of emphysema. Which action should the nurse emphasize to the client?
A Use oxygen during meals
B Drink lots of liquids with meals
C Use the rescue inhaler prior to meals
D Perform exercises to enhance appetite

Question Explanation
Correct Answer is A
Rationale: Clients with emphysema often experience shortness of breath or "air hunger" while
eating. Giving the client oxygen through a nasal cannula will alleviate the air hunger while

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eating. Clients should avoid drinking a lot of fluids with meals to prevent gastric distention,
which can worsen the shortness of breath as well as make the client feel full too soon. Engaging
in exercise before eating is not recommended since it can worsen the shortness of breath and
decrease appetite. A rescue inhaler should not be used routinely but should be reserved for
episodes of acute respiratory distress.
Concepts tested

Question 1562
The client is grimacing, crying, and reports having pain. What is the first step the nurse should
take when collecting data about the client's pain?
A Accept the client’s report of pain
B Determine any aggravating factors of the pain
C Ask the client to describe the pain’s quality and location
D Inquire about the client’s goal for pain relief

Question Explanation
Correct Answer is A
Rationale: Although all of the actions are correct, the first and most important aspect of pain
management is for the nurse to accept that the client is in pain and the pain is as severe as the
client reports it to be. Pain is a subjective phenomenon, and only the person experiencing it can
confirm its presence and severity. Pain can exist even if no physical cause is apparent.
Concepts tested

Question 1563
The nurse is evaluating a client who has been diagnosed with heart failure (HF) to gauge their
understanding of the required diet modifications. Which menu items selected by the client
indicate to the nurse that the client understood the teaching?
A Leftover turkey on a sandwich and fresh pineapple
B Grilled cheese sandwich with a glass of skim milk
C Cheeseburger and baked potato chips
D Vegetable pizza and ice cream

Question Explanation
Correct Answer is A
Rationale: Clients with HF should adhere to a low-sodium diet to prevent fluid volume excess.
A sodium-restricted diet should consist of less than 2 grams of sodium per day. (A regular diet
should include 4 to 6 grams of sodium per day.) A turkey sandwich is the healthiest meat choice
and fresh pineapple is low in sodium. Any food with more than 480 mg of sodium per serving,
such as pizza, processed cheese or meats, are considered high-sodium foods and should be
avoided.
Concepts tested

Question 1564
A 2-year-old child is brought to the pediatrician's office by the parents, who report that the child
has been having diarrhea for two days. What nutritional information should the nurse provide to
the parents?
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A Keep the child fasting, give them nothing to eat, and return the next day.
B Continue a regular diet and add electrolyte replacement drinks.
C Give the child only clear liquids and gelatin for 24 hours.
D Give the child bananas, apples, rice and toast as tolerated.

Question Explanation
Correct Answer is B
Rationale: Current recommendations for mild to moderate diarrhea are to maintain an age-
appropriate diet and include rehydration fluids that contain electrolytes. Some providers now
recommend a diet of cereal, rice and milk (the C.R.A.M. diet) because milk provides fat and
protein and the C.R.A.M. foods are shown to ease diarrhea quickly. The B.R.A.T. diet,
consisting of bananas, rice, applesauce and toast or tea, should be avoided for children with acute
gastroenteritis because it is low in energy foods, protein and fat. Both the C.R.A.M. and
B.R.A.T. diets require oral hydration therapy. The other recommendations are incorrect.
Concepts tested

Question 1565
The nurse is reviewing the history of a client with type 2 diabetes mellitus. The client’s most
recent hemoglobin A1C level was 9.5%. What information about nutritional therapy should the
nurse reinforce with the client? Select all that apply.
A Use a diabetes exchange list.
B Use carbohydrate counting.
C Limit alcohol intake.
D Limit protein intake.
E Choose foods low in fat content.

Question Explanation
Correct Answer is A, B, C, E
Rationale: A glycosolated hemoglobin A1C level of 9.5% corresponds to an average blood
glucose level of 226 mg/dL. The American Diabetic Association recommends an A1C of 7% or
less for clients with diabetes. The goals for nutrition therapy in type 2 diabetes emphasize
achieving glucose, lipid and blood pressure control. Because overweight and obesity are
associated with increased insulin resistance, the client should maintain a nutritionally adequate
meal plan with appropriate serving sizes. Carbohydrate counting is a recommended meal
planning technique to help track the amount of carbohydrates eaten and keep carbohydrates
within a healthy range. A diabetes exchange list is another method to track carbohydrates and
allows the client to form a list of exchanges for each meal and snack. Alcohol should be
consumed in moderation because it prevents gluconeogenesis and can make managing the
diabetes more difficult. The recommended daily protein intake for diabetics is the same as for
non-diabetics.
Concepts tested

Question 1566
A client reports to the nurse the passage of hard dry stools at least twice a week. Which of these
actions should the nurse suggest that the client take first to improve their bowel function?

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A Increase daily fiber intake to at least 20 grams.
B Avoid binding foods, such as cheese.
C Use a chemical laxative as needed.
D Increase physical activity.

Question Explanation
Correct Answer is A
Rationale: Incorporating high-fiber foods into their diet, especially whole grains, fruits and
vegetables, should be the client's first step to improve their bowel function. A regular
recommended diet of about 2,000 calories a day should include about 25 grams of fiber. The
client should also increase their fluid intake and avoid food that tends to bind or reduce the water
content of stool, such as cheese. Although physical activity will promote peristalsis and reduce
the risk of constipation, the effect is more indirect and less effective than increasing fiber intake.
Laxatives should be used as a last resort.
Concepts tested

Question 1567
The nurse is caring for a client with trigeminal neuralgia who has been experiencing unplanned
weight loss. Which dietary approach should the nurse recommend?
A Eat small meals of high calorie, soft foods.
B Increase intake of fish, liver and chicken.
C Increase intake of fish, liver and chicken.
D Limit intake of dairy products.

Question Explanation
Correct Answer is A
Rationale: Trigeminal neuralgia (TN) is a chronic syndrome causing impaired comfort, most
often severe pain, in areas that are controlled by the trigeminal (fifth cranial) nerve including the
jaw, lower lip, lower gum, and some of the muscles used for chewing. The client with TN is at
risk for inadequate nutritional intake and weight loss. Therefore, the nurse should teach about
foods that are high in calories and nutrients but are soft and require less chewing. To minimize
jaw movements when eating, it may help to puree foods in a blender or food processor. The other
dietary approaches are not appropriate or necessary for managing TN.
Concepts tested

Question 1568
The nurse has given discharge instructions to a client who underwent abdominal surgery. Which
of the following statements indicates that the client correctly understands how to manage their
pain at home? Select all that apply.
A "A warm shower before bed might alleviate my pain and help me sleep."
B "My goal for pain relief should be 0/10 on a pain scale."
C "My discomfort should be relieved within 10 minutes of taking my pain pill."
D "Before I take an herbal supplement for pain, I should check with my provider."
E "Listening to my favorite music might help control my pain."

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Question Explanation
Correct Answer is A, D, E
Rationale: Nonpharmacological pain-relief methods can help maximize the effects of
pharmacological therapies and lessen how much medication a client needs for pain control.
Music is considered a form of distraction. It can reduce pain, anxiety and depression. Herbal
supplements may interact with prescribed analgesics. Clients need to make sure their health care
provider is aware of all the medications they currently take. Oral pain medications usually peak
within one hour. Moist heat can alleviate muscle tension and reduce pain. Clients should set a
reasonable goal for pain control (e.g., 3/10 or 4/10). It is unrealistic to think that a client will
have no pain after surgery. They should set a pain relief goal that will allow them to rest,
participate in therapy sessions and perform activities of daily living.
Concepts tested

Question 1569
A nurse on a medical-surgical unit is caring for a client in skeletal traction. Which nursing
intervention is appropriate for this client?
A Insert an indwelling urinary catheter.
B Remove the weights when turning the client.
C Maintain a supine position at all times.
D Maintain correct body alignment.

Question Explanation
Correct Answer is D
Rationale: In skeletal traction, screws are surgically inserted directly into bone. These allow the
use of longer traction time and heavier weights, usually 15 to 30 lb (6.8 to 13.6 kg). Skeletal
traction aids in bone realignment but impairs the patient's mobility. To prevent dysfunction of
other body parts or incorrect alignment of any part of the traction, it is important to maintain
correct alignment of the client’s entire body. The weights should not be removed when the client
is moved. Although it is appropriate to lower the head to help prevent hip flexion contractures,
the client does not need to be supine at all times. Skeletal traction is not an indicator for an
indwelling catheter.
Concepts tested

Question 1570
A surgical client with acute pain refuses to participate in physical therapy. The client still has
pain despite the administration of pain medication. Based on the information provided, which
nonpharmacological intervention(s) would be appropriate for the nurse to add to the plan of
care? Select all that apply.
A Keep the client on strict bedrest until the pain completely resolves.
B Apply ice directly to the surgical incision 30 minutes before therapy.
C Provide the client with a light back massage before physical therapy.
D Ensure the client's room is kept at a comfortable temperature for physical therapy.
E Assist the client in meditating before going to physical therapy.

Question Explanation

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Correct Answer is C, D, E
Rationale: Nonpharmacological therapies are essential for pain management. For example, they
can minimize the use and duration of use of synthetic medications for pain control, which can
minimize medication side effects. Nondrug therapies can increase a client's sense of control and
their ability to cope with pain. When using cold therapy, always protect the skin before
application of the therapy, and do not apply cold objects or ice to open wounds. Keeping the
client's room well-lit, quiet and at a comfortable temperature can also help manage pain.
Massage can reduce muscle tension and stress, thus helping reduce pain. Keeping a client on
bedrest after surgery is contraindicated because it can lead to complications such as pneumonia,
pressure ulcers and deep vein thrombosis. It is also unrealistic for a surgical patient to not have
any pain. Relaxation techniques such as music, meditation and deep breathing can help reduce
stress and anxiety, alleviate muscle tension and enhance the effectiveness of other pain relief
measures.
Concepts tested

Question 1571
The nurse is assessing a client with a hip fracture who has been in Buck's traction for 24 hours.
Which nursing assessment is the priority?
A Assessing the client's level of pain.
B Monitoring the client's skin for breakdown around bony prominences.
C Checking the pulse, temperature and sensation of the client's lower extremities.
D Auscultating the client's lung sounds.

Question Explanation
Correct Answer is C
Rationale: Although all of the assessments are important, performing a neurovascular assessment
is the priority assessment when caring for a client with a hip fracture. Complications from a
fracture, such as acute compartment syndrome (ACS), venous thromboembolism (VTE) and
ischemic necrosis, can be identified early with regular and frequent neurovascular checks. The
nurse should assess the client's pedal pulses, color, temperature, sensation and capillary refill of
the lower extremities. Any abnormal findings should be promptly communicated to the health
care provider.
Concepts tested

Question 1572
The nurse is teaching a 14-year-old client about using a thoracolumbosacral orthotic for
treatment of scoliosis. Which statement made by the client indicates the need for further
teaching?
A "I should remove the brace when I take a shower."
B "I should wear a sweatshirt under the brace to protect my skin."
C "I should loosen the brace during meals."
D "I should avoid applying lotions and body powders."

Question Explanation
Correct ANSWER IS b

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Rationale: The thoracolumbosacral (TLSO) is a custom molded brace prescribed to treat and
prevent the progression of scoliosis. Clients are advised to wear only a fitted, thin shirt under the
brace to protect the skin and absorb sweat. If a thick shirt (e.g. sweatshirt) is worn under the
brace, it will not fit properly and treatment will not be effective. The brace should be removed
when showering or swimming. The client should be instructed to loosen the brace during meals
and for the first 30 minutes after eating to allow adequate nutritional intake and promote comfort.
Body powders and lotions should be avoided when possible as they may irritate the skin under
the brace. The health care provider will instruct the client about how often and how long to wear
the brace each day (typically around 18-23 hours per day).
Concepts tested
Question 1573
The nurse is caring for a client who had an appendectomy two hours ago. Which is
the most reliable approach for the nurse to assess the client’s postoperative pain?
A Monitor for non-verbal signs of pain, such as grimacing and crying.
B Ask the client to rate their pain using a pain rating scale.
C Check for changes in the client’s vital signs, such as tachycardia.
D Observe the client for behaviors such as guarding, bracing or splinting of the surgical site.

Question Explanation
Correct Answer is B
Rationale: Pain is a complex phenomenon that is perceived differently by each individual. This is
why the client’s self-report is the most reliable way to determine a client's level of pain. Nurses
should apply ethical standards when assessing pain, such as respect for autonomy (the right of
clients to make their own decisions about health care). The level of pain a client experiences is
subjective and should be measured as such. Pain may be accompanied by changes in vital signs,
grimacing, crying, guarding, bracing or splinting the affected area. However, the most reliable
way for a nurse to measure pain is the client’s self-report using a pain rating scale that is
appropriate for the client’s age.
Concepts tested

Question 1574
The nurse in a long-term care facility is observing a certified nursing assistant (CNA) change a
soiled incontinence brief on a client with incontinence-associated dermatitis. Which action by the
CNA would require the nurse to intervene?
A Applies a thin layer of barrier cream to the perineum.
B Cleanses the perineal area with toilet tissue.
C Places an absorbent dressing pad over the wound.
D Positions the client in a side-lying position.

Question Explanation
Correct Answer is B
Rationale: Incontinence associated dermatitis (IAD) is a common perineal skin injury caused by
excessive exposure to urine and stool. Perineal wound care for clients with IAD should include
use of pre-moistened soft wipes, gentle cleansing with a mild soap and warm water, application
of a thin layer of a skin-protectant barrier cream and application of an absorbent dressing or pad.
The client should be positioned in a side-lying position to avoid pressure on the buttocks and
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perineum. Toilet tissue should be avoided because it can be abrasive to the injured perineal skin.
The nurse should intervene and advise the CNA to use pre-moistened, soft wipes instead of toilet
tissue.
Concepts tested

Question 1575
The nurse is caring for a client with a large wound. Which meal selection would
be most appropriate to promote wound healing?
A Pasta, broccoli and fat free milk
B Chicken breast, potatoes and gelatin
C Green salad, apple and ice cream
D Turkey, spinach and orange juice

Question Explanation
Correct Answer is D
Rationale: Protein, vitamins A and C and zinc promote wound healing and immune system
functioning. Turkey is a poultry source rich in protein. Spinach is rich in vitamin A. Orange juice
is a source high in vitamin C. Each food choice in this meal meets important requirements for the
client with a large wound in the healing process. Gelatin does not contain any high source of
nutrition. Pasta is high in carbohydrates. Apples are a good source of carbohydrates and fiber.
Concepts tested

Question 1576
The caregiver of an older client with dementia asks the nurse to insert an indwelling urinary
catheter to prevent incontinence-associated dermatitis. What should the nurse do next?
A Obtain an order from the client's health care provider to insert the catheter.
B Explain that the risk of a catheter-associated infection outweighs the benefits.
C Place an incontinence pad or adult diaper on the client.
D Hold the client's next dose of the prescribed diuretic.

Question Explanation
Correct Answer is B
Rationale: Incontinence episodes are not a valid reason for inserting a urinary catheter. The risk
of a catheter-associated urinary tract infection (CAUTI) is too great. The nurse should advocate
for the client by educating the client's caregiver on better alternatives to prevent incontinence-
associated dermatitis (IAD). Interventions to prevent incontinence and IAD include: setting up a
toileting schedule for the client, offering to take the client to the bathroom after administration of
diuretics, applying barrier cream to the perineum and changing soiled or wet undergarments and
clothing promptly. The nurse should not hold the prescribed diuretic or place the client in an
adult diaper since those actions can be construed as dignity issues and will not help prevent IAD.
Concepts tested

Question 1577
The nurse has provided education on feeding techniques to parents of an infant girl with heart
failure (HF). Which statement by the parents indicates a need for additional teaching?

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A "We should feed our baby every 6 to 8 hours."
B "We should feed our baby right after she wakes up."
C "It will take around 30 minutes to feed her for each feeding."
D "We will hold her in a semi-upright position while she eats."

Question Explanation
Correct Answer is A
Rationale: An infant with heart failure (HF) has a higher metabolic rate and greater calorie needs.
The work of feeding increases fatigue caused by poor cardiac function; therefore, it is important
to educate parents and caregivers on feeding techniques that reduce fatigue and promote
adequate food intake. The infant should be fed upon waking and before the infant might start
crying because crying will strain the heart and increase fatigue. Infants with HF should be fed in
a well-supported and semi-upright position, approx. every three hours. A three-hour feeding
schedule requires a lower volume and won't tire out the child.
Concepts tested

Question 1578
The nurse in a pediatrician's office is educating the parents of a school age child about
interventions to help with episodes of bed-wetting. Which statement by the parents indicates that
additional teaching is needed?
A "We will take away his computer access until the bed wetting stops."
B "We will talk to the school about more bathroom breaks."
C "We will buy some cream to help protect his skin."
D "We will make sure to use only non-caffeinated beverages."

Question Explanation
Correct Answer is A
Rationale: Enuresis (bed-wetting) is a common disorder in school-age children. Enuresis can
result from an underlying primary medical condition or from a psychological source. Once a
medical cause has been ruled out, the treatment plan is focused on behavioral modifications to
manage the condition. Punishment should not be used to correct enuresis. Supportive therapy
such as teaching the child to change soiled pajamas and bed linens and restriction of fluid intake
before bedtime should be used instead. Caffeine is a bladder stimulant and should be limited or
avoided all together. Children who have enuresis should be encouraged to use the restroom every
two hours throughout the day and use of a barrier cream helps protect the skin and prevent
rashes.
Concepts tested

Question 1579
The school nurse is planning education for high school students on ways to promote healthy
eating habits. What information should the nurse include in the teaching? Select all that apply.
A Choose drinks that are sugar-free.
B Eat whole grain breads and pastas.
C Don't skip eating breakfast.
D Only eat foods listed as low-fat on the label.

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E Limit eating fast food to three times per week.
F Go for a walk to help manage stress.
G Eat several servings of fruits and vegetables per day.

Question Explanation
Correct Answer is A, B, C, F, G
Rationale: The prevalence of adolescent obesity continues to rise leading to subsequent health
issues such as cardiovascular disease and diabetes. Teaching strategies to promote healthy eating
habits is one way to help reduce adolescent obesity. Eating a second serving of fruits or
vegetables helps achieve the recommended intake of four servings of fruit and five servings of
vegetables per day. People who skip breakfast tend to overeat throughout the day. Eating whole
grains reduces the risk of obesity, cardiovascular disease, and diabetes. Incorporating activities to
manage stress, such as walking, helps reduce stress eating which leads to unhealthy, increased
calorie intake. Drinking sugary beverages greatly increases the intake of unhealthy calories.
Adolescents should not eat low-fat foods because those items are most often high in sugar.
Eating fast food should be limited to no more than once a week.
Concepts tested

Question 1580
The public health nurse is reviewing community data on childhood obesity. The nurse recognizes
which risk factors for childhood obesity and overweight? Select all that apply.
A Limited access to nutrient-dense foods
B Obese or overweight parents
C Child's social engagement with peers
D Lack of physical activity
E Tendency to skip breakfast
F Education level of parents or caregivers

Question Explanation
Correct Answer is A, B, D, E, F
Rationale: The number of overweight and obese children in the United States is significant.
Children in households headed by individuals with less than a high school degree have greater
obesity rates. Parent education also has a significant influence on the prevalence of obesity
among youth. Furthermore, parental obesity increases the risk of the child being overweight by
twofold to threefold. Limited access to nutrient-dense foods and not eating breakfast have also
shown to increase the risk of obesity. The level of social interaction with peers is not known to
increase the risk of childhood obesity.
Concepts tested

Question 1581
The nurse is reinforcing teaching for a client who has a diagnosis of gout. Which foods should be
restricted in the client's diet? Select all that apply
A Vegetables
B Liver
C Shrimp

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D Sardines
E Eggs

Question Explanation
Correct Answer is B, C, D
Rationale: Gout is a systemic disease in which urate crystals deposit in the joints and other body
tissues, causing inflammation. High levels of uric acid in the blood are found in clients who have
gout. Clients with gout should follow a low-purine diet. Purine-rich foods such as organ meats
(liver), shellfish (shrimp), red meat and oily fish with bones (sardines) should be restricted.
Vegetables and dairy, including eggs, do not need to be restricted or limited with gout.
Concepts tested

Question 1582
The nurse is caring for a client who is recovering from a below-knee amputation. Which is
the best way for the nurse to apply the prescribed elastic bandage to the stump?
A Wrap the bandage in a simple spiral manner.
B Wrap the bandage in a chevron manner.
C Wrap the bandage in a triangular manner.
D Wrap the bandage in a figure-eight manner.

Question Explanation
Correct Answer is D
Rationale: An amputation is the removal of part of the body. The limb should be wrapped with
an elastic bandage applied in a figure-eight manner. This approach reduces the risk of cutting off
circulation to the stump area. Although wrapping a bandage in a simple spiral, chevron and
triangular manner are appropriate techniques in other circumstances, they are not recommended
for use on an amputation stump.
Concepts tested

Question 1583
The nurse is caring for an 82-year-old client who reports chronic constipation. Which of the
following actions should the nurse suggest first, to improve bowel function?
A Use laxatives when necessary to treat constipation
B Avoid binding foods such as cheese and chocolate
C Encourage the client to increase activity
E Increase fiber intake to 20-30 g daily

Question Explanation
Correct Answer is E
Rationale: Constipation is a decrease in the frequency of bowel movements accompanied by the
difficult passage of hard, dry stools. Older adults are at high risk for developing constipation.
The incorporation of fiber into the diet is an effective way to promote bowel elimination in the
older adult client. However, clients should be instructed not to add fiber too quickly, because this
can promote gas, bloating and cramping. They should gradually increase fiber in their diets and
be sure to take in adequate hydration concurrently. Clients should increase their daily level of

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activity, as it increases peristalsis. However, increasing activity would not be the first action to
suggest, as it would take longer to work than increasing daily fiber intake. The client should
avoid foods such as cheese as this can lead to constipation. Using laxatives for constipation can
actually increase a clients risk for developing constipation. The overuse of laxatives makes the
intestines less responsive to stimuli.
Concepts tested

Question 1584
The nurse is caring for a client who is diagnosed with emphysema. Which of the following
information should the nurse emphasize to the client, when teaching the client about their
nutritional needs?
A Increase intake of dairy products to soothe the throat
B Use oxygen during meals to improve gas exchange
C Eat foods high in sodium to thin secretions
D Exercise after respiratory therapy to enhance appetite

Question Explanation
Correct Answer is B
Rationale: Malnutrition and muscle wasting is a frequent complication in clients with
emphysema, and affects the disease prognosis. Weight loss in clients with emphysema is a result
of increased energy requirements unbalanced with dietary intake. Breathing requires more effort
in a client with emphysema. Clients should exercise after eating to conserve energy for food
consumption. Resting before meals is recommended. Clients diagnosed with emphysema breathe
easier when using oxygen while eating. Improved gas exchange facilitates the digestion of food,
as more oxygen is available to all areas of the body, including the gastrointestinal tract. Dairy
and other mucous-producing foods should be avoided as they thicken secretions and makes them
more difficult to control and expectorate. Reducing salt intake is recommended, as it leads to
water retention, which makes it more difficult for clients to breathe. However, increased water
intake thins secretions, making them easier to expectorate.
Concepts tested

Question 1585
The nurse is caring for an obese client who says, "I just started a diet and I am eating no more
than 800 calories a day." Which of the following information should the nurse reinforce with the
client?
A Very low-calorie diets are intended for short-term use only
B Very low-calorie diets often have severe and irreversible side effects
C Very low-calorie diets are appropriate for long-term weight management
D Very low-calorie diets are adequate if balanced with fruits and vegetables

Question Explanation
Correct Answer is A
Rationale: A very low-calorie diet (VLCD), less than 1,000 calories a day, is a short-term weight
loss method for obese people (BMI greater than 30) and can result in a loss of about 3 to 5
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pounds (1.36-2.72 kg) per week. Anyone considering this type of diet should be under the care
and supervision of a health care provider (HCP). VLCDs are generally considered safe and
common side effects, such as fatigue, constipation or diarrhea, are usually minor and improve
within a few weeks. The best way to maintain weight loss though, is through a combination of
behavioral therapy, exercise and more modest caloric restrictions of around 1,200 calories per
day. Every diet should contain fruits and vegetables, but those foods are low in calories and
would not make a VLCD more balanced.
Concepts tested

Question 1586
The nurse is assessing a 7-year-old child with acute glomerulonephritis (AGN). The nurse
identifies moderate edema and oliguria and laboratory testing reveal an elevated serum blood
urea nitrogen (BUN) and serum creatinine. Based on the nurse's findings, which of the following
dietary modifications should the nurse make?
A Increase sodium and fluids
B Decrease carbohydrates and fat
C Increase potassium and protein
D Decrease sodium and potassium

Question Explanation
Correct Answer is D
Rationale: Acute glomerulonephritis (AGN) is the inflammation of the glomeruli and nephrons
caused by an immune reaction secondary to a previous infection. Clients with AGN lose protein
and red blood cells through their urine. Individuals with AGN will have a decrease in urine
output due to a decrease in glomerular filtration rate (GFR). As a result, clients with this
condition are at risk for hyperkalemia because potassium is unable to be cleared by the kidneys.
Clients with AGN are at risk for hypertension due to the decrease in urine output and sodium
retention. These clients will also have moderate edema that is secondary to the sodium retention
and decrease in urine output. As a result, this client should be on a diet that limits sodium,
potassium, fluids and protein.
Concepts tested

Question 1587
The nurse is assessing a client who has paraplegia. Which of the following findings would
indicate that the client has a probable fecal impaction?
A Presence of blood in stools
B Oozing liquid stool
C Absence of bowel movements
D Loud continuous flatulence

Question Explanation
Correct Answer is B
Rationale: Clients who suffer from chronic constipation are at risk for developing a fecal
impaction. An impaction is the accumulation of stool in the rectum. The stool can become very
hard and difficult to remove. Fecal impactions occur in clients who are not active. Common
manifestations of a fecal impaction include abdominal pain, nausea, cramping, rectal pain and
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diminished bowel sounds. Findings that are not seen with a fecal impaction include bloody stool,
increased flatulence and absent bowel sounds. When the bowel is impacted with hardened feces,
there is often a seepage of liquid feces around the obstruction. This is often mistaken for
uncontrolled diarrhea. This is a classic finding of fecal impaction.
Concepts tested

Question 1588
The nurse is caring for a client who is experiencing urinary incontinence. Which of the following
teaching points should the nurse reinforce when discussing this health issue with the client?
A Avoid eating foods high in sodium
B Hold voiding or urination
C Restrict fluids
D Avoid taking antihistamines

Question Explanation
Correct Answer is D
Rationale: Urinary incontinence is described as the leakage of urine or involuntary urine loss.
Incontinence can be separated into multiple categories, including stress, urge, overflow or
functional. Avoiding sodium has not been shown to reduce or minimize urinary incontinence.
Due to their anticholinergic action on the urinary sphincter and bladder, antihistamines can cause
urinary retention, followed by sudden overflow incontinence. Still other antihistamines relax the
bladder, which also contributes to incontinence. Clients with incontinence should control fluid
intake and not drink large amounts of fluids at one time, but they should not restrict fluids. If the
bladder becomes over-stretched, the muscle may be permanently damaged and lose its ability to
contract.
Concepts tested

Question 1589
The nurse is discussing the nutritional requirements of an 18-month-old child with the child's
parents. Which of the following statements about milk consumption is correct?
A Can have milk mixed with other foods
B Should be limited to 3-4 cups (.71-.95 L) of milk daily
C May drink as much milk daily as desired
D Will benefit from fat-free cow's milk

Question Explanation
Correct Answer is B
Rationale: Milk is not considered a good source of iron. Milk isn't absorbed well by the body.
Parents should wait until their babies are 12 months old before introducing whole milk into their
diets. Parents need to be sure their babies are getting other sources of iron before starting to drink
milk. Drinking too much milk can lead to iron deficiency anemia. Babies should drink 500 mL to
750 mL of milk each day. More than 32 ounces (946.4 mL) of milk a day considerably limits the
intake of solid foods (that contain iron) with results of a deficiency of dietary iron, as well as
other nutrients. Toddlers need to drink whole milk for healthy brain development. It is
recommended that toddlers 1 to 2 years old drink whole milk. To make sure toddlers get iron
from food sources, parents should offer milk after the child has started to eat their food.
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Concepts tested

Question 1590
The nurse on a pediatric unit is developing a plan of care for a child with a hip spica cast. Which
nursing intervention is the priority?
A Prevent the cast from getting wet
B Encourage deep-breathing exercises
C Monitor the skin at the cast edges
D Use a bedpan to help the child void

Question Explanation
Correct Answer is B
Rationale: The hip spica cast is mainly used for femur fractures in children to immobilize the
affected extremity and trunk. It extends from above the nipple line to the base of the foot and
may include the opposite extremity up to an area above the knee or both extremities. The cast
can interfere with chest expansion, leading to atelectasis and respiratory problems. Therefore,
the priority intervention is to encourage deep-breathing exercises.
Concepts tested

Question 1591
The nurse is caring for a client who recently had surgery. When assisting the client with a clear
liquid diet, the client begins to cough forcefully. Which action should the nurse take first?
A Refer the client for a swallowing assessment
B Order a soft diet for the next meal
C Call the client's family for more information
D Add a thickening agent to the fluids

Question Explanation
Correct Answer is A
Rationale: If the nurse notes a client coughing forcefully after drinking or eating liquids, the first
step would be to contact the health care provider and request a swallow evaluation. The first step
of the nursing process is assessment and further assessment in this situation is necessary.
Coughing on fluids could indicate the client is aspirating which could lead to respiratory distress
or aspiration pneumonia. Thickening fluids may be required, but following the swallow
evaluation from a speech therapist. Calling the client’s family may be required following the
swallow evaluation.
Concepts tested

Question 1592
The nurse is caring for several 70 to 80 year-old clients on bed rest. What is the most important
action to prevent skin breakdown?
A Lubricating the skin with lotion
B Applying heat to reddened areas
C Massaging the skin frequently
D Turning at least every two hours

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Question Explanation
Correct Answer is D
Rationale: Clients who are on bed rest are at risk of many complications. Complications include
pneumonia, constipation, blood clots to the legs, and skin breakdown. To prevent skin
breakdown, the nurse should turn the clients every two hours and assess the skin for any redness
or injury. Repositioning frequently will relieve prolonged pressure on any one area. All the other
options are not the most important to prevent skin breakdown.
Concepts tested

Question 1593
The nurse is teaching parents about dietary needs for a 4-month-old infant with gastroenteritis
and mild dehydration. Which diet would be most appropriate for the infant to rehydrate?
A Milk and ginger ale
B Low sodium broth and tea
C Water and apple juice
D Formula and breast milk

Question Explanation
Correct Answer is D
Rationale: Gastroenteritis, or stomach flu, is inflammation of the lining of the intestines either
caused by bacteria, a virus, or parasites. This can be spread through contaminated food or water
or by contact with an infected person. Symptoms may include watery diarrhea, vomiting,
stomach pain, or fever. The nurse must watch for furthering signs of dehydration; however, this
child just has mild dehydration. The treatment plan would be for the child to continue drinking as
much formula or breast milk as they are able. The other choices would not be the most
appropriate diet for this child’s age.
Concepts tested

Question 1595
The home health nurse is reviewing a new prescription of enteral tube feedings for a client with a
percutaneous endoscopic jejunostomy tube. Which tube feeding method would be best for this
feeding route?
A Continuous infusion over 24 hours
B Use tube for water and medication administration only
C Intermittent infusion for 12 hours on, then 12 hours off
D Bolus feedings 4 times a day

Question Explanation
Correct Answer is A
Rationale: A jejunostomy or percutaneous endoscopic jejunostomy (PEJ) tube is a type of
weighted feeding tube that is percutaneously placed in the stomach and passed into the
duodenum under endoscopic guidance; peristaltic action then advances the tube into the jejunum.
This type of tube tends to decrease the risk for aspiration because gastric pooling is minimized.
Therefore, a continuous feeding method of a constant rate over 24 hours is best. Continuous

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feeding into the jejunum is most similar to normal gastric emptying and reduces the risk for side
effects such as nausea, vomiting and aspiration.
Concepts tested

Question 1596
A school-aged child had a long leg (hip to ankle) plaster cast applied four hours ago. Which
statement from the parent indicates that additional teaching is necessary?
A "I can apply an ice pack over the area to relieve itching inside the cast."
B "My child will be able to stand on the casted leg within 24 hours."
C "The cast should be propped on at least two pillows when my child is lying down."
D "I will keep the cast uncovered for the next day to prevent burning of the skin."

Question Explanation
Correct Answer is B
Rationale: Unlike fiberglass casts, the set up and drying time of plaster casts can take up to 72
hours, especially with a long leg cast. Therefore, the child should not stand until the cast has
dried. Clients may complain of a chill from the wet cast and can be covered with a sheet or
blanket, but the cast should be uncovered for the first 24 hours. Applying ice in an ice bag is a
safe method to relieve the itching. Swelling can be managed by elevating the leg when lying
down.
Concepts tested

Question 1597
The nurse is providing information to a client with diarrhea. Which foods should the client avoid
until the diarrhea has resolved?
A Soda crackers and applesauce
B Cooked cream of wheat
C Raw vegetables and citrus fruits
D Chicken broth and tea

Question Explanation
Correct Answer is C
Rationale: Clients with diarrhea should be advised to eliminate certain foods from their diet that
may worsen their symptoms. Food choices to avoid include dairy products, spicy, fried, or greasy
foods, processed foods, raw vegetables, citrus fruits, and alcohol or any type of caffeinated
drinks. Food choices that are beneficial include cooked cereal like cream of wheat, soda
crackers, applesauce, clear broths, electrolytes, and decaffeinated tea.
Concepts tested

Question 1598
The nurse is preparing to administer an enteral tube feeding to a client via a nasogastric tube.
Prior to administration, which action should the nurse take first?
A Check that the feeding solution matches the dietary order
B Aspirate abdominal contents to determine the residual
C Verify correct placement of the tube

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D Ensure that feeding solution is at room temperature

Question Explanation
Correct Answer is C
Rationale: Before administering enteral feeding or anything else through the nasogastric tube, the
nurse should verify that the tip of the tube is in the stomach to prevent aspiration.
Concepts tested

Question 1599
An adult client is scheduled for a 300 mL bolus of enteral feeding that is scheduled every 4
hours. While preparing to administer the scheduled feeding, the nurse aspirates 100 mL of gastric
residual volume (GRV). Which action should the nurse take?
A Hold the scheduled feeding
B Notify the health care provider
C Flush the tubing with cold water
D Administer the feeding as ordered

Question Explanation
Correct Answer is D
Rationale: Many standing orders state to check residual volume every 4 hours and to only hold
the feeding if the residual is greater than or equal to a specific amount (which may be as high as
400 mL). A GRV of 100 mL is within an acceptable range and the nurse should administer the
feeding as ordered. Also, serial GRV measurements are more important than an isolated
measurement. The health care provider should be notified if the client exhibits other signs of not
tolerating the tube feedings such as gastric distention, diarrhea, and nausea and vomiting. The
tubing should be flushed before and after each use to maintain patency, but with warm water, not
cold water, to prevent cramping.
Concepts tested

Question 1600
The nurse is reviewing the medical record of an older adult client with a history of constipation,
heart failure, renal insufficiency and dehydration. Which medication should the nurse clarify
with the client's health care provider?
A Stool softener daily
B Osmotic laxative as needed
C Glycerine suppository as needed
D Fiber supplement daily

Question Explanation
Correct Answer is B
Rationale: Osmotic laxatives consist of laxative salts (e.g., sodium phosphate, magnesium
hydroxide) that are poorly absorbed salts whose osmotic action draws water into the intestinal
tract. Accumulation of water causes the fecal mass to soften and swell, thereby stretching the
intestinal wall, which stimulates peristalsis. Osmotic laxatives can cause a substantial loss of
water, increasing the risk for dehydration. In clients with renal impairment, osmotic laxative

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made with magnesium can accumulate to toxic levels. Therefore, magnesium salts are
contraindicated in clients with renal insufficiency. Sodium-based osmotic laxatives can cause
acute kidney injury and fluid retention, thus exacerbating heart failure.
Concepts tested

Question 1601
The labor &amp; delivery nurse is caring for a client in active labor.
The client requests for only non-pharmacological pain management.
Which interventions should the nurse include? Select all that apply.
A Lamaze breathing techniques
B Intrauterine pressure catheter
C Aromatherapy
D Amnioinfusion
E Counterpressure

Question Explanation
Correct Answer is A, C, E
Rationale: Nonpharmacologic labor pain management techniques incorporate special attention to
all the senses, using aromatherapy (the sense of smell), relaxing music (for the auditory channel),
and using counterpressure, massage
or effleurage (for the tactile sense). Initiation of breathing techniques to close the "gate" to nerve
stimulation caused by pain is also used. The intrauterine pressure catheter, which provides an
exact measurement of contractions, and amnioinfusion, which involves the infusion of fluid into
the uterus during labor, are unrelated to pain management.
Concepts tested

Question 1602
A client is admitted for placement of a suprapubic catheter. Which statement by the client should
the nurse identify as a misunderstanding of self-care?
A "I will drink lots of fluids to stay well-hydrated."
B "I will rinse the drainage bag with bleach once a week."
C "I will let my health care provider know if my urine looks cloudy."
D "I will change the catheter every month."

Question Explanation
Correct Answer is B
Rationale: A suprapubic catheter is an indwelling urinary catheter that has been surgically placed
to drain urine from the bladder. The client will need to change the catheter approximately once a
month. To help decrease infections, the client should drink plenty of fluids, especially after
changing the catheter. If the client notices a smell or change in color of the urine or the urine is
cloudy, the client should call the health care provider. To clean the drainage bag, the client can
disconnect the bag, swish some warm soapy water around in it and then rinse the bag with a
vinegar solution – never bleach. This can be done every few days or so. This client needs
additional instruction on the proper care of the drainage bag.
Concepts tested

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Question 1603
Which action should the nurse take before communicating with a client diagnosed with
presbycusis?
A Check the client for cerumen impaction.
B Ask for permission to turn off the television.
C Wait until family members have left.
D Request a medical translator.

Question Explanation
Correct Answer is B
Rationale: Presbycusis is a sensorineural type of hearing loss, especially of high-pitched sounds,
that occurs with aging. It is caused by degeneration of cochlear nerve cells, loss of elasticity of
the basilar membrane or a decreased blood supply to the inner ear. When planning to
communicate with a client with presbycusis, it is important to eliminate surrounding noise that
could further interfere with the client's ability to hear and understand the nurse, such as turning
off the television. The other actions are not appropriate for this client.
Concepts tested

Question 1604
The home health nurse is reviewing the plan of care for a client experiencing acute attacks of
Ménière's disease. What is the priority intervention for this client?
A Encourage bland foods and noncarbonated fluids
B Provide assistance with bathing and dressing
C Instruct the client not to drive a motor vehicle
D Communicate clearly and use visual aids

Question Explanation
Correct Answer is C
Rationale: Ménière's disease is a condition affecting the inner ear, resulting in vertigo, tinnitus
(ringing in the ears), and temporary hearing gloss. Vertigo is a sense of whirling or turning in
space. Vertigo can be so intense that, even while lying down, the client has to hold on to
something or lay on the ground to keep from falling. Severe vertigo usually lasts 3 to 4 hours, but
the client may feel dizzy long after the attack. Nausea and vomiting, rapid eye movement
(nystagmus), and severe headaches often accompany vertigo. Although all of the interventions
should be implemented, driving while the client is experiencing these symptoms is dangerous
and could lead to an accident. The priority is for the client not to drive until the attacks have been
completely resolved.
Concepts tested

Question 1605
The nurse is providing discharge teaching for a client with a long leg cast. During instructions,
the nurse should recommend which of these exercises for the affected extremity?
A Aerobic
B Isotonic

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C Range of motion
D Isometric

Question Explanation
Correct Answer is D
Rationale: A nurse should instruct the client on isometric exercises for the muscles of the casted
extremity. This means the client should be instructed to alternately contract and relax muscles
without moving the affected part. The client should also be instructed to do active range of
motion exercises for every joint that is not immobilized at regular and frequent intervals of at
least every four hours. Aerobic and cardiovascular exercises are important for overall health but
the client will likely not be able to participate in these while in a cast.
Concepts tested

Question 1606
The nurse is working on a medical-surgical floor and is performing assessments on the clients.
Which client is at greatest risk for developing a pressure ulcer?
A A 68-year-old with left-sided paresthesia who is incontinent of urine
B A 75-year-old diagnosed with peripheral vascular disease that needs assistance to walk
C A 40-year-old wearing a controlled ankle motion walker following surgical repair of a
ruptured tendon
D A 55-year-old in balanced-skeletal traction for a fractured femur

Question Explanation
Correct Answer is A
Rationale: The Braden Scale is a tool used to determine which clients are at greatest risk for the
development of pressure ulcers. The lower the score, the greater the risk of a pressure ulcer
developing. All of the clients have one area of concern, but only one client has two areas of
concern. The client with paresthesia that is incontinent of urine is at greatest risk, as the
paresthesia may impact the ability to recognize the development of a pressure ulcer on the left
side. Urine incontinence will lead to the skin remaining moist.
Concepts tested

Question 1607
The nurse is evaluating the plan of care for an 11-year-old client with glomerulonephritis. Which
assessment findings would indicate that the client is recovering? Select all that apply.
A Weight gain
B Nutrition maintained
C Edema absent or minimal
D Acute infection absent
E Fine bibasilar crackles
F Protein-free urine

Question Explanation
Correct Answer is B, C, D, F

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Rationale: Glomerulonephritis is an acute inflammation of the kidney typically caused by an
immune response. Many cases are postinfectious and have been associated with pneumococcal,
streptococcal, and viral infections. Common features include oliguria, edema, hypertension and
circulatory congestion, hematuria, and proteinuria. Protein-free urine, no evidence of edema or
an acute infection, and adequate nutritional intake are indicative of the client recovering from
glomerulonephritis. However, crackles in the lungs and weight gain are indicative of ongoing
fluid overload and continued impaired kidney function.
Concepts tested

Question 1608
The nurse is developing a plan of care for a client undergoing chemotherapy. The client tells the
nurse that they would like to try complementary and alternative approaches to help with
chemotherapy-induced nausea and vomiting. Which alternative approaches would be appropriate
to include? Select all that apply.
A Oxygen therapy
B Scopolamine patch
C Meditation
D Massage
E Acupuncture
F Music therapy

Question Explanation
Correct Answer is C, D, E, F
Rationale: Complementary and alternative medicine (CAM) refers to varied medical and health
care practices, systems, and products that are not usually considered part of conventional
Western medicine. Acupuncture, biofeedback, relaxation, music therapy, meditation, massage,
art, music, and dance therapy are some examples of CAM and are appropriate to integrate into
the client's plan of care. Oxygen and scopolamine are considered traditional medical
interventions and medications.
Concepts tested

Question 1609
The nurse is teaching meal planning to the parents of a toddler with anemia. Which meal
provides the maximum amount of iron for the child?
A Chicken nuggets, macaroni, peas, cantaloupe, and milk
B Fish sticks, french fries, banana, cookies, and milk
C Peanut butter and jelly sandwich, apple slices, and milk
D Ground beef patty, lima beans, wheat roll, raisins, and milk

Question Explanation
Correct Answer is D
Rationale: Iron-rich foods include lean red meat, fish, egg yolks, green leafy vegetables,
legumes, whole grains, nuts, and dried fruits, such as raisins. This dinner is the best choice
because it is high in iron and is appropriate for toddlers who need finger foods.

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Concepts tested

Question 1610
The client who is receiving intermittent enteral nutrition through a gastrostomy tube has had four
diarrhea stools in the past 24 hours. Which intervention is appropriate for the nurse to implement
now?Some medications, such as antibiotics or those containing sorbitol may cause diarrhea.
Increasing the amount of water to flush the gastrostomy tube may help to replace fluid lost
through diarrhea, but does not solve the problem. Increasing the infusion rate, may lead to an
increase in gastric peristalsis, leading to more diarrhea. A rectal bag may be needed for skin
protection but does not address the problem.
A Increase the infusion rate when the formula is running
B Review the medications the client is receiving
C Increase the amount of water used to flush the tube
D Attach a rectal bag to protect the skin

Question Explanation
Correct Answer is B
Rationale: Some medications, such as antibiotics or those containing sorbitol, may cause
diarrhea. Increasing the amount of water to flush the gastrostomy tube may help to replace fluid
lost through diarrhea but does not solve the problem. Increasing the infusion rate may lead to an
increase in gastric peristalsis leading to more diarrhea. A rectal bag may be needed for skin
protection but does not address the problem.
Concepts tested

Question 1611
The nurse is caring for a client diagnosed with an exacerbation of rheumatoid arthritis. What is
the priority nursing problem at this time?
Question 9 Answer Choices
A Alteration in comfort
B Self-care deficit
C Risk for injury
D Risk for an alteration in mobility

Question Explanation
Correct Answer is A
Rationale: Rheumatoid arthritis is an inflammatory disorder affecting the joints primarily in the
hands and feet. An exacerbation causes painful swelling that can lead to joint deformity and
debilitation. During an exacerbation, the priority concern is pain. The client may have limited
mobility, but this is an ongoing concern, and if the pain is managed, movement may improve.
The client may have an ongoing problem with independence in completing their ADLs, not just
during an exacerbation. The client is not at an increased risk for injury during an exacerbation.
Concepts tested

Question 1612
A 35-year-old client with sickle cell crisis is talking on the telephone but stops as the nurse
enters the room to request something for pain. The nurse should take which of these actions?
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A Encourage an increased fluid intake
B Administer the prescribed analgesic
C Administer a placebo if possible
D Recommend relaxation exercises for pain control

Question Explanation
Correct Answer is B
Rationale: Pain, especially chronic pain, may be present even without overt signs. Thus, the
nurse is to accept that the client is in pain if the client identifies such. Relief of pain is a priority
expected outcome for treatment of sickle cell crisis. The nurse can encourage relaxation
exercises if it is not time for the prescribed analgesic. Fluids may help reduce the "sickling
process" but do not relieve the immediate pain. A placebo is inappropriate at this time.
Concepts tested

Question 1613
The nurse is consulting with a nutritionist regarding an appropriate diet for a client recently
diagnosed with renal disease. Select the most appropriate diet for the client with renal disease
who is not yet receiving dialysis treatments.
A High carbohydrate, high protein, moderate fat
B High potassium, high phosphorous, low protein
C Restricted protein, low sodium, low phosphorus
D High protein, high fat, high carbohydrate

Question Explanation
Correct Answer is C
Rationale: Dietary modification is important with renal disease. Protein intake should be limited
to decrease nitrogenous waste production (typically, 1 gram of protein per kilogram of body
weight per day is recommended). The client should also follow a sodium, potassium, and
phosphorous-restricted diet. If the client needs dialysis, the amount of protein allowed in the diet
is increased.
Concepts tested

Question 1614
A nurse is teaching parents of a 7-month-old about adding table foods. Which option is an
appropriate finger food?
A Sliced bananas cut vertically
B Whole purple and white grapes
C Hot dog pieces cut in short pieces
D Popcorn with minimal kernels

Question Explanation
Correct Answer is A
Rationale: Finger foods should be bite-size pieces of soft food, such as bananas, at this age. Hot
dogs if cut horizontally and grapes can accidentally be swallowed whole and can occlude the
airway. Popcorn is too difficult to chew at this age and can irritate the airway if swallowed.

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Concepts tested

Question 1615
The nurse is evaluating a client's understanding of appropriate dietary choices with chronic
kidney disease. Which food choices by the client indicate an understanding of the
teaching? Select all that apply.
A Baked chicken
B Fresh apples
C Baked potato
D Unsalted pretzels
E Orange juice
F Slice of cheese

Question Explanation
Correct Answer is A, B, D
Rationale: A client with chronic kidney disease (CKD) must limit intake of potassium, sodium,
phosphorus, and protein. In CKD, the kidneys are unable to adequately excrete these
components. Foods low in potassium include apples, grapes, lettuce, and cauliflower. Foods high
in potassium include bananas, oranges, potatoes, and spinach. Foods low in phosphorus include
chicken, shrimp, crab, and rice. Foods high in phosphorus include organ meats, salmon, scallops,
nuts, and cheese.
Concepts tested

Question 1616
The nurse is developing a plan of care for a client who is on complete bedrest due to a spinal
cord injury. Which intervention is most important for the nurse to include?
A Apply pneumatic compression devices to both legs
B Turn and reposition the client every shift
C Insert an indwelling urinary catheter
D Administer a daily enema

Question Explanation
Correct Answer is A
Rationale: Clients on complete bedrest are at risk for several complications related to immobility,
including venous thromboembolism (VTE). Therefore, it is most important to apply pneumatic
compression devices to the legs. Turning and repositioning should be done at a minimum every
two hours to prevent skin breakdown. Inserting a urinary catheter and routinely administering an
enema should be avoided and only be done if medically indicated.
Concepts tested

Question 1617
A newly admitted client reports gaining 5 pounds (2.27 kg) over the past week despite not being
very hungry. The nurse observes edema in the client's feet and ankles. The nurse identifies which
condition as the most likely explanation for the weight gain?
A Malnutrition

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B Acromegaly
C Congestive heart failure
D Hyperthyroidism

Question Explanation
Correct Answer is C
Rationale: The unexplained rapid weight gain is probably due to fluid retention. Clients who gain
as little as two pounds (0.9 kg) in a week may require hospitalization due to worsening heart
failure. The lack of appetite (or a feeling of being full) and edema are also signs of worsening
heart failure. Hypothyroidism, and not hyperthyroidism, can lead to low body temperature,
which causes fluid retention or bloating. Low protein levels in the blood caused by malnutrition
can cause edema. However, there's not enough information given in the question to know if this
client is malnourished or not. Acromegaly is characterized by overgrowth of body tissues, not
edema, and is caused by excessive secretion of growth hormone.
Concepts tested

Question 1618
The nurse in a pediatrician's office is speaking to the parent of a 2-year-old child who has been
having diarrhea for the past two days. Which intervention should the nurse recommend to the
parent?
A Continue with a regular diet and include oral rehydration fluids
B Offer bananas, apples, rice, and toast as tolerated
C Provide clear liquids and popsicles only for 24 hours
D Offer nothing by mouth for 12 hours then rehydrate with milk

Question Explanation
Correct Answer is A
Rationale: The major goals in the management of acute diarrhea include assessment of fluid and
electrolyte imbalance, rehydration, maintenance fluid therapy, and reintroduction of an adequate
diet. Infants and children with acute diarrhea and at risk for dehydration should be first treated
with oral rehydration therapy (ORT). The evidence-based practice recommends the continued
feeding or early reintroduction of a normal diet after rehydration since no adverse effects have
been found, and a regular diet can actually lessen the severity and duration of the illness. A
BRAT diet (bananas, rice, applesauce, and toast or tea) is no longer recommended for acute
diarrhea because this diet has little nutritional value (low in energy and protein), is high in
carbohydrates, and is low in electrolytes.
Concepts tested

Question 1619
The nurse is assisting with meal planning for a client with cholelithiasis. Which food items
would be most appropriate for this client? Select all that apply.
A Lightly fried chicken legs
B Low-fat dairy products
C Unsalted soups
D Whole grain bread

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E Breakfast cereals

Question Explanation
Correct Answer is B, C, D
Rationale: The most common cause of gallbladder disease is stones that block the biliary ducts.
Other causes are due to inflammation, infection, tumors, or decreased blood flow due to
damaged vessels. Intake of high cholesterol or fatty foods can increase the risk of gallbladder
inflammation. To avoid inflammation, the client should follow a low cholesterol, low-fat diet and
limit their intake of fried and processed foods, such as breakfast cereals, lunch meats, and
microwavable meals.
Concepts tested

Question 1620
A nurse is caring for a client with continuous bladder irrigation (CBI) following a transurethral
resection of the prostate. Which finding would indicate the need for the nurse to increase the
flow of the CBI?
A Temperature of 99.8°F
B Bladder spasms
C Pain at the catheter insertion site
D Blood clots in the catheter tubing

Question Explanation
Correct Answer is D
Rationale: For benign prostatic hyperplasia, transurethral resection of the prostate (TURP) may
be performed. After this surgical procedure, the nurse should be aware of potential
complications, including hemorrhage, urinary retention, and/or infection. After a TURP, CBI
through a three-way catheter is typically initiated to irrigate the bladder of any obstruction, such
as blood clots, and maintain patency of the urethra. Having pink-tinged urine, bladder spasms, a
low-grade fever, and discomfort at the catheter site are common after the procedure, but
increased bleeding and blood clots indicate that the CBI flow is not sufficient and should be
increased. A clogged catheter is a medical emergency, and immediate steps must be taken to
prevent this from happening.
Concepts tested

Question 1621
The nurse is caring for a client with an indwelling urinary catheter. Which of the following
statements is true? Select all that apply.
A The nurse should not allow the tip of the catheter outflow tube to touch the urine collection
container
B The nurse should apply antibiotic ointment to the perineal area.
C The nurse should perform daily catheter care with soap and water.
D The nurse should utilize a clean technique when inserting the urinary catheter.
E The nurse should assure that the urine collection bag is below the level of the bladder

Question Explanation

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Correct Answer is A, C, E
Rationale: A major risk of an indwelling urinary catheter is the development of a catheter-
associated urinary tract infection (CAUTI). To reduce the risk of a CAUTI, nurses should
perform daily catheter care with soap and water and should not allow the tip of the catheter
outflow tube to touch the urine collection container as this can lead to contamination.
Additionally, obstruction of the urine flow can also lead to an increased risk of infection.
Therefore, the nurse should make sure that urine is draining appropriately and that the urine
collection bag is below the level of the bladder so that urine can be eliminated by gravity. The
nurse should not apply antibiotic ointment to the perineal area as this does not reduce the
likelihood of developing a CAUTI and can introduce the potential for contamination. The nurse
should always utilize sterile technique, as opposed to clean technique, when inserting an
indwelling urinary catheter.
Concepts tested

Question 1622
The nurse is providing education about nutrition to the parents of a child with cystic fibrosis. The
nurse should emphasize the increased intake of which foods?
A Low sodium foods
B Sugar-free foods
C High-fat foods
D Dairy-free foods

Question Explanation
Correct Answer is C
Rationale: The child with cystic fibrosis requires a well-balanced diet that is high in calories
(approximately 2,900 to 4,500 calories a day) to help decrease the loss of appetite and weight
loss that are often part of the condition. The other food choices are not appropriate for a child
with cystic fibrosis.
Concepts tested

Question 1623
The nurse is caring for a client who has stomatitis caused by Candida albicans. Which
intervention should the nurse include in the client's plan of care?
A Instruct client to "swish and swallow" the prescribed nystatin solution.
B Remind client to avoid close physical contact with others to prevent transmission.
C Instruct client to refrain from brushing teeth until the infection has resolved.
D Place the client on a full liquid diet for 7 to 10 days.

Question Explanation
Correct Answer is A
Rationale: Stomatitis is a broad term that refers to inflammation within the oral cavity. A
common type of secondary stomatitis is caused by Candida albicans. Candida is sometimes
present in small amounts in the mouth, especially in older adults. Long-term antibiotic therapy
destroys other normal flora and allows the Candida to overgrow. The result can be candidiasis, a
fungal infection that is very painful. Candidiasis is also common in those undergoing
immunosuppressive therapy, such as chemotherapy, radiation and steroids.
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Oral fungal infections are treated with antifungals such as nystatin. The goal of the "swish and
swallow" technique is to expose all of the oral mucosa to the antifungal agent. The client should
continue to perform regular oral care, including brushing teeth. Oral candidiasis is not a
transmittable disease and does not require the client to consume only liquids.
Concepts tested

Question 1624
The nurse is performing an admission assessment on an older adult male client who reports
frequent episodes of constipation. Which initial information should the nurse obtain?
A Elimination pattern over the past week
B Family history
C Trends in weight gain or loss
D Health history and client's diet.

Question Explanation
Correct Answer is D
Rationale: Initially, the nurse should obtain the client's health history, noting risk factors,
comorbid conditions, and medications that can contribute to constipation. The nurse should also
assess the client's diet, including fiber intake. Then the nurse should determine what the client's
elimination pattern has been.
Concepts tested

Question 1625
The nurse is teaching a pregnant woman who follows a vegetarian diet about prevention of iron-
deficiency anemia. Which food selection indicates that the woman understood the teaching?
A Whitefish with potatoes
B Whole grain bread with butter
C Scrambled eggs with cheese
D Cereal with dried fruits

Question Explanation
Correct Answer is D
Rationale: Iron is found in both plant and animal sources. Heme iron, found in animal sources of
meat, fish, and poultry, is more easily absorbed than nonheme iron found in plant foods. Animal
sources of iron also contain nonheme iron in addition to heme iron. Although egg yolks contain
iron, the iron in them is not absorbed as well as other heme from other sources. Nonheme iron
plant sources include vegetables, legumes, dried fruits, whole-grain cereals, and enriched grain
products, especially iron-fortified dry cereals. For this client (vegetarian), cereals with dried
fruits represent a food selection as a good source of iron.
Concepts tested

Question 1626
The nurse is teaching a client diagnosed with type 2 diabetes mellitus about the prescribed diet.
Which instructions should the nurse include?
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A Keep a regular schedule of meals and snacks.
B Reduce carbohydrate intake to 25% of total calories.
C Maintain previous calorie intake but add more protein.
D Have something sweet available at all times for hypoglycemic episodes.

Question Explanation
Correct Answer is A
Rationale: Currently, calorie-controlled diets with strict meal plans are rarely suggested for
clients diagnosed with type 2 diabetes mellitus. The proper approach to eating is an incorporation
of a schedule with food changes into clients' existing dietary patterns. Client's should learn to
read labels and identify specific canned foods, frozen entrees, or other foods that are acceptable.
Many clients can manage type 2 diabetes mellitus with diet and exercise, eliminating the need for
insulin therapy and the risk of hypoglycemia.
Concepts tested

Question 1627
An 82-year-old male client is admitted with benign prostatic hyperplasia (BPH). Which finding
by the nurse will require immediate action?
A Severe abdominal pain
B A heart rate of 110 bpm
C A blood pressure of 180/105
D A bladder ultrasound value of 900 mL

Question Explanation
Correct Answer is D
Rationale: Complications of BPH include acute urinary retention. Urinary retention is the
accumulation of urine in the bladder due to bladder outlet obstruction caused by the enlarged
prostate gland. Acute urinary retention is a medical emergency that requires prompt bladder
drainage.

The elevated heart rate and blood pressure and the severe abdominal pain are signs and
symptoms of the acute retention. They will most likely resolve when the retention is resolved.
The high bladder scan/ultrasound value confirms the retention of a large volume of urine that
will require catheterization.
Concepts tested

Question 1628
The nurse is developing a plan of care for a client who is on complete bed rest due to an unstable
spinal cord injury at the T-7 level. Which intervention is the priority?
A Increase fluid intake to 3 to 4 liters per day
B Monitor the client for constipation
C Place the client on a pressure-reducing mattress
D Assist the client with eating as needed

Question Explanation

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Correct Answer is C
Rationale: The priority intervention shall focus on maintaining skin integrity because this client
is at high risk for skin breakdown related to prolonged immobility and decreased sensation below
the level of injury. The initial approach should be the selection and then placement of the client
on the best support surface or mattress for the relief of pressure, shear and friction forces.
Concepts tested

Question 1629
The nurse is calculating the end-of-shift intake and output balance for a male client with
continuous bladder irrigation. During the shift, the client's intake consisted of 2 liters of
irrigation fluid, 1,400 mL of oral fluids, 400 mL of maintenance IV fluids and a 250 mL
antibiotic piggyback. The client's output for the shift consisted of a small emesis of 100 mL and
urine output of 3,800 mL total. What is the end-of-shift intake/output (I/O) balance?
A 150
B 100
C 250
D 200

Question Explanation
Correct Answer is A
Step 1: Add all intake: 2 liters or
Step 2: Add all output:
Step 3: Subtract output total from input total: [positive] I/O balance
Concepts tested

Question 1630
The nurse is teaching the parents of a 3-month-old infant about nutrition. During this time in
infancy, the most ideal source of nutrition should come from which source?
A Infant cereal
B Breast milk
C Commercial formula
D Whole milk

Question Explanation
Correct Answer is B
Rationale: Human milk is the most desirable complete diet for the infant during the first 6
months. An acceptable alternative to breastfeeding is commercial iron-fortified formula. Whole
cow's milk, low-fat cow's milk, skim milk, other animal milks are not acceptable as a major
source of nutrition for infants because of their limited digestibility, increased risk of
contamination, and lack of components needed for appropriate growth. Whole milk can cause
iron deficiency anemia in infants, possibly as a result of occult gastrointestinal blood loss.
Pasteurized whole cow's milk is deficient in iron, zinc, and vitamin C and has a high renal solute
load, which makes it undesirable for infants less than 12 months of age. The addition of solid
foods before 4 to 6 months of age is not recommended.
Concepts tested
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Question 1631
The community health nurse is preparing to teach a group of new parents about infant nutrition.
Which information should the nurse include?
A Give a gummy multivitamin once a day
B Add egg whites early to increase protein intake
C Mix infant cereal with 2% or skim milk
D Introduce solid foods one at a time, beginning with cereal

Question Explanation
Correct Answer is D
Solid foods should be added, one at a time, between 4 to 6 months. If the infant is able to tolerate
the food, another is then added each week. Iron-fortified cereal is the recommended first food;
rice cereal is recommended due to the low risk of food allergies. Teach parents to mix the cereal
flakes with either breast milk or formula, not cow's milk. After the baby is eating cereal, pureed
meat, vegetables and fruits can be introduced. Egg whites and wheat products should not be
given before the baby is at least a year old because these foods are more commonly associated
with allergies. Supplemental vitamins are generally not needed, as long as the child is receiving a
well-balanced diet.
Concepts tested

Question 1632
The nurse in a urology office is developing a plan of care for a client newly diagnosed with urge
urinary incontinence due to an overactive bladder. Which interventions should the nurse
include? Select all that apply.
A Avoidance of caffeinated beverages
B Surgical sphincterotomy
C Protection of skin integrity
D Pelvic floor muscle exercises
E Administration of anticholinergic drugs

Question Explanation
Correct Answer is A, C, D, E
Rationale: Incontinence is an involuntary loss of urine severe enough to cause social or hygienic
problems. It is not a normal consequence of aging or childbirth and can have several possible
causes and can be either temporary or chronic. Urge incontinence is often referred to as
overactive bladder (OAB). Nocturnal frequency and incontinence are common with OAB.
Interventions for urge incontinence or overactive bladder (OAB) are nonsurgical and include
pelvic muscle exercises (Kegel exercises), use of absorbent products and undergarments,
avoiding bladder irritants in the diet such as caffeine, and treatment with drugs that relax the
smooth muscle and increase the bladder's capacity including anticholinergics.
Concepts tested

Question 1633

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The nurse is caring for an 85-year-old client in the clinic who reports generalized muscle aches
and pains. Which action should the nurse take next?
A Request an order for a nonsteroidal anti-inflammatory drug
B Reassure the client that this is not unusual for their age
C Encourage the client to gradually increase daily activity
D Assess the severity and location of the pain

Question Explanation
Correct Answer is D
Most older adults have one or more chronic painful illnesses, and in fact, they often must be
asked about discomfort (rather than "pain") to reveal the presence of pain. There is no evidence
that pain of older adults is less intense than in younger adults. It is important for the nurse to
assess the pain thoroughly before the implementation of pain relief measures or
recommendations. The nurse should also be sure to ask clients about any drugs they are taking
(OTC, prescribed and herbal); certain medications, such as the statins, can cause muscle aches in
the legs.
Concepts tested

Question 1634
The nurse is caring for a client who has cystic fibrosis. The nurse would expect the client to be
prescribed which type of diet?
A Sodium-restricted
B High fat, high-calorie
C Dairy-free
D Gluten-free, low fiber

Question Explanation
Correct Answer is B
Rationale: Cystic Fibrosis (CF) affects the cells that produce mucus, sweat and digestive juices.
Clients with CF need a high-energy diet that includes high-fat and high-calorie foods, extra fiber
to prevent intestinal blockage, and extra salt (especially during hot weather). Clients with CF are
at risk for osteoporosis and need good intake of calcium and dairy products. There are no
recommended gluten restrictions for clients with CF.
Concepts tested

Question 1635
The nurse is assessing a 4-year-old child who is in skeletal traction 24 hours after surgical repair
of a fractured femur. The child is crying and appears to be having severe pain. The foot on the
affected extremity is pale, cool to touch and the pulse is barely palpable. What action should the
nurse take?
A Administer the ordered PRN pain medications.
B Reassess the affected extremity in 15 minutes.
C Readjust the traction for comfort.
D Notify the primary health care provider.

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Question Explanation
Correct Answer is D
Rationale: The pain and absence of a pulse suggests compartment syndrome. This condition
occurs when there is a buildup of pressure within the muscles. This pressure decreases blood
flow and can cause muscle, tissue, and nerve damage. Compartment syndrome is a medical
emergency. Delaying treatment can lead to permanent damage to the extremity. Therefore, the
nurse should contact the primary health care provider (HCP) immediately.
Concepts tested

Question 1636
The nurse is teaching a client who has coronary artery disease about nutrition. What information
should the nurse include?
A Avoid large and heavy meals.
B Do not exceed 40 grams of carbohydrates a day.
C Eat foods rich in vitamin K.
D Limit sodium intake to 7 g per day.

Question Explanation
Correct Answer is A
Rationale: Eating large, heavy meals can pull blood away from the heart to aid in the digestion
process. This may result in angina for clients with coronary artery disease (CAD). This is
important information to emphasize to the client with CAD. The other modifications are not
appropriate or required with CAD.
Concepts tested

Question 1637
The nurse is caring for a client with a nasogastric tube and is preparing to administer an enteral
feeding through the tube. Which is the best method to confirm correct tube placement prior to
beginning the feeding?
A Place the end of the tube in water to check for air bubbles.
B Measure the length of tubing from nose to epigastrium.
C Auscultate the abdomen while instilling 10 mL of air into the tube.
D Check the pH level of the aspirated contents.

Question Explanation
Correct Answer is D
Rationale: Once the initial placement of the tube has been confirmed by X-ray, the nurse should
check the pH of the aspirated contents before administering medications or enteral feeding
solutions. A properly placed nasogastric tube will contain aspirate with an acidic pH. This is
the best method for the nurse to check the tube placement. If tube placement is in doubt, an order
for an X-ray should be obtained.
Concepts tested

Question 1638

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The nurse is caring for a client on a medical-surgical unit who reports difficulty falling asleep
and sleeping through the night. The nurse should implement which interventions to promote
sleep? Select all that apply.
A Encouraging client to watch television before bedtime
B Avoiding intake of caffeine products after 4:00 pm
C Administering the prescribed diuretic in the
D Assisting client with deep breathing exercises before bedtime
E Administering a prescribed PRN sleep aid
Question Explanation
Correct Answer is B, C, D, E
Rationale: Effective interventions for falling asleep and sleeping through the night can include
the administration of a PRN sleep aid as a pharmacological intervention and deep breathing
exercises before bed as a non-pharmacological intervention to promote relaxation and
subsequent sleep. Limiting caffeine intake in the evening may also promote sleep.
Administration of diuretics close to bedtime should be avoided as the client may awaken during
the night to void when given later in the day. Watching television or computer screens before
bedtime can disrupt the sleep cycle, as blue light is known to impair circadian rhythms.
Concepts tested

Question 1639
An 80-year-old client arrives in the emergency room after a fall at home. The client has several
large skin abrasions. Which action should the nurse perform first?
A Document findings of alterations in the skin's integrity.
B Perform a head-to-toe assessment.
C Verify if the client has advance directives in place.
D Clean and apply an appropriate dressing to the abrasions.

Question Explanation
Correct Answer is B
Rationale: The nurse should first perform a head-to-toe assessment to see if other body systems
were affected by the fall. After that initial assessment, the nurse should perform the other actions.
The nurse would then document information collected during the assessment, such as any
injuries.
Concepts tested

Question 1640
A 15-year-old client has been placed in a cervico-thoraco-lumbo-sacral orthosis or CTLSO
brace. Which statement by the client indicates a need for additional teaching?
A "I can take the brace off when I shower or take a bath."
B "I will only have to wear this brace for 6 months."
C "I should inspect my skin under the brace every day."
D "The brace has to be worn all day and night."

Question Explanation
Correct Answer is B

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Rationale: The Milwaukee brace, also known as a cervico-thoraco-lumbo-sacral orthosis or
CTLSO, is a back brace used in the treatment of spinal curvatures such as scoliosis or kyphosis
in children. It is a full-torso brace that extends from the pelvis to the base of the skull.The brace
must be worn long-term, during periods of growth, usually for 1 to 2 years. The client's statement
about only having to wear it for 6 months is incorrect and indicates a need for additional
teaching. The other statements indicate a correct understanding.
Concepts tested

Question 1641
A 3-year-old client has just returned from surgery for application of a hip spica cast. Which
nursing action should the nurse implement?
A Apply waterproof plastic tape to the cast around the genital area.
B Use the crossbar to help turn the child from side to side.
C Position the child flat in the bed and reposition from supine to prone every 2-4 hours.
D Drying the cast using a hair dryer set to "warm".

Question Explanation
Correct Answer is A
Rationale: The most important aspects of caring for the cast is to keep it clean and dry. Shortly
after returning from surgery, waterproof plastic tape should be applied around the genital area to
prevent soiling of the cast. The child should be turned every 2 hours to help facilitate drying,
from side to side and front to back, with the head elevated at all times. If a crossbar is used to
stabilize the legs, it should not be used to turn the child (it may break off). After the cast has
completely dried, if it becomes damp, it can be either exposed to air or a hairdryer (set to cool)
can be used to help dry the cast.
Concepts tested

Question 1642
The nurse is preparing to administer a feeding through a percutaneous endoscopic gastrostomy
tube. What nursing action is needed before starting the feeding? Select all that apply.
A Keep the feeding product refrigerated until ready to use
B Palpate the abdomen
C Verify the length and placement of the tube
D Flush the tube with 30 mL of warm water
E Elevate the head of the bed 30 to 45 degrees
F Milk or massage the tube

Question Explanation
Correct Answer is C, D, E
Rationale: Prior to starting every feeding, the nurse should verify the length and placement of
the percutaneous endoscopic gastrostomy (PEG) tube, flush the tube with 30 mL of warm (not
hot and not cold) water, and elevate the head of the client's bed at least 30°. The nurse should
also verify the presence of bowel sounds before starting the feeding. There is no need to milk the

Page | 673
tube unless it is obstructed. Feeding products should be brought to room temperature before
administration to prevent gastrointestinal discomfort.
Concepts tested

Question 1643
A new nurse is asking about stoma care for a client with a new ostomy. Which type of ostomy
poses the highest risk for skin breakdown?
A Transverse colostomy
B Ileostomy
C Ileal conduit
D Sigmoid colostomy

Question Explanation
Correct Answer is B
Rationale: Ileostomy output, which is from the small intestine, is of a continuous, liquid nature.
This output contains gastric and enzymatic agents that when present on skin can denude the skin
in a few hours. Because of the caustic nature of this stoma output, adequate peristomal skin
protection must be delivered to prevent skin breakdown. With a transverse colostomy the stool is
of a somewhat mushy and soft nature. With a sigmoid colostomy the output is formed with an
intermittent output. An ileal conduit is a urinary diversion with the ureters being brought out to
the abdominal wall.
Concepts tested

Question 1644
The nurse is teaching a 65-year-old female client who is newly diagnosed with osteoporosis.
Which type of exercise is best for this client?
A "Start a weight loss program to reduce your weight."
B "Go running 3 to 5 times per week."
C "Do weight-bearing exercise or resistance activities."
D "Do yoga to strengthen muscles and protect bones."

Question Explanation
Correct Answer is C
Rationale: Weight-bearing or resistance exercises are best in the treatment of osteoporosis.
Although loss of bone cannot be substantially reversed, further loss can be greatly reduced if the
client includes these exercises. Placing weight on bones against gravity helps to promote
ossification. Running should be avoided because it can place too much stress on the bone and
cause stress fractures. Weight loss might be indicated for osteoarthritis. Although yoga can help
with balance and muscle strengthening, it does not directly benefit osteoporosis.
Concepts tested

Question 1645
The nurse is conducting a teaching session to new nurses about the principles of pain
management. Which principle is most important when assessing a client's pain level?
A Cultural sensitivity is fundamental to pain management.

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B The client's self-report is their actual pain level.
C Nurses should not prejudge a client's pain using their own values.
D Clients have the right to have their pain relieved.

Question Explanation
Correct Answer is B
Rationale: Pain is a complex phenomenon that is perceived differently by each individual. Pain is
whatever the client says it is. The other statements are correct but the most
important consideration when assessing a client's pain is their self-report.
Concepts tested

Question 1646
A community health nurse is speaking to a group of community members about alternative
therapies. What is the focus of chiropractic treatment?
A Exercise of the joints
B Spinal column manipulation
C Mind-body balance
D Electrical energy fields

Question Explanation
Correct Answer is B
Rationale: The theory underlying chiropractic treatment is that interference with transmission of
mental impulses between the brain and body organs produces diseases. Such interference is
caused by misalignment of the vertebrae. Manipulation reduces the misalignment (subluxation).
Concepts tested

Question 1647
The nurse is caring for a toddler who is diagnosed with an infection and whose temperature is
103°F (39.4°C). Which intervention would be most effective in lowering the child's temperature
and promoting comfort?
A Immerse the child in a tub containing cool water.
B Give a tepid sponge bath prior to giving an antipyretic medication.
C Administer the prescribed antipyretic medication.
D Apply extra layers of clothing to prevent shivering.

Question Explanation
Correct Answer is C
Rationale: A fever is not a primary illness. It is a physiologic mechanism the body uses to fight
an infection. Although tepid sponge baths can lower the body temperature, they can distress
febrile children (as evidenced by crying, shivering and goosebumps). Antipyretics can not only
reduce the fever in the child, but they can also improve comfort and decrease irritability.
Concepts tested

Question 1648

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The nurse is evaluating the plan of care for a client who has been requesting a daily laxative to
aid in having a bowel movement. What additional interventions should the nurse include in the
client's plan of care? Select all that apply.
A Request a prescription for psyllium.
B Encourage the client to drink 2 to 3 liters of fluids a day.
C Encourage the client to drink more caffeinated beverages.
D Instruct the client to walk at least 30 minutes 3 to 5 times per week.

Question Explanation
Correct Answer is A, B, D
Rationale: Some clients believe that they are constipated if they do not have a daily bowel
movement. This misconception can lead to laxative abuse, causing cathartic colon syndrome, a
condition where the colon becomes dilated and atonic (absence of muscle tone). Clients with that
condition cannot defecate without the help of a laxative. The nurse should provide additional
education (or reinforce education) about interventions to prevent constipation, such as increased
intake of dietary fiber and fluids, regular exercise, establishing a regular time to defecate and
avoiding delaying defecation and using laxatives. Daily bulk-forming laxatives such as psyllium
work like dietary fiber and do not cause dependence. Caffeine should be avoided because it will
increase urination, which in turn will reduce fluid volume and harden the stool.
Concepts tested

Question 1649
Following a surgical procedure, pneumatic compression devices are applied to both lower
extremities of an adult client. The client reports that the device is hot and the client is sweating
and itching. Which steps should the nurse take? Select all that apply.
A Confirm pressure setting of 45 mm Hg
B Check for appropriate fit
C Explain that the primary health care provider ordered the device and it cannot be removed
D Collaborate with the primary health care provider for anti-embolism stockings to be worn
under the sleeves of the device.

Question Explanation
Correct Answer is A, B, D
Rationale: In any situation in which a client has discomfort associated with a medical device, the
nurse should ensure it is applied correctly and functioning safely. The usual safe and effective
pressure range is 35-55 mmHg. Explanations to the clients should support their informed
decision-making capabilities and should not be phrased to intimidate or remove client autonomy.
Applying anti-embolism stockings under the disposable sleeves of the device may help with the
sweating and itching.
Concepts tested

Question 1650
The nurse is planning care for a 12-year-old child diagnosed with sickle cell disease who is in a
vaso-occlusive crisis of the elbow. Which intervention should be included in the plan of care?
A Cold compresses to elbow

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B Pain management
C Fluid restriction
D Passive range of motion exercise

Question Explanation
Correct Answer is B
Rationale: Management of a sickle cell crisis is directed towards supportive and symptomatic
treatment. The priority of care is pain relief. In a 12-year-old child, patient-controlled analgesia
promotes maximum comfort. Fluids are usually increased and range of motion exercises are
avoided in the acute phase of the crisis. Cold is avoided because it constricts the vessels and may
result in increased pain.
Concepts tested

Question 1651
The nurse is teaching the client about dietary changes needed to manage Addison's disease.
Which statement by the client indicates that teaching has been effective?
A "I will increase sodium, potassium and fluids."
B "I will increase sodium and fluids and restrict potassium."
C "I will increase fluids and restrict sodium and potassium."
D "I will increase potassium and sodium and restrict fluids."

Question Explanation
Correct Answer is B
Rationale: The manifestations of Addison's disease (also called adrenal insufficiency or
hypocortisolism) are due to mineralocorticoid deficiency that results in renal sodium wasting and
potassium retention. Other findings are dehydration, hypotension, hyponatremia, hyperkalemia
and metabolic acidosis.
Concepts tested

Question 1652
The nurse is reviewing the nutrition needs for a child diagnosed with cystic fibrosis. The nurse
anticipates that the client is at risk for which vitamin deficiencies?
A B12, D and K
B A, C and D
C A, B1 and C
D A, D and K

Question Explanation
Correct Answer is D
Rationale: The uptake of fat-soluble vitamins, A, D and K, is decreased in children with cystic
fibrosis. Vitamin B12 is deficient in clients who have had bariatric surgery or various degrees of a
gastrectomy. Vitamin B1 is often deficient in clients who have an alcohol addiction. These clients
are given thiamine (B1) injections three time daily to prevent Korsakoff syndrome. Vitamin D
may be deficient in people who do not get at least 10 to 15 minutes of sunlight on the arms each
day. Vitamin C deficit is associated with less than the needed intake of foods with vitamin C.

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Concepts tested

Question 1653
A client is admitted directly from surgery in skeletal traction for a fractured femur. Which
nursing intervention is priority?
A Inspect the pin sites for evidence of drainage or inflammation
B Perform frequent neurovascular assessments of the affected leg
C Apply an overhead trapeze to assist with movement in bed
D Maintain proper body alignment

Question Explanation
Correct Answer is B
Rationale: The priority postoperative action is to assess the neurovascular status of the leg after
a fracture. Nursing management of a client in skeletal traction also includes assessing and caring
for pin sites, and educating the client and family about skeletal traction. The overhead trapeze
helps the client move in bed and proper body alignment is important, but these are not the
priority.
Concepts tested

Question 1654
The community nurse is teaching a group of older adults about healthy nutrition. Which general
recommendation should the nurse include?
A Add high protein supplements to your diet
B Follow the D.A.S.H. eating plan
C Increase intake of foods fortified with iron
D Make at least half your grains whole grain

Question Explanation
Correct Answer is D
Rationale: Anyone, regardless of age, should eat a balanced diet of nutrient-dense foods.
However, the diet of the older adult without other chronic health issues should include a general
increase of fiber and whole grains to prevent such age-related problems as constipation. The
other diet recommendations are more specific to certain chronic diseases.
Concepts tested

Question 1655
A premature newborn is to be fed breast milk through a nasogastric tube. The nurse knows that
breast milk is preferred to formula in premature infants for which reason?
A Breast milk contains less lactose
B Breast milk provides antibodies
C Breast milk is higher in calories/ounce
D Breast milk has less fatty acids

Question Explanation

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Correct Answer is B
Rationale: Breast milk is ideal for the preterm baby who needs additional protection against
infection through maternal antibodies. It is also much easier to digest. Therefore, less residual is
left in the infant's stomach.
Concepts tested

Question 1656
The nurse is caring for a client admitted with a diagnosis of Meniere's disease. When teaching
the client about the disease, the nurse should explain that the client should avoid foods high in
which substance?
A Fiber
B Calcium
C Sodium
D Carbohydrates

Question Explanation
Correct Answer is C
Rationale: The client with Meniere's disease has an alteration in the balance of the fluid in the
inner ear (endolymph). A low-sodium diet will aid in reduction of the fluid. Sodium restriction is
commonly ordered as adjunct to diuretic therapy in the acute and chronic treatment.
Concepts tested

Question 1657
The client has just had an enteral feeding tube inserted. What would be the most accurate method
to verify initial placement of the feeding tube?
A Flushing tube with saline
B Abdominal x-ray
C Auscultation with air insertion
D Aspiration for gastric contents

Question Explanation
Correct Answer is B
Rationale: The most objective and recommended approach to confirm correct placement after
feeding tube insertion is radiography. This will determine if the tube is in the duodenum or
jejunum and not in the airways of the lungs. After initial placement has been confirmed, the
nurse can verify placement by checking the pH of the aspirated gastric contents. Aspirates of pH
5.5 or below will indicate correct placement in most clients. The "whoosh test," or auscultation
with air injection, is no longer recommended and should not be used.
Concepts tested

Question 1658
The nurse has been teaching a client diagnosed with heart failure about proper nutrition. Which
of these lunch selections indicates that the client has learned about sodium restriction?
A Cheese sandwich with a glass of 2% milk
B Sliced turkey sandwich with a side of canned pineapple

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C Cheeseburger and baked potato with butter
D Mushroom pizza and ice cream made from whole milk

Question Explanation
Correct Answer is B
Rationale: Sliced turkey sandwich is appropriate because it is not a highly processed food and
canned fruits are low in sodium. All of the other choices contain one or more high-sodium foods.
Concepts tested

Question 1659
A nurse is teaching parents of an infant about the introduction of solid food to their baby. What
is the first food that the nurse should teach the parents to add?
A Cereal
B Fruit
C Vegetables
D Meats

Question Explanation
Correct Answer is A
Rationale: Cereal is usually introduced first because it is well-tolerated, easy to digest and
fortified with iron. Then the meats or vegetables are introduced. The fruit is sweeter and often is
recommended to be introduced last because of this; infants often like fruit the best.
Concepts tested

Question 1660
The nurse is discussing dietary intake with an adolescent who has acne. What is
the most appropriate statement by the nurse?
A "Good nutritional habits promote healthy skin."
B "Decrease fatty foods from your diet."
C "Do not use caffeine in any form, including chocolate."
D "Increase your intake of protein and vitamin A."

Question Explanation
Correct Answer is A
Rationale: The exact cause of acne is not known, but genetics and hormones (androgens) play a
role. Stress, picking or squeezing blemishes and harsh scrubbing can make acne worse. While
poor nutrition may make acne-prone teens more susceptible to breakouts, chocolate or greasy
foods don't cause acne. Vitamin A helps regulate the skin cycle, but too much can lead to toxic
side effects. Teens should simply eat an age-appropriate, well-balanced diet.
Concepts tested

Question 1661

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The nurse is teaching the mother of a 5-month-old child about nutritional recommendations for
the chid. Which statement made by the mother indicates the need for additional teaching?
A "I dip the pacifier in honey so it is better taken."
B "I'm going to try feeding my baby some rice cereal this week."
C "I keep formula made up ahead of time in the refrigerator for 24 hours."
D "When the baby wakes at night for a bottle, I give a feeding."

Question Explanation
Correct Answer is A
Rationale: The use of honey has been associated with infant botulism and should be avoided
until after one year of age. Botulism affects the nervous system and often results in permanent
damage. Older children and adults have digestive enzymes that kill the botulism spores.
Concepts tested

Question 1662
The nurse is teaching a parent about the prevention of diaper dermatitis. Which of the statements
by the parent indicates understanding?
A "I will change the diaper every 2-3 hours during the day."
B "Diaper dermatitis is associated with chronic itching."
C "If a rash occurs, I will put oil on the skin before putting the diaper on."
D "I will use rubber pants to assist with toilet training."

Question Explanation
Correct Answer is A
Rationale: Diaper dermatitis is an inflammatory reaction of the skin that is covered by a diaper.
This inflammatory response is related to exposure to urine and feces. Prevention is the best
management of diaper dermatitis and includes frequent diaper changes and changing feces soiled
diapers as soon as possible. Atopic dermatitis is associated with chronic itching. Rubber pants
should not be used as they increase the risk of diaper dermatitis. If a rash does occur, the parents
should be instructed to allow the child to go diaper-less for a period of time during the day.
Creams are available but oils will increase the moisture on the skin.
Concepts tested

Question 1663
A nurse is providing care to a female client who is 32-weeks pregnant. The client has been
diagnosed with hypertension and will begin prescribed pharmacological treatment. The nurse
will clarify which medication if observed in the client’s record?
A Spironolactone
B Methyldopa
C Lisinopril
D Hydralazine

Question Explanation
Correct Answer is C

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Rationale: Lisinopril is an angiotensin-converting enzyme (ACE) inhibitor used in the treatment
of hypertension. ACE inhibitors are pregnancy risk category D and are contraindicated during
the second and third trimesters of pregnancy. Spironolactone and methyldopa are pregnancy risk
category B and have been used routinely and safely during pregnancy. Hydralazine is a
pregnancy risk category C, but its use has been proven to be safe during pregnancy.
Concepts tested

Question 1664
A nurse is preparing to administer plasma to a client with a coagulation disorder. Which
identification step will the nurse verify prior to initiating the transfusion?
A Cross match
B Expiration date
C ABO compatibility
D Hemoglobin level

Question Explanation
Correct Answer is C
Rationale: Plasma is a blood product that needs to be typed prior to administration to avoid a
reaction. Typing determines if the blood product is compatible with the client’s blood type. A
cross match for antigens is only required for transfusions containing red blood cells. The
expiration date is an important component to check prior to administration. However, this does
not identify the client. Plasma does not contain red blood cells, so checking the hemoglobin level
is not indicated and does not identify the client.
Concepts tested

Question 1665
The nurse is preparing to administer newly prescribed intravenous phenytoin to a client. When
reviewing the client’s medical record, which prescription should the nurse question?
A Continuous infusion of dextrose 5% in 0.9% saline
B NPH insulin 40 units before meals
C Labetalol 100 mg orally twice per day
D Ketorolac 15 mg IV push as needed for pain

Question Explanation
Correct Answer is A
Rationale: Phenytoin is not compatible with most IV fluids, especially those with dextrose. If the
nurse observes a continuous infusion of a fluid that contains dextrose, they should understand
that incompatibilities are likely and should not administer the medication as prescribed. Insulin,
labetalol, and ketorolac do not have potential incompatibilities.
Concepts tested

Question 1666
The nurse is assisting a client who is taking amlodipine with meal planning. Which fluid selected
by the client would require follow up by the nurse?
A Black coffee

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B Grapefruit juice
C Green tea
D Chocolate Milk

Question Explanation
Correct Answer is B
Rationale: Grapefruit juice affects the metabolism of certain medications, such as amlodipine,
and may cause toxicity if taken together. Clients who are taking antibiotics, such as tetracycline,
should avoid consuming milk products. Clients who are taking warfarin should avoid consuming
green tea. Clients who are taking stimulants should avoid consuming black coffee.
Concepts tested

Question 1667
The nurse is providing teaching to the client taking metoclopramide. Serious side effects that
should be reported to the provider are included in the teaching plan. Which of the following side
effects is the priority?
A Involuntary muscle movements
B Report of increased fatigue
C Onset of headaches
D Difficulty with sleep

Question Explanation
Correct Answer is A
Rationale: Metoclopramide is a GI stimulant that is effective in reducing headache, nausea, and
vomiting. Metoclopramide can cause a serious movement disorder called tardive dyskinesia
(TD). This condition is often irreversible. TD is characterized by involuntary movements of the
face, tongue, or extremities. The risk of developing TD is increased with longer treatment and
increased dosage. To help prevent TD, this drug shouldn’t be used for longer than 12 weeks. The
more common side effects of metoclopramide can include headache, confusion, drowsiness,
dizziness, restlessness, and insomnia.
Concepts tested

Question 1668
The nurse is assessing a client who is taking rifampin for the treatment of tuberculosis. Which
finding reported by the client should the nurse immediately report to the healthcare provider?
A Blurred vision
B Orange-tinged tears
C Dark amber urine
D Diarrhea

Question Explanation
Correct Answer is C
Rationale: Rifampin causes a temporary yellow-orange discoloration of body fluids. Soft contact
lenses may be permanently stained. Dark amber urine is an indication of liver dysfunction and

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should be reported. A major adverse effect of ethambutol, not rifampin, is optic neuritis.
Diarrhea is a common side effect of antibiotics and is not the priority in this case.
Concepts tested

Question 1669
The nurse is collecting the health history for a client who reports a sudden onset of generalized
weakness and fatigue. The nurse notes the client has a new prescription for spironolactone.
Which action should the nurse take first?
A Review the drug formulary for side effects
B Request the health care provider to stop the medication
C Notify the pharmacist of the findings
D Document the findings

Question Explanation
Correct de Answer is A
Rationale: During medication administration, it is important for the nurse to assess knowledge of
drugs, including adverse effects and physiologic factors that affect drug action. Information
about specific drugs is available in pharmacology texts and drug reference books. Calling the
health care provider may be an option after reviewing the drug formulary. The nurse should
notify the pharmacist if the medication is the cause of the symptoms. The nurse will document
the findings, but the priority is to review the formulary.
Concepts tested

Question 1670
A nurse is assessing a client who started taking prescribed olmesartan 2 weeks ago. Which
finding indicates an expected response to the medication?
A Heart rate of 85 beats/min
B Urinary output of 45 ml/hr
C Blood pressure of 125/79 mmHg
D Respiratory rate of 20 breaths/min

Question Explanation
Correct Answer is C
Rationale: Olmesartan is an angiotensin II receptor antagonist used in the treatment of
hypertension. The expected outcome is to maintain the blood pressure within normal limits.
Although within normal limits, the heart rate, urinary output, and respiratory rate are not used to
evaluate the efficacy of olmesartan.
Concepts tested

Question 1671
A nurse is providing dietary instructions to a client who is taking prescribed amiloride. Which
information will the nurse include in the teaching?
A “Avoid eating foods that are rich in potassium such as bananas.”
B “It is important to control high-sodium foods such as canned soups.”
C “Eat plenty of foods that contain calcium such as milk.”

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D “Choose foods that are high in iron content such as shellfish.”

Question Explanation
Correct Answer is A
Rationale: Amiloride is a potassium-sparing diuretic used in the treatment of edema,
hypertension, and potassium loss caused by other diuretic medications. Amiloride may cause
hyperkalemia, so the client should be informed to limit their potassium intake. Sodium, calcium,
and iron are not affected by the use of amiloride.
Concepts tested

Question 1672
The nurse is educating a client with preeclampsia about magnesium sulfate. Which statement
should the nurse include in the teaching?
A “This medication is used to reduce your risk of seizures.”
B “This medication will raise your blood pressure.”
C “This medication might make you urinate more frequently.”
D “This medication will be discontinued once your headache subsides.”

Question Explanation
Correct Answer is A
Rationale: Magnesium sulfate is a medication that is used to prevent seizures for clients with
preeclampsia. The medication will not raise blood pressure and has no effect on urination.
Magnesium is given continuously and will not be discontinued if the client’s headache subsides.
Concepts tested

Question 1673
The nurse is providing medication teaching for a client prescribed famotidine for the treatment of
gastroesophageal reflux disease (GERD). Which statement by the client indicates an
understanding of the teaching?
A “I will take this medication once a day in the morning.”
B “I will no longer have discomfort at night once I begin this medication.”
C “This medication will both prevent and treat heartburn.”
D “My treatment will be done in one week.”

Question Explanation
Correct Answer is C
Rationale: H2 receptor blockers (antagonists) are used to prevent and treat conditions caused by
too much acid being produced in the stomach. These conditions include gastric ulcers, duodenal
ulcers, and GERD. Famotidine may be prescribed to take twice a day, in the morning and
evening, or just once daily in the evening. Duration of treatment varies but is at a minimum two
weeks.
Concepts tested

Question 1674

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The nurse is educating a client on self-administration of a fluticasone inhaler. What statement
indicates an understanding of the teaching?
A “I will rinse my mouth with water after using the inhaler.”
B “Disinfectant wipes can be used to clean the spacer.”
C “I need to wait 15 minutes between puffs.”
D “This inhaler should be used before the others.”

Question Explanation
Correct Answer is A
Rationale: To prevent thrush, the client should rinse his or her mouth with water and spit it out.
The spacer should be washed with warm water and dish detergent. The client may need two
puffs but does not have to wait 15 minutes between. Bronchodilators should be used before
corticosteroids.
Concepts tested

Question 1675
The nurse is caring for a female client who is requesting hormonal contraceptives. Which of the
following questions should the nurse ask to assess for contraindications?
A “Have you ever had a blood clot?”
B “How many children do you have?”
C “Do you drink alcohol?”
D “Did you experience acne in adolescence?”

Question Explanation
Correct Answer is A
Rationale: A history of thromboembolic disorders is a contraindication to hormonal
contraceptives; therefore, any history of thrombus should be assessed. The number of
children/pregnancies and use of alcohol are probable history questions but are not
contraindications to this method. Acne is a side effect of oral contraceptives but not a
contraindication.
Concepts tested

Question 1676
The nurse is preparing to administer a client’s oral medications. Which action should the nurse
take prior to administration?
A Assess the client’s swallowing ability
B Place the client in the supine position
C Remove any oxygen delivery devices
D Place all tablets into a pill cup together

Question Explanation
Correct Answer is A
Rationale: Prior to administration, the client’s swallowing ability should be assessed. If any
difficulty swallowing is identified, oral medications should not be administered. When
administering oral medications, the client should be placed in a high-Fowler’s position, and

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oxygen delivery devices should only be removed temporarily if they impede the ability to take
the medication (a nasal cannula should not be removed). Oral medications should be
administered one at a time rather than all together.
Concepts tested

Question 1677
A nurse is assessing a client diagnosed with diabetic ketoacidosis. The client is on a prescribed
regular insulin infusion at 0.1 units/kg/hr. The client appears restless and verbalizes tingling to
the extremities. Which action does the nurse perform next?
A Check the client’s capillary blood glucose
B Stop the regular insulin infusion
C Increase the infusion to 0.15 units/kg/hr
D Give the client 4 oz of fruit juice

Question Explanation
Correct Answer is A
Rationale: The client is experiencing symptoms of hypoglycemia. Prior to decreasing the dose of
the infusion, the nurse should assess the client’s blood glucose level to confirm the
hypoglycemia. Prior to stopping the infusion, the nurse needs to assess the client’s blood sugar
level and notify the healthcare provider of the results. Increasing the infusion will cause further
hypoglycemia. Prior to performing an intervention to correct the hypoglycemia, the nurse needs
to assess the blood glucose level first.
Concepts tested

Question 1678
During morning rounds, a healthcare provider informs a client with hypertension that a calcium
channel blocker will be added to their treatment regimen. The nurse notes a new prescription for
amiloride 10 mg PO daily. Which action does the nurse perform next?
A Clarify the prescription with the healthcare provider
B Educate the client on the new prescription
C Administer the medication with food
D Assess the client’s blood pressure

Question Explanation
Correct Answer is A
Rationale: The nurse should clarify the new prescription. Amiloride is a potassium-sparing
diuretic. It is also a look-alike/sound-alike medication commonly confused with amlodipine, a
calcium channel blocker. Educating the client on a new prescription, administering the
medication with food, and assessing the blood pressure are important interventions for amiloride.
However, this prescription should be clarified.
Concepts tested

Question 1679
A nurse is assessing a client with a continuous intravenous infusion. The nurse notes the infusion
pump frequently alerts, pauses, and then restarts. Which action should the nurse perform first?

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A Check the tubing for any kinks
B Replace the infusion pump
C Initiate intravenous access in a new location
D Flush the line with normal saline

Question Explanation
Correct Answer is A
Rationale: The nurse should ensure the intravenous tubing is not bent or kinked. An alert
followed by a pause indicates the fluid is not flowing adequately. This is commonly due to an
occlusion. The nurse should troubleshoot the infusion before replacing the equipment. Initiating
new intravenous access is not indicated unless the current access site is not functional. There is
no indication the current access is not functioning. Flushing the line assesses for adequate flow.
However, the nurse should first assess for any external occlusions.
Concepts tested

Question 1680
A nurse has administered acetaminophen for pain relief to an infant. Based on the client’s
development stage, which action is most important to include in the medication administration
record?
A The dose administered based on the client’s weight
B The client’s pain level after administration of the medication
C The time the dose was administered to the client
D The client’s vital signs before the medication was administered

Question Explanation
Correct Answer is A
Rationale: The most important action to document in the client’s medical record is the dose
administered. The dose of acetaminophen administered to infants is based on weight. Infants
should not exceed more than 5 doses of 10-15 mg/kg/dose in a 24-hour period. Documenting the
pain level after administration of analgesics, the time the dose was administered, and the latest
vital signs should be performed on every client regardless of their developmental stage.
Concepts tested

Question 1681
The nurse is caring for a client receiving total parenteral nutrition (TPN). The TPN has been
infusing 24 hours. Which of the following findings requires intervention?
A Blood sugar is 115 mg/dl
B White blood cell count is 11,500
C Albumin level is 3.7 g/dl
D Potassium level is 3.6 mmol/l

Question Explanation
Correct Answer is B
Rationale: An increase in WBC count is an indication of infection. Dextrose in TPN increases
the risk of infection. Assess for signs and symptoms of infections at the site (redness, tenderness,

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discharge) and systemically (fever, increased WBC, malaise). The site dressing should be dry
and intact. Blood glucose, albumin, and potassium are some of the labs that are monitored while
a client is on TPN. The results in this example are expected findings.
Concepts tested

Question 1682
The nurse is caring for a client prescribed warfarin therapy for treatment of persistent atrial
fibrillation. Which of the following may potentiate the effect of this medication?
A St. John’s wort
B Estrogen
C Vitamin K
D Green tea

Question Explanation
Correct Answer is D
Rationale: Warfarin, an anticoagulant agent used to prevent thrombosis and risk of stroke in
clients with atrial fibrillation, is associated with many drug and food interactions. Careful
assessment with a pharmacist/formulary is recommended to avoid potential complications. Green
tea can potentiate the effect of warfarin and increase bleeding. St. John’s wort, estrogen, and
vitamin K may inhibit the action requiring higher doses of the anticoagulant.
Concepts tested

Question 1683
A nurse is reviewing a client’s medical history. The client has been newly diagnosed with
hypertension and has been prescribed oral losartan as treatment. The nurse will clarify the use of
losartan if which comorbidity is noted in the client’s medical record?
A Renal stenosis
B Hyperlipidemia
C Atrial fibrillation
D Diabetes

Question Explanation
Correct Answer is A
Rationale: Losartan is an angiotensin II receptor blocker used in the treatment of hypertension.
Losartan is contraindicated in clients with renal stenosis due to the risk of kidney injury.
Hyperlipidemia, atrial fibrillation, and diabetes are not known to be contraindicated in the use of
losartan.
Concepts tested

Question 1684
A nurse is preparing to initiate a blood transfusion on a client with anemia. Which step will the
nurse perform to prevent a transfusion error?
A Check the client’s wristband against the blood component
B Verify the blood component independently against the provider’s prescription
C Match the blood component to the client’s consent form

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D Place a blood component identification label in the client’s medical record

Question Explanation
Correct Answer is A
Rationale: One of the verification steps before a transfusion is to match the client to the blood
component. Checking the client’s wristband against the blood component verifies the correct
client is receiving the transfusion. The verification should be between two people or one person
accompanied by automated identification technology such as a bar code. The consent form
verifies the client agreed to the transfusion. However, this does not prevent a misidentification
error. Placing an identification label in the client’s medical record verifies the transfusion
occurred but does not prevent a transfusion error.
Concepts tested

Question 1685
The nurse is monitoring a client who received a first dose of intravenous ampicillin. Which
finding should indicate to the nurse that the client may be experiencing an allergic reaction?
A Abdominal pain
B Increase in blood pressure
C Hypotensive bowel sounds
D Hives on the extremities

Question Explanation
Correct Answer is D
Rationale: If the client experiences an allergic reaction to medications they may display systemic
signs such as hives, pruritus, dyspnea, etc. Abdominal pain, hypertension, and hyperactive bowel
sounds do not indicate an allergic reaction.
Concepts tested

Question 1686
The nurse is caring for a pregnant client who is receiving intravenous magnesium sulfate
therapy. Which of the following medication prescriptions should the nurse clarify with the
provider?
A Nifedipine
B Ondansetron
C Lactated ringers
D Betamethasone

Question Explanation
Correct Answer is A
Rationale: The effect of the calcium channel blocker can be increased if it is taken with
magnesium sulfate; therefore, the nurse should question a new prescription of nifedipine. All
other medications will not create adverse effects if given with magnesium sulfate.
Concepts tested

Question 1687

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The nurse is providing teaching to the client prescribed albuterol for the management of asthma.
The nurse is including reportable side effects in the teaching plan. Which of the following side
effects is the priority?
A Nervousness
B Headache
C Palpitations
D Muscle aches

Question Explanation
Correct Answer is C
Rationale: Side effects of albuterol include nervousness, shakiness, headache, throat irritation,
and muscle aches. Muscle tremor is the most frequent adverse effect. The main risks with
adrenergic bronchodilators, particularly in older adults, are excessive cardiac and central nervous
system (CNS) stimulation. Symptoms of cardiac stimulation include angina, tachycardia, and
palpitations. Symptoms of central nervous system (CNS) stimulation consist of agitation,
anxiety, insomnia, seizures, and tremors. Other reported effects may include serious
dysrhythmias and cardiac arrest.
Concepts tested

Question 1688
The nurse is assessing a client with tuberculosis who has been taking prescribed pyrazinamide.
Which finding reported by the client should the nurse immediately report to the healthcare
provider?
A Joint pain
B Fatigue
C Nausea
D Decreased appetite

Question Explanation
Correct Answer is A
Rationale: Joint pain is a symptom of gout, which is a side effect of pyrazinamide. While fatigue,
nausea, and loss of appetite are common side effects of the drug, the joint pain is the priority.
Concepts tested

Question 1689
The nurse is preparing to administer prescribed digoxin to client with atrial fibrillation. The
nurse notes the packaging for the medication is provided in a different route than prescribed.
Which action should the nurse take?
A Administer the medication as ordered
B Consult the pharmacist regarding the error
C Alert the charge nurse to the medication error
D Contact the health care provider

Question Explanation
Correct Answer is B

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Rationale: Careful consultation with a pharmacist regarding the error is the most appropriate
action for the nurse to take if an error occurs when the pharmacy dispenses the medication. The
medication as provided by the pharmacy is incorrect and cannot be administered. The charge
nurse may be alerted, but the pharmacy can correct the error.
Concepts tested

Question 1690
A nurse has administered sublingual nitroglycerin to a client in the emergency department.
Which clinical finding indicates an adverse response to the medication?
A Persistent chest pain
B Orthostatic hypotension
C Decreased heart rate
D Labored breathing

Question Explanation
Correct Answer is B
Rationale: Decreased blood pressure when changing positions is an unexpected response to
nitroglycerin. The nurse should instruct the client to lay down and elevate the feet to promote
venous return. Persistent chest pain is not an unexpected response. Additional doses may be
required to alleviate angina. A side effect of nitroglycerin is tachycardia, not a decreased heart
rate. Nitroglycerin is not associated with respiratory effects.
Concepts tested

Question 1691
A nurse is providing education to a client about newly prescribed diltiazem. Which statement
will the nurse include in the teaching?
A “Skip the dose if your systolic blood pressure is less than 120 mmHg.”
B “Hold the dose if your heart rate is less than 50 beats/min.”
C “Call your healthcare provider if you experience any fever.”
D “Notify your healthcare provider if you notice any weight loss.”

Question Explanation
Correct Answer is B
Rationale: Diltiazem is a calcium channel blocker medication used in the treatment of
hypertension and cardiac arrhythmias such as atrial flutter and fibrillation. Diltiazem can cause
bradycardia. The nurse should instruct the client how to take their pulse and hold the dose if less
than 50 beats/min. Diltiazem should be held if the systolic blood pressure is below 90 mmHg.
Fever and weight loss are not effects associated with the use of diltiazem.
Concepts tested

Question 1692
The nurse is educating a pregnant client about newly prescribed betamethasone. Which of the
following statements should the nurse include in the teaching?
A “Betamethasone reduces your risk of preterm labor if administered correctly.”

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B “You will need to return to the clinic tomorrow for your second dose of betamethasone.”
C “Betamethasone may cause significant maternal weight gain.”
D “Take betamethasone every four hours unless you begin having contractions.”

Question Explanation
Correct Answer is B
Rationale: Betamethasone steroid is administered to hasten fetal lung maturity. It is given in two
doses, 24 hours apart, as an intramuscular injection. Betamethasone does not affect contraction
pattern, maternal weight, or reduce the likelihood of preterm labor.
Concepts tested

Question 1693
The nurse is educating a client with end-stage renal failure about newly prescribed aluminum
hydroxide. Which statement should the nurse include in the teaching?
A “This medication binds with phosphates from food to decrease absorption.”
B “This medication is used to decrease urea to prevent urticaria.”
C “This medication will coat the lining of the stomach to decrease acid production.”
D “This medication treats hyperkalemia by exchanging sodium for potassium in the intestines.”

Question Explanation
Correct Answer is A
Rationale: Hyperphosphatemia occurs in end-stage renal failure when kidneys can no longer
filter out phosphorus. Treatment of hyperphosphatemia may include the administration of
aluminum hydroxide as a phosphate-binding agent. The aluminum binds with phosphates which
are excreted in the feces. Sodium polystyrene is used to treat hyperkalemia by exchanging
sodium for potassium in the intestines. Dialysis is used to remove urea from the blood, and
diphenhydramine is used to treat urticaria. Sucralfate is a medication that coats the stomach
lining to decrease acid production.
Concepts tested

Question 1694
The nurse is teaching a pediatric client and family about prescribed albuterol sulfate extended-
release tablets. Which statement should be included?
A “If you cannot swallow the tablet, it is ok to chew it.”
B “This medication can cause restlessness.”
C “Rinse your mouth after taking this medication.”
D “Oral albuterol can cause an increase in urination.”

Question Explanation
Correct Answer is B
Rationale: The adverse reactions to albuterol are the same whether administered orally or via
inhalation. The most frequent adverse reactions to albuterol are nervousness, tremors, headache,
tachycardia, and palpitations. Less frequent adverse reactions are muscle cramps, insomnia,
nausea, weakness, dizziness, drowsiness, flushing, restlessness, irritability, chest discomfort, and
difficulty in urination. Extended-release medications should not be chewed or crushed. Doing so

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can release all of the drug at once, increasing the risk of side effects. Inhaled corticosteroids
require the mouth to be rinsed. This medication is not inhaled and is not a corticosteroid.
Concepts tested

Question 1695
The nurse is collecting a client’s health history before administering oxytocin for induction of
labor. Which of the following statements by the client is a contraindication?
A “This is my fourth baby.”
B “I have a placenta previa.”
C “My water broke an hour ago.”
D “I have gestational diabetes.”

Question Explanation
Correct Answer is B
Rationale: Placenta previa is a condition in which the placenta blocks the cervical opening;
therefore, a vaginal delivery is contraindicated. The number of pregnancies and membrane status
are not contraindications to oxytocin. Presence of certain medical conditions, such as gestational
diabetes, are important to include in the client’s history but are not contraindications.
Concepts tested

Question 1696
The nurse is preparing to administer a medication via a transdermal patch to a client. Which
action by the nurse is appropriate?
A Apply lotion to the skin prior to placement
B Utilize heat therapy over top of the patch after placement
C Remove the previous patch prior to placement
D Apply the patch in the same location as the previous placement

Question Explanation
Correct Answer is C
Rationale: Any previous medication patches should be removed prior to placing the new
transdermal patch to ensure that the client receives the correct dose. Heat and cold therapy
should be avoided at the patch location as temperature may affect the absorption rate. The skin
should be clean and dry before application, and sites should be rotated to decrease the risk of
skin breakdown.
Concepts tested

Question 1697
A nurse is providing care to a client in cardiogenic shock. The client is on a prescribed dopamine
infusion at 10 mcg/kg/min with orders to titrate as needed. The latest blood pressure is 75/40
mmHg. Which action does the nurse perform next?
A Recheck the client’s blood pressure
B Increase the infusion rate to 12 mcg/kg/min
C Report the findings to the healthcare provider
D Decrease the infusion rate to 8 mcg/kg/min

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Question Explanation
Correct Answer is B
Rationale: The nurse should increase the dose of dopamine. The therapeutic goal of dopamine is
to increase blood pressure and improve cardiac output. A blood pressure of 75/40 mmHg
indicates the current rate is not effective. Rechecking the client’s blood pressure is not necessary.
The client is in cardiogenic shock and hypotension is an expected finding. The nurse can recheck
the blood pressure after titrating the dose. Reporting the findings to the healthcare provider is
important. However, the nurse should first titrate the dose to ensure the client’s blood pressure is
maintained. Decreasing the infusion rate will cause further hypotension.
Concepts tested

Question 1698
A nurse is reviewing new prescriptions for a client diagnosed with heart failure. The nurse notes
captopril 25mg PO. Which action does the nurse perform next?
A Administer the medication before meals
B Clarify the prescription with the healthcare provider
C Take the client’s weight
D Check the client’s latest creatinine level

Question Explanation
Correct Answer is B
Rationale: The nurse should clarify the prescription with the healthcare provider. The
prescription is missing a frequency, a necessary component of a medication prescription.
Captopril should be administered before or after meals. However, the prescription does not have
a frequency and should be clarified. Taking the client’s weight and checking renal labs are
important interventions after the prescription is clarified.
Concepts tested

Question 1699
A nurse is assessing a client on continuous IV therapy. The client’s IV access site is cool to the
touch, and the dressing feels moist. Which action should the nurse take?
A Discontinue the intravenous infusion
B Initiate IV access in a different site
C Apply a new dressing to the access site
D Place a warm compress on the client’s extremity

Question Explanation
Correct Answer is B
Rationale: The nurse should initiate IV access in a different site. The signs at the current access
site are indicative of infiltration. Continuous intravenous therapy should not be discontinued
without a healthcare provider’s prescription. Applying a new dressing and placing a warm
compress does not address the issue of possible infiltration. The intravenous catheter should be
removed, and access should be initiated in a different site.
Concepts tested

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Question 1700
A nurse receives a prescription to administer 0.05 mg/kg of morphine IM to an infant who
weighs 9 kg. How will the nurse document the administration of the medication?
A 0.2 mg administered IM into the ventrogluteal site
B 0.45 mg administered IM into the vastus lateralis
C 0.2 mg administered IM into the dorsogluteal site
D 0.45 mg administered IM into the deltoid muscle

Question Explanation
Correct Answer is B
Rationale: The vastus lateralis is the preferred site for intramuscular injections in an infant. The
thickness of the thigh muscle is better developed than in other areas during infancy. The correct
dosage to administer is 0.45 mg (0.05 mg x 9 kg = 0.45 mg). The deltoid muscle is not well
developed in infants and is not the preferred site for intramuscular injection administration. The
ventrogluteal site is not the preferred area for IM administration in an infant. Additionally, 0.2
mg is not the correct dose of medication. The dorsogluteal site is not indicated for IM injections
in an infant. There is an increased risk of nerve damage when using this site.
Concepts tested

Question 1701
The nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the
following findings indicates the client is experiencing an adverse effect from the TPN?
A Hypophosphatemia
B Hyperglycemia
C Hypokalemia
D Hyperuricemia

Question Explanation
Correct Answer is B
Rationale: Dextrose in TPN increases the risk of hyperglycemia until the pancreas begins to
produce more insulin or exogenous insulin is administered. TPN increases the likelihood of
hyperphosphatemia and hyperkalemia, so electrolytes should be monitored. Hypouricemia is
seen commonly after several days of total parenteral nutrition. Solutions rich in dextrose may
increase urate excretion due to an osmotic effect.
Concepts tested

Question 1702
A client with a history of chronic kidney disease is prescribed an antibiotic prior to discharge.
Which lab findings should the nurse monitor to detect adverse reactions to the medication?
A Glomerular filtration rate (GFR)
B Color of urine
C Urine specific gravity
D Urine osmolality

Question Explanation

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Correct Answer is A
Rationale: Patients with chronic kidney disease will have a diminished ability to excrete
medications. Monitoring the GFR is the best marker to monitor kidney function. The color of
urine does not necessarily correlate with kidney function. Urine specific gravity and urine
osmolality measure urine concentration and are used to assess renal disorders of urinary
concentration and status of fluid hydration.
Concepts tested

Question 1703
A nurse is providing care to a client diagnosed with a myocardial infarction. The client has a
history of hypothyroidism and hypertension. Which prescribed medication will the nurse clarify
before administering it to the client?
A Morphine
B Levothyroxine
C Aspirin
D Labetalol

Question Explanation
Correct Answer is B
Rationale: Levothyroxine is a synthetic thyroid hormone used in the treatment of
hypothyroidism. Levothyroxine can induce cardiac stimulant effects and is contraindicated in
clients with a recent myocardial infarction (MI). Morphine and aspirin are commonly
administered after a cardiac event. Morphine relieves pain associated with cardiac ischemia and
aspirin decreases platelet aggregation that leads to blood clotting. Labetalol is a beta-blocker
used in the treatment of hypertension. There is no known contraindication for the use of labetalol
after an MI.
Concepts tested

Question 1704
A nurse is reviewing a blood transfusion prescription for a client with esophageal bleeding.
Which client safety action will the nurse perform prior to initiating the transfusion?
A Check the client’s record for a signed informed consent
B Run the blood warmer for at least 10 minutes
C Ensure the client has at least a 22-gauge intravenous catheter
D Prime the administration set with normal saline

Question Explanation
Correct Answer is A
Rationale: An informed consent is required prior to administering blood products to a client. The
client must be informed of risks, benefits, and alternatives prior to obtaining signed consent.
Blood should be administered through a large-bore IV, ideally an 18-20 gauge. A blood warmer
is only used if indicated, not as a standard procedure. Priming the administration set is standard
practice. Checking the client’s consent form is a safety intervention.
Concepts tested

Question 1705
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The nurse is monitoring a client who received the first dose of a newly prescribed medication.
Which statement by the client would require immediate follow up by the nurse?
A “My pain is the same.”
B “My throat feels scratchy.”
C “I need to go to the bathroom.”
D “I would like a glass of water.”

Question Explanation
Correct Answer is B
Rationale: The client who is having a systemic allergic reaction may experience swelling or
itching of the throat after administration of the medication. A pain level that is unchanged, thirst,
or the need to void does not indicate an allergic reaction.
Concepts tested

Question 1706
The nurse is assessing a postpartum client who is taking labetalol. Which client report should the
nurse identify as a potential adverse effect of the medication?
A Nausea
B Ankle edema
C Abdominal pain
D Dizziness

Question Explanation
Correct Answer is D
Rationale: Labetalol is a beta-blocker that is used for blood pressure management in postpartum
clients. The mechanism of action for labetalol is to vasodilate, which could lead to a decrease in
blood pressure. A client with a sudden drop in blood pressure could report dizziness. Report of
nausea or ankle edema is normal during pregnancy. Abdominal pain in pregnancy could be from
active labor or constipation.
Concepts tested

Question 1707
The nurse is providing education to the client with sinusitis who has asked about taking over-the-
counter pseudoephedrine. Which of the following statements is appropriate?
A “If you take pseudoephedrine and phenylephrine together, you will get more relief.”
B “Continue the medication until your congestion resolves.”
C “Using these kinds of medications may make you jittery and restless.”
D “It is safe to chew over the counter medications if you have trouble swallowing pills.”

Question Explanation
Correct Answer is C
Rationale: Do not combine two drug preparations containing the same or similar active
ingredients. For example, pseudoephedrine is the nasal decongestant component of most
prescription and over-the-counter (OTC) sinus and multi-ingredient cold remedies. Taking more
than one preparation containing pseudoephedrine (or phenylephrine, a similar drug) may increase

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the dosage to toxic levels and cause irregular heartbeats and extreme nervousness. Oral OTC
decongestants should not be used longer than one week. Excessive or prolonged use may damage
nasal mucosa and produce chronic nasal congestion. Common side effects include tachycardia,
impaired coordination, dizziness, excitability, headache, insomnia, restlessness, seizures, vertigo,
dysuria, urinary retention, urinary difficulty, and thrombocytopenia.
Concepts tested

Question 1708
The nurse is caring for a client who has been prescribed vancomycin intravenous infusion for the
treatment of methicillin-resistant staphylococcus aureus. Which of the following laboratory
values should be immediately reported to the healthcare provider?
A Vancomycin trough of 15 mcg/dl
B Blood urea nitrogen level of 18 mg/dl
C Creatinine level of 1.1 mg d/l
D White blood cell count of 11,500 per microliter

Question Explanation
Correct Answer is A
Rationale: Vancomycin has a low therapeutic index, with nephrotoxicity and ototoxicity
complicating therapy if toxicity develops. In contrast, underdosing (less than the minimum
inhibitory concentration) can lead to treatment failure. Nephrotoxicity is associated with a trough
level above 10 mcg/dl. The BUN and creatinine in this case are still within a normal range.
While the WBC count is elevated, this is an expected finding.
Concepts tested

Question 1709
The nurse is caring for a client with diabetes type I who received a prescribed dose of regular
insulin 30 minutes prior to the meal. The client reports nausea and vomiting. Which action
should the nurse take?
A Administer another dose of regular insulin
B Encourage the client to eat a small amount of carbohydrates
C Assess blood glucose level
D Notify the healthcare provider

Question Explanation
Correct Answer is C
Rationale: When a client who has been administered a regular insulin injection vomits, the nurse
should monitor blood glucose and frequently assess for signs of hypoglycemia. After 30 minutes,
most of the medication would have been absorbed. Any food ingested may be lost, and repeating
the dose would further lower glucose levels. Giving intravenous insulin would also lower
glucose levels, causing further hypoglycemia. Before the nurse notifies the healthcare provider,
the nurse should assess the client's blood glucose level.
Concepts tested

Question 1710

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A nurse is reviewing laboratory data for a client taking pramlintide for diabetes management.
Which clinical finding indicates medication effectiveness?
A Postprandial glucose of 160 mg/dL
B Hemoglobin A1c of 8.5%
C Fasting blood glucose of 135 mg/dL
D Preprandial glucose of 150 mg/dL

Question Explanation
Correct Answer is A
Rationale: Pramlintide is an antidiabetic medication used in the treatment of diabetes mellitus in
conjunction with other hypoglycemic drugs. The therapeutic goal of pramlintide is to achieve
postprandial glucose levels below 180 mg/dL. A preprandial blood glucose of 150 mg/dL, a
hemoglobin A1c of 8.5%, and a fasting blood glucose of 135 mg/dL are all indicative of poor
disease management. The goal is a preprandial glucose level of less than 130 mg/dL, a
hemoglobin A1c level of less than 7%, and a fasting blood glucose of less than 100 mg/dL.
Concepts tested

Question 1711
A nurse is providing discharge education on the use of sustained-release procainamide to a client
with newly diagnosed atrial flutter. What will the nurse include in the teaching?
A “You will need to have laboratory blood tests performed every 3 months.”
B “Hold the medication if your heart rate is below 70 beats/min.”
C “Notify your healthcare provider if you begin experiencing joint pain.”
D “Crush your medication and mix it with food to mask the taste.”

Question Explanation
Correct Answer is C
Rationale: Procainamide is an antiarrhythmic medication used in the management of atrial
flutter. One of the adverse effects of procainamide is systemic lupus syndrome characterized by
fever and painful joints. The client should be instructed to notify the healthcare provider of any
adverse symptoms. Lab tests need to be conducted frequently (every week) at the start of therapy
to monitor complete blood counts and procainamide blood levels. Procainamide does not have a
direct effect on heart rate. Sustained-release medications should not be crushed or chewed.
Concepts tested

Question 1712
The nurse is preparing to administer oxytocin to a client for induction of labor. Which of the
following statements by the nurse is appropriate to include in client education?
A “This medication can cause you to feel sleepy.”
B “This medication will be discontinued once your cervix starts to dilate.”
C “This medication will be increased until you have an adequate contraction pattern.”
D “This medication can make you feel dizzy.”

Question Explanation
Correct Answer is C

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Rationale: Oxytocin is used to increase the frequency, duration, and strength of contractions and
will be increased until the client’s contractions are 2-3 minutes apart. The medication will not
cause the client to feel sleepy and they can get out of bed dependent on the client's condition.
Oxytocin will not be discontinued until delivery unless the maternal or fetal condition is
unstable.
Concepts tested

Question 1713
The nurse is educating a client with end stage chronic obstructive pulmonary disease (COPD)
about medication management. Which statement by the client indicates an understanding of the
teaching?
A “I will use the albuterol in the nebulizer before my other inhalers each morning.”
B “I can use my tiotropium inhaler if I get short of breath.”
C “I will only use the fluticasone inhaler on the days I am really out of breath.”
D “The side effects of these medications will be less severe because I’m not taking them by
mouth.”

Question Explanation
Correct Answer is A
Rationale: Medication regimens used to treat COPD are based on disease severity. For grade III
or IV (severe and very severe) COPD, medication therapy includes treatment with one or more
bronchodilators and inhaled corticosteroids. Clients with COPD experience significant
breathlessness and reduced FEV1 upon waking. Use of nebulized albuterol prior to
administration of long-acting medications relaxes the airway and allows other medications to get
deeper into the lungs. Tiotropium is a long-acting anticholinergic (muscarinic) and is not meant
for rescue purposes. Fluticasone prevents inflammation and therefore, must be used every day.
Clients with COPD will experience side effects of the medications due to the long duration of
use.
Concepts tested

Question 1714
The nurse is teaching the client with bacterial vaginosis who has been prescribed metronidazole
tablets. What statement is appropriate?
A “You may continue to experience symptoms after you stop the medication.”
B “You should avoid drinking alcohol while taking this medication.”
C “Call your healthcare provider if you experience diarrhea.”
D “Your sexual partner will need to be treated as well.”

Question Explanation
Correct Answer is B
Rationale: Alcohol should be avoided while on metronidazole to reduce the risk of a disulfiram
reaction. Routine treatment of male sexual partners is not needed and does not affect re-infection
rates. If the client experiences continued symptoms, this may indicate treatment failure and the
need for follow-up may be required. Diarrhea is a common side effect of metronidazole and
should subside once treatment ends.
Concepts tested
Page | 701
Question 1715
The nurse is preparing to administer magnesium sulfate IV to a client with preeclampsia. Which
medication in the client’s record should the nurse question this prescription?
A Penicillin
B Betamethasone
C Lactated ringers
D Amlodipine

Question Explanation
Correct Answer is D
Rationale: Magnesium sulfate potentiates the action of calcium channel blockers so the nurse
should be concerned about administering amlodipine and magnesium sulfate together.
Betamethasone is a steroid that is commonly given to clients in preterm labor but does not
interact with magnesium sulfate. Penicillin does not have any known interactions with
magnesium sulfate, and lactated ringers is an IV fluid that magnesium sulfate is mixed into to
administer intravenously.
Concepts tested

Question 1716
The nurse is preparing to replace a client’s prescribed transdermal patch. Which of the following
actions should the nurse perform first?
A Place the patch on the client’s skin
B Label the new patch with date and time
C Apply clean gloves
D Remove the old patch

Question Explanation
Correct Answer is C
Rationale: The nurse should apply gloves before handling any topical medication; this includes
gloving prior to removing an old transdermal patch. The patch should be removed and then a
new patch placed on an alternative location. After it has been placed, the nurse should label the
patch with the date and time.
Concepts tested

Question 1717
A nurse is providing care to a client with diabetes insipidus. The client is on a prescribed
vasopressin infusion with orders to titrate as needed. The nurse decreases the dose of vasopressin
based on which clinical finding?
A Increased blood pressure
B Decreased urine osmolarity
C Reduced volume of urine output
D Elevated heart rate

Question Explanation

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Correct Answer is C
Rationale: Diabetes insipidus is an endocrine disorder that causes the excretion of large
quantities of diluted urine. Vasopressin decreases urine output by allowing the reabsorption of
water in the kidneys. A reduction in the volume of urine output indicates the medication is
delivering the intended effect, and the dose can be decreased. Vasopressin can increase blood
pressure and heart rate. However, these are not the intended effects of vasopressin for a client
with diabetes insipidus. A decrease in the urine osmolarity indicates dilution is still present.
Concepts tested

Question 1718
A nurse is reviewing prescriptions for a post-operative client. The nurse notes “resume previous
medications” on the client’s record. Which action does the nurse perform?
A Verify the medications on the client’s medication administration record
B Notify the pharmacy to dispense the client’s previous medications
C Contact the healthcare provider for new medication prescriptions
D Ask the client to provide a list of all home medications

Question Explanation
Correct Answer is C
Rationale: The nurse should contact the healthcare provider to re-write all medication
prescriptions. Blanket orders such as “resume previous medications” are not acceptable practice
after a client has had surgery and their condition has changed. Verifying the medications on the
client’s medication administration record is good practice. However, the prescriptions need to be
re-ordered. Notifying the pharmacy to dispense the client’s previous medications is not indicated.
The pharmacy will require new medication prescriptions. Asking the client to provide a list of all
home medications should be performed upon admission.
Concepts tested

Question 1719
A nurse initiates a continuous IV infusion on a client. An hour later, the nurse notes the IV
solution bag contains the same volume as when therapy was first initiated. Which action does the
nurse take?
A Bolus the fluid that was not infused
B Initiate a new IV access
C Flush the IV site with normal saline
D Raise the fluid bag higher on the infusion pole

Question Explanation
Correct Answer is C
Rationale: The nurse should flush the IV line with normal saline. The fluid has not infused,
indicating there is an obstruction in the tubing or the catheter is no longer functional. A fluid
bolus requires a prescription. The nurse should adjust the intake and output on the client’s
record. Initiating a new IV access is not indicated at this time. The catheter should first be
checked for any occlusions. Raising the fluid bag will not address the concern. While gravity can
assist with the flow of the infusion, the catheter needs to be checked for occlusions.
Concepts tested
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Question 1720
A nurse is reviewing analgesic prescriptions for a client with a history of liver cirrhosis. The
prescriptions state to administer PRN for pain. Which medication is the nurse most likely to
administer to this client?
A Fentanyl
B Acetaminophen
C Ibuprofen
D Ketorolac

Question Explanation
Correct Answer is A
Rationale: The nurse is most likely to administer fentanyl to a client with liver disease. Fentanyl
is an opioid analgesic with a short duration. The medication should be used cautiously in hepatic
disease but is not contraindicated. Acetaminophen is highly metabolized by the liver and is
contraindicated in clients with active liver disease. Ibuprofen and ketorolac are non-steroidal
anti-inflammatory medications that may cause gastrointestinal bleeding. A client with liver
disease is at risk for bleeding.
Concepts tested

Question 1721
The nurse is caring for a client with a paralytic ileus who is receiving total parenteral nutrition
(TPN). The client has developed hypernatremia and is confused. Which of the following
prescriptions would the nurse anticipate?
A Initiating a 5% dextrose infusion
B Encouraging oral intake of plain water
C Giving a furosemide injection
D Modifying the sodium in the subsequent TPN infusion

Question Explanation
Correct Answer is A
Rationale: Abnormalities of serum electrolytes and minerals should be corrected by modifying
subsequent infusions or, if correction is urgently required, by beginning appropriate peripheral
vein infusions. Elevated blood urea nitrogen and hypernatremia may reflect dehydration, which
can be corrected by giving free water as 5% dextrose or hypotonic saline via a peripheral vein.
The client is NPO, so oral intake is contraindicated. Furosemide will worsen hypernatremia.
Concepts tested

Question 1722
The nurse is monitoring a client who is taking newly prescribed phenelzine for depression.
Which finding reported by the client would indicate the client is experiencing an adverse effect
of the mediation?
A Constipation
B Dry mouth

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C Headache
D Muscle fatigue

Question Explanation
Correct Answer is C
Rationale: Clients that are prescribed an MAO-inhibitor, such as phenelzine, could experience
the adverse effect of hypertension. The client should be assessed for sudden onset of headache,
tachycardia, or neck stiffness. Dry mouth, muscle fatigue, and constipation are common side
effects of the medication but not the priority for the nurse.
Concepts tested

Question 1723
A nurse is reviewing prescribed medications for a client diagnosed with diabetic ketoacidosis.
Which medication will the nurse clarify with the healthcare provider?
A Regular insulin
B Potassium
C 0.9% sodium chloride
D Glipizide

Question Explanation
Correct Answer is D
Rationale: Glipizide is an oral antidiabetic medication used in the treatment of type 2 diabetes
mellitus. The intended effect of glipizide is to lower glucose levels and maintain adequate
management of the disease. Oral antidiabetic agents are contraindicated in clients with diabetic
ketoacidosis (DKA). Glucose levels must be carefully lowered and monitored following insulin
therapy. Regular insulin, potassium, and 0.9% sodium chloride are all expected pharmacological
treatments for DKA.
Concepts tested

Question 1724
A nurse is assessing a client’s peripheral intravenous (IV) access prior to initiating a blood
transfusion. Which finding will prompt the nurse to initiate new venous access?
A The IV site is on the client’s wrist.
B The catheter has been in place for 72 hours.
C The skin around the IV site is cool to the touch.
D The IV catheter is a 20-gauge.

Question Explanation
Correct Answer is C
Rationale: Coolness surrounding the IV site is a sign of infiltration. The nurse should discontinue
the IV access and initiate a new IV for the blood transfusion. An IV site on the wrist is not
contraindicated. The nurse should ensure the IV is patent. IV catheters may be left in place
according to manufacturer recommendations. The indwelling time of the catheter is not sufficient

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information to determine its patency. A 20-gauge catheter is acceptable for a blood transfusion.
A large-bore catheter (18-20) should be used.
Concepts tested

Question 1725
The nurse is assessing a client who is receiving antibiotic therapy for an infection. Which finding
should indicate to the nurse that the client may be experiencing an allergic reaction to a
medication?
A Xerostomia
B Hypertension
C Pruritus
D Lymphadenopathy

Question Explanation
Correct Answer is C
Rationale: If the client experiences pruritus, the nurse should be concerned about the possibility
of an allergic reaction. Xerostomia, or dry mouth, and lymphadenopathy are not signs of a
hypersensitivity reaction. A client experiencing an allergic reaction will experience hypotension.
Concepts tested

Question 1726
The nurse is assessing a pregnant client who has just received terbutaline for preterm labor.
Which statement by the client would indicate to the nurse the client is experiencing an adverse
effect of the medication?
A “I am feeling very nervous right now.”
B “I think I am going to vomit.”
C “I am no longer having contractions.”
D “I can tell the baby is moving.”

Question Explanation
Correct Answer is A
Rationale: Terbutaline is a medication used to stop or delay preterm labor by preventing or
slowing contractions. A client who is experiencing an adverse effect of terbutaline will report
feeling nervous, shaking, and may have tremors. Vomiting and feeling the baby move are normal
findings in pregnancy. The client who reports a decrease in contractions would indicate the
medication is having a therapeutic effect.
Concepts tested

Question 1727
The nurse is educating an older adult client about newly prescribed levofloxacin for the treatment
of pneumonia. The nurse should teach the client that which side effect is a priority for the client
to report to the provider?
A Joint tenderness
B Diarrhea
C Dizziness

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D Difficulty sleeping

Question Explanation
Correct Answer is A
Rationale: There is a black box warning for fluoroquinolones alerting health professionals not
only to the increased disabling risk of tendinitis and tendon rupture but also to the significant risk
of peripheral neuropathy, central nervous system and cardiac effects, and dermatologic and
hypersensitivity reactions. Signs of tendonitis and tendon rupture include pain and tenderness in
the affected limb or joint. The medication must be stopped immediately. The other options are
common side effects and while reportable, are not a priority.
Concepts tested

Question 1728
The nurse is administering multiple infusions into single intravenous access. The nurse notes
precipitates in the IV tubing. Which action is appropriate?
A Stop the infusion
B Slow the infusion rate
C Continue to monitor the infusion
D Change the tubing

Question Explanation
Correct Answer is A
Rationale: Drug incompatibilities are chemical and physical reactions between drugs and/or with
the carrier fluid during their IV administration through the same venous access. These
incompatibilities can lead to precipitate formation. Particles administered to patients through IV
infusion may lead to complications, as well as an increased risk of venous thromboembolism.
Rare cases of fatal pulmonary embolism have even been reported. If precipitates are identified,
infusions should be stopped immediately.
Concepts tested

Question 1729
The nurse is reviewing discharge instructions with the parent of a 3-year-old client who was
admitted for poisoning after ingesting cherry-flavored acetaminophen. Which statement by the
parent would require follow up by the nurse?
A “I should use non-flavored medications.”
B “I will reach out to the poison control center if this happens again.”
C “I will use ipecac syrup to induce vomiting.”
D “I will have all medications in a locked cabinet.”

Question Explanation
Correct Answer is C
Rationale: Accidental ingestions (poisoning) are the most frequent accident in toddlers.
Therefore, it is imperative to focus on keeping all poisonous substances, drugs, and small objects

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securely out of the reach of children and medications in a locked cabinet. Parents should be
instructed to call the poison control center in case of accidental ingestion and to have the number
listed on their cell phone. Since 2003, the American Academy of Pediatrics has discouraged the
use of syrup of ipecac to induce vomiting after accidental ingestion. Instead, families should call
the poison control center immediately. Using non-flavored medications will decrease the
likelihood the child will consume a large amount; it does not prevent the ingestion of the
medication or determine what should be done after accidental ingestion.
Concepts tested

Question 1730
A nurse is assessing a client with hyperthyroidism and is taking prescribed methimazole. Which
client statement indicates a therapeutic response to the medication?
A “My intolerance to cold has improved.”
B “I no longer feel heart palpitations.”
C “I don’t get constipated as easily.”
D “I have lost a few pounds.”

Question Explanation
Correct Answer is B
Rationale: Methimazole is an antithyroid medication used in the treatment of hyperthyroidism.
Tachycardia and heart palpitations are signs of hyperthyroidism. The expected response of
methimazole is a decrease in the severity of hyperthyroidism symptoms. Intolerance to cold,
constipation, and weight gain are signs of hypothyroidism. Improvement in these symptoms do
not evaluate the effectiveness of methimazole.
Concepts tested

Question 1731
A nurse is providing education on activities of daily living to a client taking warfarin. Which
statement made by the client indicates further teaching is required?
A “I will brush my teeth using a soft-bristled toothbrush.”
B “I will wear a medical alert bracelet on my wrist.”
C “I will be sure to consume plenty of green leafy vegetables.”
D “I need to shave using an electric razor.”

Question Explanation
Correct Answer is C
Rationale: Warfarin is an anticoagulant medication used in the treatment of blood clotting
disorders. Green leafy vegetables contain a high amount of vitamin K, the antidote for warfarin.
The client should be instructed to limit their intake of vitamin K-containing foods. Using a soft-
bristled toothbrush and an electric razor decrease the risk of bleeding. A medical alert bracelet is
necessary for clients who are on blood-thinning medications to alert first responders in case of an
emergency.
Concepts tested

Question 1732

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The nurse is educating a client on the use of misoprostol for induction of labor. Which of the
following statements should the nurse include in the teaching?
A “This medication will soften your cervix.”
B “This medication increases the risk of bleeding.”
C <“This medication is used to help reduce the pain of contractions.”
D “This medication can cause nausea.”

Question Explanation
Correct Answer is A
Rationale: Misoprostol is a medication that is used to soften the cervix and increase contractions.
It can be administered vaginally or orally for induction of labor. This medication does not
increase the risk of bleeding or reduce pain. Nausea is not a side effect of misoprostol.
Concepts tested

Question 1733
A nurse is educating a client with diabetes type 2 about newly prescribed glipizide. Which
statement by the nurse best describes the action of glipizide?
A “This medication absorbs the excess carbohydrates from your intestinal tract.”
B “This medication will inhibit the release of glucose stored in the liver.”
C “This medication will stimulate your pancreas to release insulin.”
D “This medication works by increasing the ability of the cells to uptake glucose.”

Question Explanation
Correct Answer is C
Rationale: The action of sulfonylureas, such as glyburide, is to stimulate the pancreas to release
insulin. Biguanides, such as metformin, work by decreasing the release of glucose from the liver
and increasing the uptake of glucose into the cells. The action of a-glucosidase inhibitors is to
decrease the absorption of carbohydrates in the gastrointestinal tract.
Concepts tested

Question 1734
The nurse is preparing to administer prescribed IV pantoprazole to the hospitalized client. The
medication has been stocked in tablet form. Which action by the nurse is appropriate?
A Administer the medication to the client in oral form
B Call the pharmacy to stock the correct form of the medication
C Request that the healthcare provider change the order to tablets
D Ask the pharmacist if it is safe to give the client oral pantoprazole

Question Explanation
Correct Answer is B
Rationale: Safety is of the utmost importance in preparing and administering medications.
Suggested rights of administration vary from the classic five rights (listed first) through upward
of eleven rights, including right medication, right patient, right dosage, right route, right time,
right reason, right assessment data, right documentation, right response, right education, and
right to refuse. In this case, the nurse has identified a potential issue with the right route of

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administration. The nurse should call the pharmacy and have the correct form of the medication
provided for administration. Administering the medication by the incorrect route is considered a
medication error. The healthcare provider’s order is not incorrect, and the safety of
administration via this route is not what is in question.
Concepts tested

Question 1735
The nurse is preparing to administer doxycycline to a client to treat syphilis. Which lab results
should the nurse review before administering this medication?
A Pregnancy test
B Hematocrit
C Sodium level
D Arterial blood gas

Question Explanation
Correct Answer is A
Rationale: Tetracyclines, such as doxycycline, may cause fetal harm and should not be
administered during pregnancy. It is important to know the client’s pregnancy status prior to
administration. Reviewing hematocrit, serum sodium level, and ABGs may be a part of the
client’s assessment, but these do not affect the prescription for doxycycline.
Concepts tested

Question 1736
The nurse is administering an intravenous push medication through a client’s peripheral IV site.
Which of the following actions by the nurse is appropriate?
A Insert the medication into the client’s maintenance IV fluids
B Remove the transparent dressing from the IV site
C Aspirate blood from the IV site after administration
D Flush the peripheral IV prior to administration

Question Explanation
Correct Answer is D
Rationale: Prior to administering an IV push medication, the line should be flushed to ensure
patency. Aspiration of blood can be done before administration. but doing this action after
administration increases the risk for occlusion. Inserting the medication into the maintenance
fluids slows the administration down significantly; if the medication needs to be diluted, it
should be added to a secondary IV bag. The transparent dressing should not be removed unless
the intention is to replace the dressing or discontinue the IV.
Concepts tested

Question 1737
An older adult client has been prescribed zolpidem for insomnia. The nurse should monitor the
client for which side/adverse effect of this medication?
A Tachypnea
B Hypotension

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C Tachycardia
D Constipation

Question Explanation
Correct Answer is B
Rationale: Zolpidem is classified as a non-benzodiazepine and acts as a GABA agonist which
can cause central nervous system depression, including drowsiness and lightheadedness. Nurses
should be aware of the sedative effects and assess for hypotension, bradycardia, and bradypnea.
Diarrhea, not constipation, is more commonly associated with the administration of this
medication.
Concepts tested

Question 1738
A nurse receives a prescription to administer regular insulin U-500 to a client with diabetes
mellitus. How will the nurse administer this medication?
A Intravenously using an infusion pump
B Subcutaneously using an insulin pump
C Intramuscularly using a U-100 syringe
D Subcutaneously using a U-500 syringe

Question Explanation
Correct Answer is D
Rationale: Insulin U-500 is a highly concentrated form of insulin that is five times stronger than
regular insulin. This medication should only be administered subcutaneously with a specialized
U-500 syringe for accurate measurement. Concentrated insulin should not be administered
intravenously, intramuscularly, or via an insulin pump due to the high risk of hypoglycemic
episodes.
Concepts tested

Question 1739
A nurse is assessing a client receiving intravenous potassium chloride. The client verbalizes pain
to the IV site. The site appears swollen and is warm to touch. Which action does the nurse
perform?
A Decrease the rate of the infusion
B Apply ice to the IV access site
C Inform the client that this is an expected finding
D Discontinue the IV catheter

Question Explanation
Correct Answer is D
Rationale: The nurse should discontinue the IV catheter. The client’s symptoms are indicative of
phlebitis, inflammation of the vein. Decreasing the rate of the infusion will not treat the swelling
or injury to the vein. Applying ice to the access site does not address the possible vein injury
caused by the medication. Pain, swelling, and warmth are not expected findings for a patent IV
access site.

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Concepts tested

Question 1740
A healthcare provider is prescribing an analgesic to a client who is pregnant. Which medication
does the nurse expect to administer and record in the client’s medication administration record?
A Naproxen
B Diclofenac
C Acetaminophen
D Ibuprofen

Question Explanation
Correct Answer is C
Rationale: Acetaminophen is safe for use in clients who are pregnant. Acetaminophen is a
Pregnancy Risk Category B. Naproxen, diclofenac, and ibuprofen are first-generation non-
steroidal anti-inflammatory medications with a Pregnancy Risk Category D, which are
contraindicated for a client who is pregnant.
Concepts tested

Question 1741
The nurse is educating the client with third degree burns who has been prescribed total parenteral
nutrition (TPN). The client has not tolerated enteral feedings. Which statements should be
included in the teaching?
A “Parenteral nutrition will help with wound healing.”
B “This type of nutrition is administered through a short catheter in your arm.”
C “The bag and tubing will be changed every other day.”
D “Your electrolyte levels and blood sugar will not be affected by this type of nutrition.”

Question Explanation
Correct Answer is A
Rationale: TPN provides calories; restores nitrogen balance; and replaces essential fluids,
vitamins, electrolytes, minerals, and trace elements. TPN can also promote tissue and wound
healing and normal metabolic function. Potential complications include complications related to
the use of central venous access devices, infection and sepsis, hyperglycemia or hypoglycemia,
fluid and electrolyte, and acid–base imbalances, phlebitis, hyperlipidemia, and liver and
gallbladder disease. Infusion administration sets should include an in-line filter and are changed
every 24 hours.
Concepts tested

Question 1742
The nurse is educating a client about newly prescribed chlorpromazine. Which of the following
should the nurse include in the teaching as an adverse effect of the medication?
A Photosensitivity
B Muscle rigidity
C Weight gain
D Dry mouth

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Question Explanation
Correct Answer is B
Rationale: Muscle rigidity may indicate neuroleptic malignant syndrome (NMS) and should be
reported to the health care provider immediately. Weight gain has been associated with first-
generation (conventional) antipsychotics. Photosensitivity is a common side effect associated
with chlorpromazine. Anticholinergic effects (e.g., dry mouth, hypotension, and urinary
retention) are also common side effects with this medication and should be monitored but do not
require immediate intervention.
Concepts tested

Question 1743
A nurse is reviewing laboratory data prior to administering methotrexate to a client with breast
cancer. Which clinical finding will the nurse report to the healthcare provider before
administering the medication?
A ALT of 55 IU/mL
B WBC of 12,000/mm³
C AST of 34 U/L
D HGB of 11.5 g/dL

Question Explanation
Correct Answer is A
Rationale: Alanine transaminase (ALT) is a liver enzyme that is released into the bloodstream
when liver damage is present. Methotrexate is an antineoplastic used in the treatment of various
carcinomas. Methotrexate is contraindicated in clients with hepatic impairment. A higher than
normal white blood cell (WBC) count is an expected finding in a client with carcinoma.
Aspartate aminotransferase (AST) is a liver enzyme used to assess hepatic function. An AST
level of 34 U/L is a normal finding. Anemia (low hemoglobin) is an expected finding in a client
with carcinoma.
Concepts tested

Question 1744
A nurse is evaluating a client 10 minutes after the administration of 1 unit of packed red blood
cells. Which clinical finding will the nurse immediately document in the client’s medical record?
A The post-transfusion hemoglobin level
B The client’s weight
C The pain level pre-transfusion
D The client’s vital signs

Question Explanation
Correct Answer is D
Rationale: Vital signs should be taken pre- and post-procedure to evaluate the client’s response
to blood products. Any significant changes from baseline should be reported to the healthcare
provider. Ten minutes is not enough time to assess a post-transfusion hemoglobin level. The
client’s weight should not be affected by 1 unit of packed red blood cells. The client’s response,
including pain, should be assessed before, during, and after the transfusion.
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Concepts tested

Question 1745
The nurse is monitoring a client who received the first dose of penicillin for a systemic infection.
Which statement by the client should indicate to the nurse that the client might be experiencing a
severe allergic reaction?
A “I am developing a headache.”
B “I feel like I can’t breathe.”
C “I have lost my appetite.”
D “I think my blood sugar is low.”

Question Explanation
Correct Answer is B
Rationale: If a client expresses that they are unable to breathe as they normally would, the nurse
should be concerned about the possibility of an allergic reaction. Headaches are not a direct
symptom of an allergic reaction. Clients who are taking antibiotics may report a change in
appetite or bowel habits. Decreased blood sugar does not occur with allergic reactions.
Concepts tested

Question 1746
The nurse is performing a follow-up assessment for a client who received methylprostaglandin
postpartum. Which question would be appropriate for the nurse to ask when assessing the client
for side effects?
A “Have you noticed if the bleeding has decreased?”
B “Do your breasts feel engorged?”
C “Are you having any pain?”
D “Have you experienced any diarrhea?”

Question Explanation
Correct Answer is D
Rationale: Methylprostaglandin is a medication used to treat postpartum bleeding. A common
side effect of methylprostaglandin is diarrhea. Asking if the bleeding has decreased would assess
the effectiveness of the medication. Engorged breasts and pain are normal findings in postpartum
women and are not associated with methylprostaglandin.
Concepts tested

Question 1747
The nurse is providing medication teaching for a client who has been prescribed tetracycline.
The client regularly takes calcium supplements to prevent osteoporosis. Which statement is
appropriate for the nurse to make?
A “Take your calcium two hours before you take the antibiotic.”
B “You can take the calcium with the antibiotic to decrease an upset stomach.”
C “Try taking the antibiotic and calcium with orange juice.”
D “It is best to take the antibiotic and calcium on an empty stomach.”

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Question Explanation
Correct Answer A
Rationale: All tetracycline derivatives are bacteriostatics, and their concentration in serum should
not fall during the therapy below the generally accepted minimum therapeutic concentration.
Tetracyclines have a high affinity to form chelates with iron, aluminum, magnesium, and
calcium. These complexes are poorly absorbed in the gastrointestinal tract; therefore, an interval
between the ingestion of tetracyclines and cations is necessary. Taking tetracyclines with orange
juice may increase irritation because the medication itself is also acidic. Additionally, orange
juice may have added calcium, which would interact with the antibiotic. It is okay to take
tetracyclines with food as long as it doesn’t contain dairy. This may reduce stomach-related side
effects.
Concepts tested

Question 1748
The nursing is preparing to administer phenytoin IV push to a client. The client has dextrose 5%
in water infusing continuously. Which action is appropriate?
A Pinch the line above the infusion port during the administration
B Hold the medication and collaborate with the provider prior to administration
C Stop the infusion and flush the port with normal saline prior to administration
D Ask the pharmacy to mix the medication into an IV piggyback (IVPB) infusion

Question Explanation
Correct Answer is C
Rationale: If giving phenytoin as an infusion, it cannot be administered with D5W because it will
precipitate. The D5W should be disconnected, the port flushed with normal saline solution
(NSS), medication administered, and the port flushed again with NSS before the D5W is
reconnected. The provider does not need to be contacted as this is best practice and aligns with
hospital protocol. Administering the medication via IVPB does not reduce the risk for
precipitation.
Concepts tested

Question 1749
The nurse is planning care for a pediatric client with a new prescription for adenosine to treat
symptomatic supraventricular tachycardia (SVT). Which action should the nurse include in the
plan of care?
A Monitor for ventricular dysrhythmias
B Monitor for shortness of breath
C Monitor for hypertension
D Monitor for nausea.

Question Explanation
Correct Answer is B
Rationale: After giving adenosine, the nurse would monitor for shortness of breath, dyspnea, and
a worsening of asthma, as they are expected effects/outcomes with this medication. Monitoring
for ventricular dysrhythmias is necessary when giving dobutamine, dopamine, and epinephrine
Page | 715
but not adenosine. Vomiting is not an expected outcome of adenosine. The nurse should include
monitoring for hypotension, not hypertension, in the plan of care after administration of
adenosine and instruct parents to change positions slowly to minimize orthostatic hypotension.
Concepts tested

Question 1750
A nurse is providing care to a client who takes phenytoin for seizure prevention. The latest
laboratory report shows a phenytoin level of 32 mcg/mL. Which action does the nurse take next?
A Examine the oral cavity
B Percuss the abdomen
C Check the skin turgor
D Assess the pupillary response

Question Explanation
Correct Answer is D
Rationale: A phenytoin level of 32 mcg/mL is not an expected response to therapy. The
therapeutic range of phenytoin is 10 to 20 mcg/mL. Signs of phenytoin toxicity include
nystagmus, ataxia, and confusion. The pupillary response will assess for symmetrical movements
of the eye. Examining the oral cavity, percussing the abdomen, and checking for skin turgor do
not evaluate symptoms of phenytoin toxicity.
Concepts tested

Question 1751
A nurse is administering vincristine to a client with cancer. The client asks the nurse how the
medication works. Which statement by the nurse is appropriate?
A “It stops the synthesis of proteins in cancer cells.”
B “It prevents cell division of cancer cells.”
C “It interrupts the S-phase of cancer cell reproduction.”
D “It alters the DNA structure of cancer cells.”

Question Explanation
Correct Answer is B
Rationale: Antimitotics, such as vincristine, kill cancerous cells by inhibiting cell division and
mitosis. Stopping the synthesis of proteins in cancer cells is the expected action of antitumor
antibiotics. Interruption of the S-phase of cell reproduction is the expected action of
antimetabolites. Altering the DNA structure of cancer cells is the expected action of alkylating
agents.
Concepts tested

Question 1752
The nurse is educating a client on the use of nalbuphine for labor pain management. Which of
the following statements should be included in the teaching?
A “This medication may cause you to be drowsy.”
B “This medication will reduce the strength of your contractions.”
C “This medication can be given all the way up until delivery.”

Page | 716
D “This medication may cause maternal hypertension.”

Question Explanation
Correct Answer is A
Rationale: Nalbuphine can cause sedation, drowsiness, nausea, and vomiting. The medication
does not affect the strength of contractions or cause maternal hypertension. Nalbuphine should
not be given immediately before delivery, as it increases the risk for respiratory distress.
Concepts tested

Question 1753
The nurse is providing education to the client prescribed montelukast for the treatment of
asthma. What medication should the nurse instruct the client to avoid?
A Ibuprofen
B Prednisone
C Amoxicillin
D Formoterol

Question Explanation
Orrect Answer is A
Rationale: Montelukast should not be taken with NSAIDs. It increases the risk of bleeding as
well as has the potential to make asthma symptoms worse. Prednisone, amoxicillin, and
formoterol are all safe to administer to the client on montelukast.
Concepts tested

Question 1754
The nurse is preparing to administer 0600 medications to a client. The client is prescribed
levothyroxine 125 mcg PO daily for hypothyroidism. The medication package states
levothyroxine tablet 0.125 mg. Which action is appropriate?
A Administer the medication
B Call the pharmacy and ask them to deliver the correct dose
C Hold the medication until the healthcare provider arrives
D Call the healthcare provider and request that the time of administration be changed

Question Explanation
Correct Answer is A
Rationale: Levothyroxine is taken in the morning on an empty stomach. Administering the
medication later in the day reduces the efficacy. A typical dose of levothyroxine ranges from
100-200 mcg/day. Often the medication packages display the dose in milligrams, so the dose
must be converted. In this case, it is safe to administer the medication as provided. It is important
to check the dosage as part of the checks/rights of medication administration (right medication,
right patient, right dosage, right route, and right time).
Concepts tested

Question 1755

Page | 717
The nurse is preparing to administer ceftriaxone to a client. Which of the following findings from
the client’s medical record should cause the nurse to question this prescription?
A White blood cells in the urine
B History of hypertension
C Allergy to cephalexin
D Current tobacco smoker

Question Explanation
Correct Answer is C
Rationale: Ceftriaxone and cephalexin are both cephalosporins; therefore, an allergy to
cephalexin should cause the nurse to question any prescription for a cephalosporin. Hypertension
and tobacco use do not affect the ability to take ceftriaxone. Elevated white blood counts
(WBCs) in the urine indicate a possible infection and may be why antibiotics were prescribed,
but this finding should not cause the nurse to be concerned about the medication.
Concepts tested

Question 1756
The nurse is preparing to administer a subcutaneous injection to a client. Which of the following
locations would be an appropriate administration site?
A Posterior surface of the upper arm
B Anterior to the sternum
C Dorsal surface of the hand
D Medial aspect of the lower leg

Question Explanation
Correct Answer is A
Rationale: Appropriate subcutaneous injection sites have a higher proportion of adipose tissue,
and common sites include the posterior surface of the upper arm, the abdomen, and the anterior
surface of the thigh. The sternum, dorsal surface of the hand, and medial aspect of the lower leg
do not have significant adipose tissue present.
Concepts tested

Question 1757
A nurse has removed a 2 ml vial of fentanyl from the medication dispensing system. After
dosage calculations, the nurse determines only 1 ml will be administered to the client. Which
action will the nurse perform with the remainder of the medication?
A Request another nurse to witness wasting of the unused medication
B Dispose of the unused medication in the sink
C Store the unused of the medication in the medication cart
D Return the unused medication to the dispensing system

Question Explanation
Correct Answer is A
Rationale: Unused controlled substances such as fentanyl should be wasted. The waste of
narcotics requires a witness. The nurse should request another licensed nurse to witness the

Page | 718
waste of the additional 1 ml of medication. Disposal of controlled substances should be
witnessed. Unused controlled substances should be wasted, not stored or returned to the
dispensing system.
Concepts tested

Question 1758
A nurse is assessing a client receiving alteplase for a pulmonary embolism. The client suddenly
becomes confused and is unable to follow commands. What action does the nurse take first?
A Notify the healthcare provider
B Reorient the client
C Check the client’s pupils
D Stop the infusion

Question Explanation
Correct Answer is D
Rationale: Alteplase is a thrombolytic medication that causes lysis of blood clots. Alteplase is a
high-risk medication that can cause internal bleeding. Sudden neurological deficits may indicate
an intracranial bleed. The nurse should stop the infusion. Reorienting the client, checking the
pupils, and notifying the healthcare provider are all necessary interventions after the infusion is
stopped for safety.
Concepts tested

Question 1759
A nurse is assessing a client receiving an intravenous fluid bolus. Which clinical finding
indicates an adverse effect to the fluid therapy?
A Crackles auscultated in the lungs
B Urine output of 100 mL in an hour
C Decreased skin turgor
D Heart rate of 98 beats/min

Question Explanation
Correct Answer is A
Rationale: Crackles upon auscultation of the lungs can be an indication of fluid overload. A
bolus is a rapid administration of fluid, which should be carefully monitored. A urine output of
100 mL in one hour is not indicative of an adverse effect to fluid therapy. An increase in urine
output is expected. Decreased skin turgor is an indication of dehydration, not an adverse effect to
fluid replacement. A heart rate of 98 beats/min is on the higher side of normal (60-100
beats/min).
Concepts tested

Question 1760
A nurse is preparing to administer morphine to a client with chronic pain. Which assessment
finding would prompt the nurse to withhold the medication?
A Heart rate of 117 beats/min

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B Urine output of 35 ml/hr
C Oxygen saturation of 92%
D Respiratory rate of 11 breaths/min

Question Explanation
Correct Answer is D
Rationale: The nurse should withhold the medication if the respiratory rate is 11 breaths/min.
Opioid medications, such as morphine, can cause respiratory depression. A respiratory rate of 11
breaths/min increases the risk of respiratory depression and arrest. The normal respiratory rate is
12-20 breaths/min. A heart rate of 117 beats/min (tachycardia) is not contraindicated with the use
of morphine. Morphine can cause the opposite effect, bradycardia. Morphine can cause urinary
retention; however, a urine output of 35 ml/hr is a normal finding. Oxygen saturation of 92% is a
low-normal finding. The nurse should administer the medication and monitor the client’s
respiratory status.
Concepts tested

Question 1761
The nurse is providing education to the client receiving total parenteral nutrition (TPN) in the
home setting. Which of the following statements by the client indicates the need for further
teaching?
A “The bags can be stored on the kitchen counter.”
B “I need to contact my provider if I feel numbness or weakness.”
C “I should weigh myself at the same time daily.”
D “There should be no redness around the catheter insertion site.”

Question Explanation
Correct Answer is A
Rationale: Nurses are involved in educating the client about the techniques and responsibilities
associated with TPN and providing technical and psychological support to the client receiving
TPN in the home. Client education should specifically include proper storage of parenteral
nutrition containers and supplies, infection prevention measures, signs and symptoms of glucose
alterations, signs and symptoms of abnormal electrolytes and fluid volume excess, signs of
infection, and basic care of the venous access device.
Concepts tested

Question 1762
The nurse is educating a client about newly prescribed alprazolam. Which information should the
nurse include in the teaching?
A Tardive dyskinesia is common early in treatment.
B Administration of paroxetine may be needed to prevent adverse effects.
C The use of grapefruit juice should be avoided.
D Hyperactivity is seen with long-term use.

Question Explanation
Correct Answer is C

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Rationale: Grapefruit or grapefruit juice is a known food-drug interaction and may increase drug
levels of alprazolam to potentially toxic concentrations. Paroxetine when given with alprazolam
will increase the incidence of adverse side effects. Alprazolam is used to treat tardive dyskinesia
and is not an adverse side effect of this medication. In general, side effects of benzodiazepines
with long-term use include drowsiness, lethargy, and weight gain but not hyperactivity.
Concepts tested

Question 1763
A nurse is reviewing laboratory data of a client taking paclitaxel for ovarian cancer. Which
finding would the nurse report to the healthcare provider before administering the next dose of
medication?
A Platelet count of 475,000/mm³
B Eosinophil level of 400/mm³
C Red blood cell count of 6.5 million/mm³
D Neutrophil count of 1,200/mm³

Question Explanation
Correct Answer is D
Rationale: Paclitaxel is an antineoplastic medication used in the treatment of various cancers.
Paclitaxel causes neutropenia and is contraindicated in clients with a neutrophil count below
1,500/mm³. A platelet count of 475,000/mm³ is above normal. Paclitaxel can cause
thrombocytopenia (low platelet count). Eosinophils are white blood cells that fight infectious
organisms. An eosinophil level of 400/mm³ is a normal finding. A red blood cell (RBC) count of
6.5 million/mm³ is above normal. Paclitaxel can cause anemia (low RBCs).
Concepts tested

Question 1764
A nurse has initiated a blood transfusion on a client 15 minutes ago. As the nurse is assessing the
client’s response, the client states, “My lower back is starting to hurt, and I feel nauseous.”
Which action does the nurse take next?
A Slow the transfusion rate and administer an anti-emetic
B Continue the transfusion and offer the client an emesis basin
C Stop the transfusion and take the client’s vital signs
D Pause the transfusion and administer pain medication

Question Explanation
Correct Answer is C
Rationale: The client’s symptoms are indicative of a transfusion reaction. The nurse should stop
the transfusion and take the client’s vital signs. Any abnormal findings should immediately be
reported to the healthcare provider. Administering an anti-emetic will correct the nausea but it
does not address the possibility of the client having a transfusion reaction. Continuing the
transfusion may cause a further, serious reaction to the blood product. Administering pain
medication will relieve the client’s back pain but does not address the possible transfusion
reaction.
Concepts tested

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Question 1765
The nurse is monitoring the client who is taking newly prescribed antihypertensive medication.
Which finding should indicate to the nurse that the client might be experiencing an allergic
reaction to the medication?
A Mild decrease in blood pressure
B Increased urine output
C Left-sided weakness
D Development of a rash

Question Explanation
Correct Answer is D
Rationale: Allergic reactions are often manifested by the presence of a rash, urticaria,
gastrointestinal symptoms, and itching. A mild decrease in blood pressure is the intended effect
of the medication. Increased urinary output and unilateral weakness are not indications of an
allergic reaction.
Concepts tested

Question 1766
The nurse has administered a dose of betamethasone to a client who is 34 weeks gestation.
Which statement should the nurse make when discussing the side effects of the medication with
the client?
A “This medication will treat your hypertension.”
B “Your blood glucose level could increase with this medication.”
C “Taking this medication will prevent pre-term labor.”
D “You may experience increased urination while taking this medication.”

Question Explanation
Correct Answer is B
Rationale: Betamethasone is a glucocorticoid that often causes an increase in maternal blood
glucose. The nurse should monitor blood glucose closely after administration in clients with
diabetes. Beta-blockers, such as metoprolol, decrease blood pressure. Terbutaline is a medication
used to treat pre-term labor. Diuretics, such as furosemide, will increase urine output.
Concepts tested

Question 1767
The nurse is teaching a client about newly prescribed inhaled budesonide. The nurse should
teach the client to report which finding to the healthcare provider?
A Rounded face
B Bradycardia
C Increased thirst
D Cough

Question Explanation
Correct Answer is C

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Rationale: Respiratory disorders, such as asthma, status asthmatic, chronic obstructive
pulmonary disease (COPD), and rhinitis, may all be treated with corticosteroids, including
budesonide. Corticosteroids have many common side effects including cushingoid features, such
as “moon face” due to redistribution of fat. Fluid retention is also common when using
corticosteroids. Increased thirst may be an indication of hyperglycemia and should be reported.
Corticosteroids can increase heart rate. A cough is normal with corticosteroids as the airway is
dilated.
Concepts tested

Question 1768
The nurse is caring for a client diagnosed with diabetic ketoacidosis who is receiving 50 mEq of
sodium bicarbonate in 1 L of dextrose 5% in water via a central venous access device. The client
has three new prescriptions for continuously infused medications. Which action is appropriate?
A Refer to an IV compatibility chart
B Request that an additional IV access be inserted
C Use a Y-site connector to infuse two medications in the same port
D Insert a peripheral intravenous access

Question Explanation
Correct Answer is A
Rationale: Sodium bicarbonate is incompatible with many other drugs and solutions. The nurse
should consult a drug compatibility reference for more information on which drugs can be
administered via connection at the most distal IV tubing port. Y tubing should not be added to an
IV until compatibility is determined. Y tubing does not prevent the mixing of infusions. Adding
an additional access may be unnecessary if compatibility is determined and may pose an
unnecessary infection risk to the client. A central line is the preferred access for drugs that have a
pH less than 5 and greater than 9. Certain drugs are venous irritants regardless of pH or
concentration; therefore, a PIV would be inappropriate.
Concepts tested

Question 1769
The nurse is collecting the health history of a client who reports taking over-the-counter
pseudoephedrine for nasal congestion. Which statement by the client would require follow-up by
the nurse?
A “I take this medication at night before I go to bed.”
B “I have to use a normal saline nasal spray since I started this medication.”
C “I avoid drinking beverages with caffeine while taking the medication.”
D “I chew gum when I take this medication to help with my dry mouth.”

Question Explanation
Correct Answer is A
Rationale: Pseudoephedrine is a nasal decongestion that causes vasoconstriction in the
respiratory mucosa and bronchodilatation making it easier for the client to breathe. The
medication is a stimulant, so clients should avoid taking the medication before bed to prevent
insomnia. The use of caffeine will exacerbate the alpha-adrenergic effect of this drug. Chewing
gum helps alleviate dry mouth that accompanies respiratory mucosa constriction that occurs
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when taking this medication. This medication can dry mucus membranes, so clients may use a
normal saline nasal spray.
Concepts tested

Question 1770
A nurse is assessing a client with heart failure who is taking prescribed torsemide. Which clinical
finding indicates effectiveness of the medication?
A Symmetrical pulses bilaterally
B Full strength to bilateral extremities
C Intact whisper test
D Absence of peripheral edema

Question Explanation
Correct Answer is D
Rationale: Torsemide is a loop diuretic used in the treatment of hypertension and fluid overload.
The expected therapeutic response of torsemide is a decrease in fluid retention evidenced by the
absence of peripheral edema. Symmetrical pulses bilaterally and full strength to bilateral
extremities do not evaluate the effectiveness of torsemide. An intact whisper test indicates the
absence of ototoxicity, an adverse effect of torsemide. However, this does not evaluate
medication effectiveness.
Concepts tested

Question 1771
A nurse is administering insulin glargine to a client with diabetes type I. The client asks the nurse
why insulin is the only option for therapy. Which statement by the nurse is appropriate?
A “Your body does not produce an adequate amount of insulin.”
B “Insulin is better at controlling the disease than oral pills.”
C “Your body has a resistance to insulin.”
D “Oral pills take longer to produce therapeutic effects than insulin.”

Question Explanation
Correct Answer is A
Rationale: Diabetes mellitus type 1 is characterized by the inability of the beta cells to produce
insulin. The disease is managed by implementing an insulin regimen. Oral hypoglycemic
medications are not effective in treating diabetes type 1. The body’s resistance to insulin is
characteristic of diabetes mellitus type 2. The onset of oral hypoglycemic medications is not
relevant to a client with diabetes mellitus type 1.
Concepts tested

Question 1772
The nurse is preparing a laboring client for placement of epidural analgesia. Which statement by
the nurse is appropriate to include in the client education?
A “An epidural might cause a decrease in blood pressure.”
B “An epidural will slow down your labor.”
C “An epidural increases your risk of cesarean section.”

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D “An epidural allows your body to have more effective contractions.”

Question Explanation
Correct Answer is A
Rationale: One of the more common adverse effects of an epidural is maternal hypotension. This
should be explained to the client prior to epidural placement. An epidural does not affect
contraction frequency or strength and does not increase the risk of cesarean section
Concepts tested

Question 1773
The nurse is providing education to the parent of a pediatric client receiving amoxicillin
clavulanate suspension. Which of the following statements is appropriate?
A “Use the measuring device provided by the pharmacy.”
B “You should take this medication on an empty stomach.”
C “Avoid shaking the medication before opening.”
D “Take the medication with a glass of juice.”

Question Explanation
Correct Answer is A
Rationale: Take augmentin (amoxicillin clavulanate) with meals to increase absorption and
decrease GI upset. Acidic fluids may destroy the drug, so avoid taking the medication with citrus
juice. The client should be taught to shake liquid penicillins well as the medication tends to
separate out of the suspension. Measure liquid doses carefully. Use the measuring device that
comes with this drug. If there is none, ask the pharmacist for a device to measure this drug.
Concepts tested

Question 1774
The nurse is caring for a client with a diagnosis of cardiogenic shock who has been prescribed
dobutamine infusion. Which action should the nurse take first?
A Compare the packaging of the medication to the prescription
B Prime the IV tubing with the medication
C Set the infusion pump for the correct infusion rate
D Increase the frequency of blood pressure and heart rate monitoring on the bedside monitor

Question Explanation
Correct Answer is A
Rationale: The Food and Drug Administration and Institute for Safe Medication Practices has
maintained a list of drug name pairs and trios that look and sound similar. These medications are
called out with tall man lettering on dissimilar lettering on the packaging (capital letters).
Dobutamine is often confused with dopamine and is included in the list. Ensuring the use of the
right medication is a part of the rights of medication administration. This should be done before
priming the tubing with the medication and setting the infusion pump. While frequent vital signs
are important for the client with shock, it isn’t the most important action in this scenario.
Concepts tested

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Question 1775
The nurse is preparing to administer methylergonovine to a client for postpartum hemorrhage.
Which of the following questions by the nurse is appropriate to assess for contraindications
before administration?
A “How many pregnancies have you had?”
B “Have you ever had uterine surgeries?”
C “Did you have asthma as a child?”
D “Do you have a history of high blood pressure?”

Question Explanation
Correct Answer is D
Rationale: The nurse should assess for any history of hypertension, hypotension, or preeclampsia
before administration because these are contraindications to methylergonovine. Asthma is not a
contraindication for this medication. The number of pregnancies or uterine surgeries does not
have any effect on the ability to administer this medication.
Concepts tested

Question 1776
The nurse is preparing to administer an intramuscular injection to an adult client using the
deltoid site. Which of the following needle sizes would be an appropriate choice for this
injection?
A 18 gauge, 5/8 inch needle
B 30 gauge, 2 inch needle
C 25 gauge, 1 inch needle
D 16 gauge, 1.5 inch needle

Question Explanation
Correct Answer is C
Rationale: An intramuscular injection requires a needle that is long enough to reach the muscle
tissue at the deltoid site; this is typically 5/8 inches to 1.5 inches. The gauge of the needle should
be 20-25 gauge.
Concepts tested

Question 1777
A nurse is preparing a medication for a client in the medication room. The nurse receives an
emergency call while withdrawing medication into a syringe. Which action should the nurse
take?
A Discard the medication from the syringe into the sink
B Place the syringe in the clothes pocket before leaving the medication room
C Store the syringe in the client’s drawer in the medication cart
D Leave the syringe on the counter in the medication room

Question Explanation
Correct Answer is C

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Rationale: The nurse should store the syringe in the client’s drawer in the medication cart. This
action ensures the medication is secured and ready to administer after the nurse responds to the
emergency call. Discarding the medication into the sink is not necessary. The medication can be
stored in a secure location. Placing unlabeled medication in a clothes pocket is not safe nursing
practice. Leaving the syringe on the counter in the medication room is not appropriate nursing
practice. The medication is not labeled and can be diverted.
Concepts tested

Question 1778
A nurse is preparing to administer intravenous mannitol to a client with increased intracranial
pressure. Which action will the nurse perform prior to administering the medication?
A Connect an in-line filter to the infusion tubing
B Dilute the medication with lactated ringers
C Prepare an infusion warmer
D Ensure the client has a patent central line

Question Explanation
Correct Answer is A
Rationale: The nurse should connect a filter to the infusion tubing prior to administering
mannitol. Mannitol is an osmotic diuretic that may contain crystals within the solution. The in-
line filter prevents the administration of particulates into the bloodstream. Mannitol should be
administered undiluted. An infusion warmer is not required for the administration of mannitol.
Mannitol can be administered through a peripheral line.
Concepts tested

Question 1779
A nurse is assessing a client who is receiving IV intermittent fluid replacements. Which finding
indicates the client is experiencing fluid volume excess?
A Neck veins appear full when client is supine.
B The client is lethargic.
C Dark yellow urine is present.
D Dependent edema is present in bilateral lower extremities.

Question Explanation
Correct Answer is D
Rationale: Edema to bilateral lower extremities is indicative of fluid overload and fluid retention.
The nurse should report this finding to the healthcare provider. Full neck veins when the client is
supine is a normal finding. Distended neck veins when the client is upright is a cause for
concern. Lethargy is a sign of severe fluid volume deficit. Dark yellow urine is indicative of
extracellular volume deficit. The kidneys will attempt to reduce urine production to maintain
volume.
Concepts tested

Question 1780
A nurse is preparing to administer indomethacin to a client with acute pain. Which medication on
the client’s medical record will prompt the nurse to monitor the client more frequently?
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A Pantoprazole
B Warfarin
C Simvastatin
D Alprazolam

Question Explanation
Correct Answer is B
Rationale: Indomethacin is a non-steroidal anti-inflammatory drug (NSAID) used in the
treatment of mild to moderate pain. NSAIDS increase the risk of gastrointestinal bleeding.
Warfarin is an anticoagulant medication that can increase the risk of bleeding. The nurse should
monitor the client for adverse effects more frequently. Pantoprazole is a proton pump inhibitor
used in the treatment of gastric ulcers. Simvastatin is an antilipemic medication used in the
treatment of high cholesterol. Alprazolam is a benzodiazepine used in the treatment of anxiety.
Pantoprazole, simvastatin, and alprazolam have no known drug interaction with indomethacin.
Concepts tested

Question 1781
The nurse is caring for the client with a triple lumen central venous access device prescribed total
parenteral nutrition (TPN). Which of the following actions is appropriate?
A Dedicate one lumen to TPN administration
B Initiate the infusion at the goal infusion rate
C Add a .22-micron filter to the infusion set
D Change the infusion set every 96 hours

Question Explanation
Correct Answer is A
Rationale: TPN is administered using an electronic infusion device with anti-free-flow
protection, via continuous or cyclic infusion. If the patient has a multilumen catheter in place,
dedicate one lumen for the administration of the parenteral nutrition. Do not use that lumen or
administration set for any other purpose to prevent incompatibility problems. Use a 1.2-micron
filter for total nutrient admixtures (3-in-1, all-in-one). Change infusion administration sets every
24 hours. TPN should be initiated slowly and titrated up to reduce swings in blood sugar.
Concepts tested

Question 1782
The client has been prescribed sertraline for depression. Which action should the nurse include in
the plan of care?
A Advise that the medication will be tapered prior to discontinuation
B Monitor for signs of physical addiction
C Emphasize that relief of symptoms occurs in one week
D Assess for symptoms of a thrombus formation

Question Explanation
Correct Answer is A

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Rationale: Sertraline, a selective serotonin reuptake inhibitor (SSRI), should be tapered with
provider supervision prior to discontinuation. Abrupt discontinuation can result in withdrawal
symptoms including nausea, sweating, agitation, tremors, insomnia, and seizures. Sertraline does
not cause physical addiction. Therapeutic actions include enhancement of mood after several
weeks. Increased incidence of clotting disorders is not associated with sertraline and may have a
blood-thinning effect.
Concepts tested

Question 1783
A charge nurse is observing a staff nurse prepare 1 ml of intravenous digoxin for a client with
heart failure. After the staff nurse prepares the medication, the nurse notices precipitate in the
syringe. Which action by the staff nurse likely caused this reaction?
A D5W was used as the diluent.
B The medication was not allowed to reach room temperature.
C The medication was added to 1 mL of diluent.
D Air was not inserted into the vial.

Question Explanation
Correct Answer is C
Rationale: When administering digoxin, 1 milliliter of digoxin should be mixed into at least 4
milliliters of diluent. Using a smaller amount of diluent will cause precipitation of the
medication. Dextrose 5% in water (D5W) is compatible with digoxin and can be used to dilute
the medication. Digoxin is not a temperature-controlled medication. Precipitation occurs as a
result of incompatibilities or improper mixing. The insertion of air into a vial facilitates the
withdrawal of the medication. Omission of this does not cause medication precipitation.
Concepts tested

Question 1784
A preop nurse is initiating peripheral intravenous access on a client scheduled for surgery. The
nurse selects an 18-gauge catheter for insertion. The client asks the nurse why the catheter needs
to be so large. How will the nurse respond to the client’s concern?
A “You may require rapid fluid infusions during the surgery.”
B “I can use a smaller gauge if that makes you feel comfortable.”
C “You have large veins that can accommodate this catheter.”
D “Tell me why you are concerned about the size of the catheter.”

Question Explanation
Correct Answer is A
Rationale: A larger gauge catheter (18 to 20) should be initiated on clients scheduled for surgery.
Unexpected events during surgery may require rapid fluid infusions or blood administration. The
nurse should educate the client on the need for a large gauge. A smaller gauge should be avoided
unless initiating access on the client is difficult. Vein size is not the reason that a large gauge is
required. Surgery requires larger gauge catheters for rapid fluid infusions. Asking the client to
express their concerns is part of therapeutic communication but does not address the concerns.
Concepts tested

Page | 729
Question 1785
The nurse is assessing a client who reports urticaria on the chest and abdomen. Which question
would be most appropriate for the nurse to ask?
A “Have you recently started taking any new medications?”
B “Do you have a family history of psoriasis?”
C “How much water do you drink each day?”
D “Has anyone in your home been sick?”

Question Explanation
Correct Answer is A
Rationale: Allergic reactions to medications can happen immediately but may take hours or days
to have visible signs or symptoms. It is important for the nurse to ask the client if they have taken
any new medications and if they have, to ask about the frequency of that medication. Drinking
water is important to prevent dry skin; however, urticaria, or hives, occurs with allergic
reactions. A family history of psoriasis would be appropriate to assess if the client is reporting a
rash that appears like plaques. Assessing if anyone in the home has been sick is appropriate if the
client has a contagious condition, like scabies.
Concepts tested

Question 1786
The nurse is teaching a client who is pregnant about the prescribed infusion of magnesium
sulfate. Which statement by the nurse would be appropriate to include in client education about
this medication?
A “You may experience an increase in contractions while taking this medication."
B “Vaginal bleeding is normal with this medication.”
C “Hot flashes are a side effect of the medication.”
D “You may feel the baby move more with this medication.”

Question Explanation
Correct Answer is C
Rationale: Magnesium sulfate infusion is used in pregnancy to prevent seizure due to
preeclampsia. When teaching the client about side effects, the nurse should advise the client of
hot flashes, feelings of warmth, and diaphoresis. Vaginal bleeding does not occur with
magnesium and could indicate a complication of the pregnancy. Magnesium does not affect the
movement of the baby or contractions.
Concepts tested

Question 1787
The nurse is counseling a client with gastroesophageal reflux disease (GERD) who has been
taking prescribed famotidine for two days. Which statement would require immediate follow up
by a healthcare provider?
A “I take digoxin for my heart failure.”
B “I use calcium carbonate if I have symptoms after meals.”
C “I use alendronate for my osteoporosis.”
D “I’m still having some symptoms of heartburn.”

Page | 730
Question Explanation
Correct Answer is A
Rationale: Most medications for heartburn decrease stomach acid. Histamine blocking drugs
such as famotidine (H2 receptor antagonist) are available as both prescription and over-the-
counter. It is often advised to take an antacid with an H2RA to relieve pain. Symptoms should be
improved after one week. Famotidine does not cause bone loss, unlike proton pump inhibitors,
and is an acceptable choice for clients with osteoporosis. Famotidine is used cautiously in clients
on digoxin as it decreases absorption. This client needs to have their digoxin level checked, and
the dosage may need to be adjusted.
Concepts tested

Question 1788
The nurse is caring for a client prescribed furosemide and digoxin for the treatment of heart
failure. The client reports seeing halos and bright lights. Which laboratory result would be
anticipated?
A Low sodium level
B Low digitalis level
C Low potassium level
D Low serum osmolality

Question Explanation
Correct Answer is C
Rationale: Digitalis toxicity is an accumulation of digitalis (digoxin) in the body that leads to
nausea, vomiting, visual disturbances, atrial or ventricular tachydysrhythmias, ventricular
fibrillation, sinoatrial block, and atrioventricular block. Clients with heart failure who take
digoxin are commonly given diuretics. Hypokalemia can increase the risk of digitalis toxicity.
Digitalis toxicity may also develop in the presence of hypomagnesemia. Clients with dig toxicity
would have elevated digoxin levels. Sodium would likely be normal. The serum osmolality
would likely be normal or high in a client on a diuretic.
Concepts tested

Question 1789
The nurse is collecting the health history from a client with depression who is taking prescribed
phenelzine. Which statement would be appropriate for the nurse to make?
A “How often do you exercise in a week?”
B “Do you drink a lot of water?”
C “Can you describe the types of foods you eat?”
D “When was the last time you had blood work done?”

Question Explanation
Correct Answer is C
Rationale: Phenelzine is a monoamine oxidase inhibitor (MAOI), which is a medication used to
treat depression when other drug classes are not effective. MAOIs are contraindicated with foods
that contain tyramine, which can cause severe hypertension and tachycardia. Foods such as aged
Page | 731
cheeses, smoked meats, and dried fruits contain tyramine. A client taking lithium is at risk for
electrolyte imbalance and should be evaluated for exercise, blood work, and drinking water.
Concepts tested

Question 1790
A nurse is assessing a client who takes prescribed oral indomethacin. Which client statement
indicates an intended response to the medication?
A “My appetite is greater in the mornings.”
B “I am able to rotate my wrists without pain.”
C “I no longer have to urinate in the middle of the night.”
D “My endurance while exercising has improved.”

Question Explanation
Correct Answer is B
Rationale: Indomethacin is a non-steroidal anti-inflammatory medication used in the treatment of
rheumatoid arthritis and other inflammatory disorders. The expected outcome is increased
mobility of the joints without pain. Full range of motion without pain is an expected response.
Improved appetite, decreased nocturia, and increased endurance are responses unrelated to the
effects of indomethacin.
Concepts tested

Question 1791
A nurse has administered oral radioactive iodine to a client with thyroid cancer. What
instructions will the nurse provide to the client upon discharge?
A “Do not share utensils with your family members.”
B “Remain isolated until instructed by your healthcare provider.”
C “Limit your fluid intake for the first several days.”
D “Use a bedside commode for your elimination needs.”

Question Explanation
Correct Answer is A
Rationale: Radioactive medications such as iodine remain active until the substance decays. It is
important to advise the client to not share food utensils as secretions are radioactive and can be
transmitted to another person. The client does not need to be isolated. The nurse should instruct
the client to maintain a 6-foot distance from others. Fluid intake should be increased after taking
radioactive iodine to aid in waste removal. Bodily fluids and secretions remain radioactive and
should be disposed of properly. Using a bedside commode increases the risk of transmission to
others.
Concepts tested

Question 1792
The nurse is educating a client about the use of fentanyl citrate via a patient-controlled analgesia
pump. Which of the following statements should be included in the teaching?
A “You cannot breastfeed your baby while using a patient controlled analgesia pump.”
B “You may get drowsy if you press the administration button too many times.”

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C “The administration button should not be pressed by anyone other than you.”
D “A patient controlled analgesia pump reduces the risk of post-partum hemorrhage.”

Question Explanation
Correct Answer is C
Rationale: A patient-controlled analgesia (PCA) pump is a device that the client can use to self-
administer medication. The client is the only person who should press the administration button.
These devices have a “lockout” that prevents the client from administering too many doses. The
PCA pump does not affect the likelihood of hemorrhage, and clients may breastfeed while using
the device.
Concepts tested

Question 1793
The nurse is educating a client receiving chemotherapy about newly prescribed ondansetron
regular tablets. What statement by the nurse is appropriate?
A “The medication works best if taken before you are nauseous.”
B “Take the medication with only a sip of water.”
C “This medication could cause difficulty with sleep.”
D “You may experience constipation with this medication.”

Question Explanation
Correct Answer is A
Rationale: Ondansetron is a serotonin 5-HT3 receptor antagonist. It works by blocking the action
of serotonin to treat nausea and vomiting. When taking ondansetron for nausea that occurs with
meals, then the standard tablet should be taken half an hour to 1 hour before meals. Headache
and diarrhea are common side effects. It can also cause dizziness and impaired gait and balance.
Ondansetron may mask an ileus and gastric distention.
Concepts tested

Question 1794
The nurse is preparing to administer an intravenous medication to a client who is obtunded. What
action is appropriate to confirm the client’s identity?
A Wake the client and ask them to state their name
B Use the room number as an identifier
C Compare the armband to the medical record
D Ask the previous nurse to confirm the client’s identity

Question Explanation
Correct Answer is C
Rationale: As part of the rights of medication administration, the nurse should identify a client by
checking the name and record number on the wristband and comparing it to the health record.
The nurse should not ask the client with a decreased level of consciousness for their name
because it is not reliable information and/or the client may be unable to self-report. Obtundation
means that the client only remains awake when stimuli are applied. The client is often confused

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when awake. The room number should not be used as an identifier as room assignments often
change. Other staff should not be used to confirm identity.
Concepts tested

Question 1795
The nurse is preparing to administer metoprolol to a client with a history of hypertension. Which
of the following data is the priority for the nurse to review prior to administration?
A Potassium level
B Most recent heart rate
C Creatinine level
D Respiratory rate

Question Explanation
Correct Answer is B
Rationale: Beta-blockers, such as metoprolol, can decrease heart rate and blood pressure, so the
nurse should review these specific vital signs prior to administering the medication. Most
prescriptions will state to hold the medication if the heart rate or blood pressure is less than a
designated value. Potassium and creatinine levels are monitored with clients who are taking
lisinopril, an ACE inhibitor. Respiratory rate is an important part of assessment but is not the
priority for the administration of a beta-blocker.
Concepts tested

Question 1796
The nurse is interviewing a client about home medications. Which of the following information
should the nurse document in the medical record as a part of the medication reconciliation?
A The client’s demographic information
B The frequency of each medication
C The client’s preferred pharmacy
D The name of the provider that prescribed each medication

Question Explanation
Correct Answer is B
Rationale: The medication reconciliation should be completed during the initial interview and
should include the name of the medication(s), the dose, the frequency, and compliance to the
prescribed medication regimen. The demographic information, the pharmacy information, and
the prescribing provider are not included as a part of the medication reconciliation.
Concepts tested

Question 1797
A nurse is preparing to administer a piggyback infusion to a client. The unlicensed assistive
personnel (UAP) enters the room and informs the nurse another client is requesting immediate
assistance. Which action will the nurse perform?
A Instruct the UAP to finish connecting the medication
B Continue to administer the medication to the client

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C Leave the medication hanging on the client’s IV pole
D Store the solution bag in the medication cart

Question Explanation
Correct Answer is D
Rationale: Administering a piggyback infusion requires priming the tubing and setting up the
infusion pump. This process can be lengthy, and the nurse is immediately needed in another
room. The medication cart provides a safe storage environment for the medication.
Administering intravenous medication is not a task that can be delegated to unlicensed assistive
personnel. The nurse should prioritize client needs. A client requesting immediate assistance
needs to be assessed first before administering a piggyback infusion to the current client. Unused
medication should not be left unattended.
Concepts tested

Question 1798
A nurse is preparing to administer doxorubicin to a client with bladder carcinoma. How will the
nurse prepare this medication?
A While wearing sterile gloves
B In a biological safety cabinet
C Inside a temperature-controlled room
D By withdrawing into a syringe undiluted

Question Explanation
Correct Answer is B
Rationale: Doxorubicin should be prepared in a biological safety cabinet. Doxorubicin is a high-
risk medication whose fumes may cause health hazards. A biosafety cabinet controls the airflow
while preparing this medication. Sterile gloves are not required. Standard gloves, a gown, and a
mask should be worn when preparing this medication. The temperature of the room is not a
specified guideline for preparing this medication. Doxorubicin should be diluted with normal
saline before administration.
Concepts tested

Question 1799
A nurse is assessing a client who received an intravenous fluid bolus for dehydration. Which
finding indicates the fluid therapy was effective?
A Capillary refill of +2
B Oxygen saturation of 91%
C Heart rate of 105 beats/min
D Urinary output of 25 ml/hr

Question Explanation
Correct Answer is A
Rationale: A capillary refill of +2 is a normal finding and an intended cardiovascular effect of
fluid replacement. Oxygen saturation of 91% indicates hypoxia, which occurs with dehydration.
Tachycardia is an indication of dehydration. An elevated heart rate is an attempt to maintain

Page | 735
normal blood pressure when there is a deficiency in volume. Urinary output of 25 ml/hr is
indicative of oliguria, a decreased production of urine. Oliguria occurs with dehydration.
Concepts tested

Question 1800
A nurse is preparing to discontinue a client’s fentanyl patient-controlled analgesia infusion.
Which priority action will the nurse take before discontinuing the infusion?
A Assess the client’s pain level
B Document the frequency of doses on the medication administration record
C Take the client’s vital signs
D Verify the infusion record with another registered nurse

Question Explanation
Correct Answer is D
Rationale: The nurse should verify the infusion record with another licensed healthcare provider
before discontinuation. Fentanyl is a controlled substance that requires recordkeeping of its
usage. Assessing the client’s pain level and checking vital signs are important assessments;
however, these actions are not specific to patient-controlled analgesia with a controlled
substance. Documenting the frequency of doses is important but must be verified with another
licensed provider.
Concepts tested

Question 1801
The nurse is caring for a client receiving a prescribed infusion of total parenteral nutrition (TPN).
Which of the following actions is appropriate?
A Monitor blood glucose levels daily
B Discard the remaining TPN solution after 24 hours
C Change the transparent dressing every 48 hours
D Review the provider’s order weekly

Question Explanation
Correct Answer is B
Rationale: TPN orders should be reviewed each day so that changes in electrolytes or the acid-
base balance can be addressed appropriately without wasting costly TPN solutions. Blood
glucose levels should be monitored 4 times a day initially to monitor for glycemic control.
Generally, new TPN tubing is required every 24 hours to prevent catheter-related bacteremia.
Any TPN remaining should be discarded and a new bag be hung. Transparent dressings may
remain in place for up to 7 days. Gauze dressings are changed every 48 hours.
Concepts tested

Question 1802
The nurse is caring for a client admitted for an acute mania episode of bipolar disorder. The
client reports stopping the prescribed lithium. Which action should the nurse do first?
A Ask the client why the medication was stopped
B Determine the client’s serum lithium level

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C Administer a stat lithium dose
D Assess the client’s physiological needs

Question Explanation
Correct Answer is D
Rationale: Because the client is experiencing an acute mania episode, the priority action would
be for the nurse to address the client’s physiological needs. It is important for the nurse to assess
why the client is non-compliant with the medication prescribed for his condition. However, the
client would not be able to answer the question in an acute manic state. Obtaining a serum
lithium level would help guide treatment but does not take priority over the client’s physiological
needs. Since lithium takes 2-8 weeks to become therapeutic, a stat dose would not be effective.
Concepts tested

Question 1803
A nurse is preparing to administer insulin to a client with diabetes mellitus type 1. The client has
regular insulin and insulin glargine prescribed. How will the nurse prepare these medications?
A Draw up the glargine insulin before the regular insulin
B Mix the insulins in a larger syringe
C Use a separate syringe for each insulin
D Draw up the regular insulin before the glargine insulin

Question Explanation
Correct Answer is C
Rationale: Insulin glargine is a clear, long-acting insulin that should not be mixed with other
insulins. Mixing insulin glargine with other medications can cause precipitate formation. The
insulins should be drawn up in separate syringes. Short-acting insulins should be drawn up
before long-acting insulins. However, insulin glargine should not be combined with any other
medication. A larger syringe does not address incompatibility issues.
Concepts tested

Question 1803
A nurse is administering multiple IV push medications to a client through a subclavian central
line. Which action will the nurse perform to prevent occlusion of the catheter?
A Flush the line between each medication
B Clamp the line after administering the medications
C Clean the catheter hub for 10 seconds between medication syringes
D Use a 1-ml syringe to flush the line

Question Explanation
Correct Answer is A
Rationale: Intravenous medications have different viscosities. Flushing the line between each
medication administration helps to prevent the formation of a thrombus, precipitate, or occluding
particles. Clamping the line after administering medications prevents a pneumothorax. Cleaning

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the catheter hub between syringes prevents infection, not occlusion. Syringes should ideally be
10-ml to avoid excess pressure and damage to the catheter.
Concepts tested

Question 1804
The home health nurse is completing a medication reconciliation of a client who has a new
prescription for warfarin. Which medication should the nurse question the healthcare provider
about?
A Aspirin
B Nifedipine
C NPH insulin
D Vitamin D supplement

Question Explanation
Correct Answer is A
Rationale: Warfarin is an anticoagulant that prevents blood from clotting by blocking the
synthesis of vitamin K. Clients taking warfarin are at increased risk for bleeding. Aspirin, which
is an anti-platelet aggregation, prevents platelets from clumping together. Taking warfarin and
aspirin together could increase the risk of bleeding and should be questioned. Nifedipine is a
calcium channel blocker and does not interact with warfarin. Insulin and vitamin D supplement
do not cause adverse effects when taken with warfarin.
Concepts tested

Question 1805
The nurse is teaching a client who is postoperative cesarean section about newly prescribed
oxycodone. Which statement should the nurse include in the client teaching about this
medication?
A “You may experience some constipation while taking this medication.”
B “Mothers who take this medication often have trouble with breastfeeding.”
C “This medication may cause difficulty with sleeping.”
D “Your vaginal bleeding may increase while taking this medication.”

Question Explanation
Correct Answer is A
Rationale: Opioids, such as oxycodone, are used to treat postoperative pain. Opioids can slow
down the gastrointestinal system, which may result in constipation. Opioids do not affect the
ability to breastfeed. Opioids can cause increased drowsiness. Opioids do not increase vaginal
bleeding.
Concepts tested

Question 1806
The nurse is educating a client prescribed metronidazole. Which of the following findings should
the nurse include in the education as reportable to the healthcare provider?
A Pinpoint red spots on the skin
B Nausea after beginning the medication

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C Metallic taste
D Occasional diarrhea

Question Explanation
Correct Answer is A
Rationale: The most common gastrointestinal effects of metronidazole are nausea, vomiting,
diarrhea, and metallic taste. Drug-induced immune thrombocytopenia (DITP) is a rare, but
serious, adverse effect where medications cause the body to produce antibodies to platelets. The
medication must be stopped immediately because DITP can be life-threatening. Heparin-induced
thrombocytopenia is one example. Metronidazole is associated with DITP. Petechiae are
pinpoint, round spots that appear on the skin as a result of bleeding. The bleeding causes the
petechiae to appear red, brown, or purple.
Concepts tested

Question 1807
The nurse is caring for a client who received digoxin-specific immune fab. Which finding
indicates the treatment is having the intended effect?
A Increased heart rate
B Decreased potassium levels
C Decreased blood pressure
D Increased serum digoxin levels

Question Explanation
Correct Answer is A
Rationale: Digoxin-specific immune fab is an antidote that binds molecules of digoxin, making
them unavailable for binding at their usual sites of action in the body. After administration of the
medication, serum digoxin levels may be misleading, as they will be elevated until the drug is
excreted by the kidneys. The goal of treatment is to lower digoxin levels and treat symptomatic
digoxin toxicity, specifically cardiac dysrhythmias including bradycardia. Potassium levels may
be low, triggering digoxin toxicity, and then elevated due to shifts caused by digoxin toxicity, so
fluctuating levels are not a sign of effective treatment. Effective treatment of dysrhythmia should
raise blood pressure.
Concepts tested

Question 1808
The clinic nurse is collecting data from a client who is taking prescribed methylphenidate for the
treatment of attention deficit hyperactivity disorder (ADHD) and is requesting an increase in the
dose. Which statement by the client would require immediate follow-up by the nurse?
A “I think I have lost weight since I started taking the medication.”
B “This medication is not calming me down even with green tea.”
C “I take more naps during the day on this medication.”
D “I am performing better at work but need to be more engaged.”

Question Explanation
Correct Answer is B

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Rationale: The use of caffeine-containing beverages (green tea) should be avoided with
methylphenidate as it may potentiate the common side effects of this medication, including
nervousness, restlessness, and palpitations. This statement would require follow-up by the nurse
first. Anorexia (loss of appetite) and insomnia are other common side effects of this medication
and should be discussed after addressing the misconception of the use of green tea.
Methylphenidate acts to stimulate the central nervous system to increase focus, but it will not
increase social interaction.
Concepts tested

Question 1809
A nurse is assessing a client who was prescribed fluoxetine for panic disorder 5 days ago. The
client tells the nurse their symptoms are not improving. Which statement will the nurse make to
the client?
A “It might be a few more weeks before your symptoms improve.”
B “I will contact the healthcare provider to increase your dose.”
C “Have you been taking the medication as directed?”
D “Why do you feel your symptoms are not improving?”

Question Explanation
Correct Answer is A
Rationale: Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) used in the treatment of
anxiety and panic disorders. SSRIs can take between 1 to 4 weeks to exert their effects. The
nurse should educate the client on the onset of fluoxetine. The client has not been taking the
medication long enough to warrant an increase in the dose. Asking the client if they have been
taking the medication as directed does not address their concerns. “Why” questions do not
promote therapeutic communication and do not address the client’s concern.
Concepts tested

Question 1810
A nurse is providing education on the use of subcutaneous octreotide to a client who will be
administering the medication at home. What will the nurse include in the teaching?
A “Store any remaining medication at room temperature.”
B “Inject the medication into the gluteal area.”
C “Administer the medication between meals.”
D “Use the medication immediately after removing it from the refrigerator.”

Question Explanation
Correct Answer is C
Rationale: Side effects of octreotide include abdominal pain, ileus, and diarrhea. The client
should be instructed to administer the medication between meals to decrease gastrointestinal
effects. Unused medication should be discarded. The prescription is for a subcutaneous injection.
The gluteal area is indicated for intramuscular injections. The medication should be allowed to
reach room temperature before administration to decrease skin reactions at the injection site.
Concepts tested

Question 1811
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The nurse is educating a client about the use of nitrous oxide in labor. Which of the following
statements should the nurse include in the teaching?
A “Using nitrous oxide may cause the baby to have lower APGAR scores.”
B “Nitrous oxide is administered through your IV catheter.”
C “If you use nitrous oxide, you cannot get an epidural afterward.”
D “The most common side effects of nitrous oxide are nausea and dizziness.”

Question Explanation
Correct Answer is D
Rationale: Nitrous oxide is an inhaled medication that has a rapid onset and clearance. Because
its half-life is so short, other methods of pain control, such as an epidural, can be used almost
immediately after discontinuing the medication. Nitrous oxide does not affect APGAR scores,
and the most common side effects are nausea, vomiting, and dizziness.
Concepts tested

Question 1812
The nurse is collecting the health history of a client with heart disease who reports experiencing
episodes of diarrhea. The client reports taking loperamide at home. Which of the following
statements should the nurse make?
A “Taking this medication may increase your risk of an abnormal heart rhythm.”
B “It is safe to drink alcohol while using this medication.”
C “Using this medication may cause dependence.”
D “Stop taking this medication if your symptoms do not improve by tomorrow.”

Question Explanation
Correct Answer is A
Rationale: Loperamide decreases GI motility and is a nonprescription drug. It does not cause the
central nervous system effects associated with opiate derivatives and lacks the potential for
abuse. Loperamide should not be continued after 48 hours if improvement has not occurred.
Loperamide has a black box warning because torsades de pointes, cardiac arrest, and death have
been reported in people using higher than recommended dosages. Alcohol can increase the
nervous system side effects of loperamide, such as dizziness, drowsiness, and difficulty
concentrating.
Concepts tested

Question 1813
The nurse is preparing to administer prescribed warfarin to a client with a mechanical heart
valve. Which finding should the nurse report to the healthcare provider?
A The INR is 3.0.
B The peripheral IV site has been oozing blood.
C The aPTT is 30.
D The client has cola-colored urine.

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Question Explanation
Correct Answer is D
Rationale: Cola-colored urine is a sign of hematuria. This may be caused by the warfarin or a
sign of another problem. It is common to have oozing around IV sites in clients on
anticoagulants. The INR of 3.0 is an expected finding. The aPTT should not be affected by
warfarin and is also an expected finding.
Concepts tested

Question 1814
The nurse is preparing to administer a client’s prescribed NPH and regular insulins. Which
action should the nurse take first when mixing the insulins in one syringe?
A Draw up the NPH
B Draw up the regular insulin
C Inject air into the NPH
D Inject air into the regular insulin

Question Explanation
Correct Answer is C
Rationale: When mixing insulins in the same vial, the process should be to inject air into the
long-acting insulin, inject air into the short-acting insulin, draw up the short-acting insulin, and
then draw up the long-acting insulin.
Concepts tested

Question 1815
The nurse is completing a client’s medication reconciliation. Which of the following questions
by the nurse is necessary to ask the client during this process?
A “Can you provide the dosage of these medications?”
B “Do you experience any side effects when taking these?”
C “How long have you been taking these medications?”
D “Where do you store your medications?”

Question Explanation
Correct Answer is A
Rationale: The medication reconciliation should include the name of the medication(s), the dose,
the frequency, and compliance to prescribed medication regimen. Side effects, history of
prescription, and medication storage are not included as a part of the medication reconciliation.
Concepts tested

Question 1816
A staff nurse is assisting a charge nurse with checking controlled substances at the change of
shift. The charge nurse is urgently called to a client’s room and has to leave the medication
room. Which action will the staff nurse take?
A Continue performing the check while the charge nurse assists the client

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B Leave the medication room to find another nurse to assist with the check
C Stop the check and sign out of the medication dispensing system
D Pause the check until the charge nurse returns to the medication room

Question Explanation
Correct Answer is C
Rationale: Performing inventory on controlled substances with another nurse should be finalized
in one session. If one of the nurses is unable to complete the count, the session should be
terminated, and the dispensing system should be secured. Performing an independently
controlled substance check is not safe nursing practice. An open medication dispensing system
should never be left unattended, especially with controlled substances. The charge nurse should
not leave the medication room after entering credentials into the dispensing system. Both nurses
should sign out of the system if unable to complete the check.
Concepts tested

Question 1817
A nurse is preparing to administer total parenteral nutrition (TPN) to a client. The nurse knows
that TPN should be administered through which access site?
A Antecubital peripheral line
B Brachial midline
C Subclavian central line
D External jugular peripheral line

Question Explanation
Correct Answer is C
Rationale: Total parenteral nutrition (TPN) is a hypertonic, highly concentrated solution that
should only be administered through a central venous access device. Administration through a
peripheral line is not safe practice due to the density of the nutrition. A midline does not cross
the axillary line and is considered a peripheral access.
Concepts tested

Question 1818
A nurse is assessing a client who is sedated after sustaining a traumatic fall. Which physiologic
response indicates the client may require pain medication?
A The client is diaphoretic.
B The client verbalizes an 8/10 pain.
C The client changes positions frequently.
D The client is grimacing.

Question Explanation
Correct Answer is A
Rationale: Acute pain stimulates the sympathetic nervous system. Diaphoresis is a sympathetic,
physiologic response to pain. A numerical pain scale would not be indicated for a client who is
sedated. The client would not be able to change positions frequently under sedation. Grimacing
is a behavioral, not a physiologic, response to pain.

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Concepts tested

Question 1819
A nurse is preparing to administer a hydromorphone injection to a client. As the nurse begins to
connect the syringe to the intravenous port, the client refuses the medication. Which action does
the nurse perform next?
A Discard the medication in the presence of another nurse
B Dispose of the syringe in the sharps container
C Flush the unused medication in the sink
D Document the client’s refusal of the medication in the electronic record

Question Explanation
Correct Answer is A
Rationale: Hydromorphone is a controlled substance that is regulated by federal law. Any unused
medication should be discarded in the presence of another licensed provider. The medication in
the syringe should be discarded before disposing of the supplies. The medication should be
flushed according to policy; however, it should be performed in the presence of another licensed
provider. Documenting refusal of medications is an important nursing action; however, this
should be done after the medication is discarded according to policy.
Concepts tested

Question 1820
The nurse is reviewing the plan of care for a group of assigned clients. For which client should
the nurse anticipate a prescription for total parenteral nutrition (TPN)?
A Bladder cancer
B ST elevation myocardial infarction
C Acute pancreatitis
D Diabetes type 2

Question Explanation
Correct Answer is C
Rationale: Clients with pancreatitis need to be NPO to prevent stimulation of the pancreas. Total
parenteral nutrition (TPN) is a nutrient solution consisting of dextrose, amino acids, lipids, and
select electrolytes, vitamins, minerals, and trace elements that must be infused through a central
vein because of its hypertonicity. TPN is frequently given to clients with severe inflammatory
bowel disease, severe pancreatitis, or acquired immunodeficiency syndrome (AIDS), who are
unable to meet their nutritional needs through the oral or enteral routes. Enteral nutrition is still
considered optimal.
Concepts tested

Question 1821
The client is admitted for evaluation of lithium toxicity. Which of the following observations by
the nurse would indicate that the condition is worsening?
A Dry mouth
B Drowsiness

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C Increased thirst
D Ataxia

Question Explanation
Correct Answer is D
Rationale: Ataxia, or loss of control of body movements, is a worsening sign of lithium toxicity.
Common side effects of lithium therapy include drowsiness, dry mouth, and increased thirst.
Concepts tested

Question 1822
A nurse is preparing to administer reconstituted doxorubicin (Myocet) to a client with thyroid
carcinoma. Nuclear medicine calls for the client, and the nurse is unable to administer the
medication. Which action should the nurse perform with the medication?
A Save the medication in a syringe with an aluminum needle
B Store the medication in the refrigerator inside the syringe
C Discard the medication in the hazardous waste container
D Add the medication to the intravenous fluids in the client’s room

Question Explanation
Correct Answer is B
Rationale: Doxorubicin that is stored in a refrigerator is stable for up to 48 hours. The medication
remains stable at room temperature for up to 24 hours. Saving the medication with an aluminum
needle will cause discoloration of the solution and form a dark precipitate. Discarding the
medication is not necessary. The medication can be stored for 24-48 hours. Doxorubicin should
not be added to intravenous fluids. The medication should be dissolved completely with a
diluent.
Concepts tested

Question 1823
A nurse is observing a graduate nurse (GN) perform a dressing change on a client’s femoral
central line. Which action by the GN requires an intervention by the nurse?
A Puts on a mask prior to performing the dressing change
B Cleans the skin around the site with CHG solution
C Applies clean gloves after opening the dressing kit
D Uses an alcohol pad to remove the adhesive stabilization device

Question Explanation
Correct Answer is C
Rationale: A central line dressing change is a sterile procedure. The graduate nurse (GN) should
apply sterile gloves after opening the sterile dressing kit. A mask protects the central line access
site from airborne microorganisms. Chlorhexidine gluconate is the preferred antiseptic solution
for cleaning the skin around the central line access site. Using an alcohol pad to remove adhesive
devices reduces the risk of skin injury.
Concepts tested

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Question 1824
The nurse is preparing to administer prescribed sertraline to a client with a history of depression.
Which statement by the client would require immediate follow-up?
A “I noticed this medication gives me a dry mouth.”
B “I would prefer to crush that medication.”
C “I also take St. John’s wort with that medication.”
D “I typically take the medication at night.”

Question Explanation
Correct Answer is C
Rationale: Sertraline is a selective serotonin reuptake inhibitor, which treats depression by
increasing the amount of available serotonin. St. John’s wort enhances serotonin transmission
and could cause an exacerbation of the effects of serotonin. Taking the medication at night or
crushing the tablet does not increase the likelihood of a reaction. Dry mouth is a common side
effect of the medication and is not the priority.
Concepts tested

Question 1825
The nurse is teaching a client who is postoperative cesarean section about prescribing morphine
via a patient-controlled device. Which statement should the nurse include in client teaching about
the medication?
A “It is normal for this medication to cause burning at the IV site.”
B “You will probably experience some itching each time you administer a dose.”
C “Tell your family members to press the administration button if you are feeling tired.”
D “Let a staff member know if you experience any trouble breathing.”

Question Explanation
Correct Answer is D
Rationale: Opioids, such as morphine, are used to treat postoperative pain. A patient-controlled
device allows the client to administer the medication at prescheduled intervals. Opioids can
cause respiratory depression. When teaching about the patient-controlled device, the nurse
should instruct the client to report any changes in respiratory status, including shortness of
breath. Only the client should push the administration button for the device. Burning at the IV
site and reports of itching are not normal findings and should be reported.
Concepts tested

Question 1826
The home health nurse is teaching a female client about self-administering vancomycin. Which
statement by the client demonstrates understanding of the teaching?
A “I need to call my provider if my urine changes.”
B “Muscle tingling and weakness is an expected side effect of this medication.”
C “Ringing in the ears is common when taking vancomycin.”
D “I should avoid eating food with active cultures in it.”

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Question Explanation
Correct Answer is A
Rationale: Vancomycin is commonly linked to nephrotoxicity, leading to the need for monitoring
trough levels. Signs of kidney injury include decreased urination, blood in the urine, and other
changes in urine color and clarity. Antibiotic-associated diarrhea (colitis) results from oral or
parenteral antibiotic therapy. Another pathogen is Candida albicans, which results in vaginal
yeast infection and oral thrush. Probiotics can reduce these risks. Antibiotic-induced neuropathy
is a rare complication of several antimicrobial agents. Hypokalemia can result from vancomycin;
therefore, muscle weakness and numbness or tingling should be reported. Ototoxicity is a serious
complication from vancomycin due to vestibular damage.
Concepts tested

Question 1827
The nurse is caring for a client with a sore throat who developed urticaria after the administration
of prescribed antibiotics. The client is now receiving cetirizine. Which finding indicates that the
cetirizine is having the intended effect?
A The client reports less itching.
B The tonsils are decreasing in size.
C The client reports less muffled hearing.
D The pain rating is decreased.

Question Explanation
Correct Answer is A
Rationale: Cetirizine is a second-generation H1 receptor antagonist (antihistamine). Cetirizine
binds preferentially to peripheral rather than central H1 receptors. This selectivity reduces the
occurrence of drowsiness and CNS depression. Second-generation antihistamines are now
commonly used to treat pruritis in urticaria. Almost any drug can lead to an allergic response,
especially in the case of sore throats, which can be mononucleosis misdiagnosed as strep throat.
A characteristic of infectious mononucleosis is that up to 90 percent of the time that amoxicillin
or ampicillin is taken, a rash then develops. The pattern of the rash is commonly maculopapular
in appearance. It is very itchy.
Concepts tested

Question 1828
The nurse is reviewing the laboratory results for a client with cancer who is being treated with
chemotherapy and recently started prescribed filgrastim. Which laboratory value indicates the
treatment is effective?
A Hemoglobin level of 9.8 g/dL
B White blood cell count (WBC) of 5,200/mm3
C Platelet count of 200,000/mm3
D Red blood cell count (RBC) of 4 million/mm3

Question Explanation
Correct Answer is B
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Rationale: The client has a normal white blood cell count indicating that filgrastim has been
effective. The action of filgrastim is to increase neutrophil production, thereby increasing the
white blood cell (WBC) count. Decreased hemoglobin (Hgb) indicates anemia. The hemoglobin
and red blood cell (RBC) count are below normal limits for an adult male. Epoetin alfa is used to
treat low RBC counts (anemia) caused by chemotherapy. The platelet count is within normal
limits for an adult client.
Concepts tested

Question 1829
A nurse is educating a client on insulin administration. Which statement made by the client
indicates further teaching is required?
A “I will inject the insulin in the same site every day.”
B “The best injection area is around my abdomen.”
C “I will squeeze my skin together to inject the medication.”
D “Gentle pressure should be applied to the site after injection.”

Question Explanation
Correct Answer is A
Rationale: The nurse should further educate the client on rotating injection sites to prevent
lipohypertrophy. Lipohypertrophy is the development of scar tissue under the skin that prevents
adequate absorption of the medication. The absorption rate is greater in the subcutaneous tissue
of the abdomen. Squeezing or bunching the skin together ensures the medication is administered
into the subcutaneous layer. Gentle pressure helps the medication to absorb better.
Concepts tested

Question 1830
A nurse is providing education on the use of carbidopa/levodopa to a client with Parkinson’s
disease. What will the nurse include in the teaching?
A “This medication will stop the progression of your condition.”
B “Notify your healthcare provider if your urine appears dark.”
C “Eat plenty of whole-grain foods when taking this medication.”
D “Avoid eating meals that are high in protein.”

Question Explanation
Correct Answer is D
Rationale: Carbidopa/levodopa is a combination medication used in the management of
Parkinson’s disease. Consuming high-protein meals can impair the effects of levodopa. The
nurse should instruct the client to eat protein in small portions. Carbidopa/levodopa does not halt
the progression of Parkinson’s disease. The medication is intended to reduce the symptoms
associated with the condition. Darkening of bodily fluids can occur when taking the medication.
However, the client should be informed this is not a harmful side effect. Whole grains contain
pyridoxine, a vitamin that interferes with the effects of levodopa.
Concepts tested

Question 1831

Page | 748
The nurse is preparing to administer penicillin to a laboring client who is group beta strep
positive. Which of the following statements by the nurse should be included in the client
education?
A “This medication will prevent outbreaks after delivery.”
B “You will receive additional doses of the medication until delivery.”
C “This medication may cause facial flushing.”
D “Your contractions will become more frequent while taking this medication.”

Question Explanation
Correct Answer is B
Rationale: IV penicillin is used to treat group beta strep (GBS) positive mothers while the client
is in labor and additional doses will be administered until delivery. GBS is not a sexually
transmitted infection and does not affect contraction pattern. Facial flushing is not a side effect of
this medication.
Concepts tested

Question 1832
The nurse is teaching a client with diabetes about newly prescribed trimethoprim and
sulfamethoxazole (TMP-SMX) to treat a urinary tract infection. Which statement by the client
indicates understanding?
A “I will stop taking this medication if I develop a rash."
B “This antibiotic will kill mature bacteria in my urinary tract."
C “I should avoid dairy products when taking this medication."
D "My blood sugar will not be affected by this medication."

Question Explanation
Correct Answer is A
Rationale: TMP-SMX is a sulfonamide medication. These drugs are bacteriostatic and therefore,
halt the multiplication of new bacteria, but do not kill mature bacteria. Clients using
sulfonylureas for the management of diabetes should know that other sulfa drugs may increase
the chances of hypoglycemia. The action of metformin is also enhanced. Dairy is avoided when
clients are taking tetracyclines. TMP-SMX is the most common cause of erythema multiforme.
Sulfonamides are also often implicated in cases of both toxic epidermal necrosis and Stevens-
Johnson syndrome, which can be fatal.
Concepts tested

Question 1833
The nurse is preparing to administer trimethoprim and sulfamethoxazole (TMP-SMX) to a client.
When assessing client allergies, the client reports that they are allergic to glipizide. What action
by the nurse is most appropriate?
A Prepare to administer the medication
B Report the allergies to the healthcare provider
C Review the health record to see if the client is on glipizide
D Assess the client’s blood sugar

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Question Explanation
Correct Answer is B
Rationale: While administering a sulfonamide with a sulfonylurea may increase the risk of a
hypoglycemic reaction, the real concern is the potential allergy to TMP-SMX. It may be safe to
administer the medication, but the healthcare provider should be notified first.
Concepts tested

Question 1834
The nurse is preparing to administer a client’s prescribed insulins and needs to mix NPH and
lispro. Which of the following actions should the nurse take first?
A Inject air into the long-acting insulin
B Draw up the short-acting insulin
C Draw up the long-acting insulin
D Inject air into the short-acting insulin

Question Explanation
Correct Answer is A
Rationale: When mixing insulins in the same vial, the process should be to inject air into the
long-acting insulin, inject air into the short-acting insulin, draw up the short-acting insulin, and
then draw up the long-acting insulin.
Concepts tested

Question 1835
The nurse is completing a client’s medication reconciliation. The nurse notes a discrepancy
between the current prescribed medications and the client’s home medications. Which action by
the nurse is most appropriate?
A Document the discrepancy in the medical record
B Discontinue the prescription that was incorrect
C Notify the provider about the discrepancy
D Complete an incident report

Question Explanation
Correct Answer is C
Rationale: The purpose of a medication reconciliation is to identify and prevent prescription
duplications, omissions, errors, and potential interactions between the currently prescribed
medications and those that the client is taking regularly. If an issue is identified, the nurse should
notify the provider to determine if the current medication has been prescribed correctly or if the
order needs to be modified. Discontinuing the prescription is out of the nurse’s scope of practice.
Documenting in the medical record may be necessary but is not the most appropriate action. An
incident report is not needed unless a medication error occurred.
Concepts tested

Question 1836
A nurse is providing care to an older adult client with newly diagnosed heart failure. The nurse
receives a prescription for digoxin PO 1.5 mg daily. Which action does the nurse perform next?

Page | 750
A Instruct the client to take the heart rate before administration
B Educate the client on the purpose of digoxin
C Administer the medication to the client
D Clarify the prescription with the healthcare provider

Question Explanation
Correct Answer is D
Rationale: Older adult clients (geriatric) have a high sensitivity to the toxic effects of digoxin. A
dose of 1.5 mg daily is above the recommended range for adults. The initial daily dose for a
geriatric client should not exceed 0.125 mg. Educating the client on the purpose of digoxin and
performing related assessments are expected interventions. However, the nurse should clarify the
dose first. Administering the prescribed medication dose to the client may result in significant
side effects.
Concepts tested

Question 1837
A nurse is providing care to a client with ovarian cancer prescribed intravenous topotecan. The
nurse expects to administer the medication via which venous access site?
A Implanted port
B PICC
C Central line
D Peripheral

Question Explanation
Correct Answer is A
Rationale: Topotecan is an antineoplastic medication administered over the course of 21 days.
Chemotherapy medications are commonly administered via an implanted port. An implanted port
is accessed through the skin only when therapy is needed. A peripherally inserted central line
(PICC), a central line, and a peripheral line have continuous external access and have a higher
risk of infection.
Concepts tested

Question 1838
A nurse is providing care to a client post-cholecystectomy. Which observation indicates the
client may require PRN pain medication?
A Slow gait when ambulating to the restroom
B Guarding when the abdomen is palpated
C Muscle tension when repositioning in bed
D Refusal to eat the provided meals

Question Explanation
Correct Answer is C
Rationale: Pain is an expected response for a postoperative client. The nurse should assess
behaviors that prevent activities of daily living (ADLs) due to pain. Sustained muscle tension can
prevent the client from performing ADLs. A slow gait is a protective response to movement after

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a surgical procedure. Palpation around the surgical area will produce an expected pain response.
A refusal to eat is not specific to pain. It may be due to other factors, such as nausea.
Concepts tested

Question 1839
A nurse is evaluating a client who takes naproxen for pain associated with osteoarthritis. Which
documented statement indicates the expected outcome was met?
A Decreased erythema noted to joints
B Muscle strength 3/5 to lower extremities
C Client observed with steady gait upon ambulation
D Deep tendon reflexes +3

Question Explanation
Correct Answer is C
Rationale: The observation of a steady gait while ambulating indicates the relief of pain
associated with osteoarthritis. Osteoarthritis causes limping due to knee and/or hip pain.
Erythema of the joints is associated with rheumatoid arthritis and does not indicate pain relief. A
muscle strength of 3/5 indicates muscle atrophy and is not an expected outcome of the
medication. Brisk reflexes are not associated with osteoarthritis or the intended effect of the
medication.
Concepts tested

Question 1840
The nurse is caring for the client receiving total parenteral nutrition. Which of the following
findings indicates that the treatment is therapeutic?
A Blood glucose level of 160 mg/dl
B Serum albumin level of 3.6 g/dl
C Serum bilirubin level of 1.3 mg/dl
D Hemoglobin level of 10 g/dl

Question Explanation
Correct Answer is B
Rationale: The goal of total parenteral nutrition (TPN) is to increase serum total protein and
serum albumin concentrations and improve nitrogen balance. Unintended effects include
hyperglycemia and liver dysfunction (elevated bilirubin levels). This client is demonstrating a
low hemoglobin level, which is not a result of TPN.
Concepts tested

Question 1841
The nurse is caring for an older adult client with a history of epilepsy who is taking prescribed
bupropion. Which of the following statements by the client should the nurse report to the health
care provider?
A “I can sleep at night since I take this medication in the morning.”
B “I chew gum for the dry mouth I get with this medication.”
C “It helps when I take this medication with food.”

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D “I take my epilepsy medication with this medication every day.”

Question Explanation
Correct Answer is D
Rationale: Administration of epileptic medications with bupropion is contraindicated because it
increases the risk of seizures. Bupropion may be given with food to decrease gastrointestinal
irritation. Gum or candy are recommended to help activate saliva and decrease symptoms of dry
mouth. Taking bupropion in the morning decreases insomnia that may occur if taken in the
evening.
Concepts tested

Question 1842
A nurse receives a prescription to administer intravenous cefepime to a client with a bacterial
infection. The client has a history of lung cancer and is on a continuous cisplatin infusion. How
will the nurse administer the prescribed medication?
A Piggyback the cefepime onto the cisplatin infusion
B Wait for the cisplatin infusion to finish before administering cefepime
C Infuse the cefepime via IV push at the proximal port
D Initiate a new intravenous line for the cefepime infusion

Question Explanation
Correct Answer is D
Rationale: Cefepime is an antibiotic medication used to treat bacterial infections. Cisplatin is an
antineoplastic medication used in the treatment of various cancers. Cefepime and cisplatin are
not compatible and should not be mixed. The nurse should initiate a new intravenous line for the
administration of cefepime. Piggybacking the cefepime will cause the medication to mix with
cisplatin. The medications are not compatible. A continuous cisplatin infusion is administered
over 24 hours to 5 days. The nurse should not wait to administer other medications. Cefepime
should be administered as an infusion, not an IV push.
Concepts tested

Question 1843
A nurse receives a prescription to administer 200 mcg of hydromorphone to a client. The
hydromorphone is supplied in a 1 mg/ml vial. How many milliliters will the nurse administer to
the client?
A 0.5
B2
C 0.2
D 2.5

Question Explanation
Correct Answer is C
Rationale: The nurse will administer 0.2 milliliters (ml) of hydromorphone. The vial contains 1
milligram (mg) of medication for every 1 ml. 1 mg = 1,000 micrograms (mcg). The prescription

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is for 200 mcg. (200 / 1,000 = 0.2 mg). The total volume needed is 0.2 ml. The other volumes are
not consistent with the dosage calculations.
Concepts tested

Question 1844
The nurse is assessing a client who is taking prescribed opioids for pain. Which finding should
indicate to the nurse that the client is having a side effect of the medication?
A Decreased skin turgor
B No bowel movement for four days
C Hypertension
D Increased respiratory effort

Question Explanation
Correct Answer is B
Rationale: A side effect is a mild, predictable response to a medication. Opioids slow down
processes in the body, including gastrointestinal motility, so a possible side effect of this
medication would be constipation. Skin turgor is not directly affected by opioids. A client who is
having side effects of opioids will have hypotension and decreased respiratory effort.
Concepts tested

Question 1845
The nurse educating a client who is postpartum about the use of ibuprofen for uterine cramping.
Which statement should the nurse include in the teaching?
A “This medication could cause gastrointestinal discomfort.”
B “You may experience decreased vaginal discharge with this medication.”
C “Taking this medication could decrease your breast milk production.”
D “You could experience dizziness while taking this medication.”

Question Explanation
Correct Answer is A
Rationale: Ibuprofen, which is an NSAID, can cause gastrointestinal upset, especially if taken
frequently without food. Ibuprofen can increase the risk for bleeding, so the client should
monitor vaginal discharge. Ibuprofen does not affect breast milk production. Medications that
cause vasodilation, such as beta-blockers, could cause dizziness.
Concepts tested

Question 1846
The nurse is monitoring an older adult client prescribed diphenhydramine for contact dermatitis
related to poison ivy exposure. Which finding should be reported to the provider as a potential
drug-related side effect?
A Confusion
B Hypertension
C Incontinence
D Bradypnea

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Question Explanation
Correct Answer is A
Rationale: Diphenhydramine and other first-generation H1 receptor antagonists may cause
confusion (with impaired thinking, judgment, and memory), dizziness, hypotension, sedation,
syncope, unsteady gait, and paradoxical central nervous system stimulation in older adults. Older
adults may experience urinary retention, especially those with prostatic hypertrophy. Some of
these adverse reactions derive from the anticholinergic effects of the drugs and are likely to be
more severe if the patient is also taking other drugs with anticholinergic effects.
Diphenhydramine is sometimes prescribed as a sleep aid for occasional use in older adults. As
with many other drugs, smaller-than-usual dosages are indicated.
Concepts tested

Question 1847
The nurse is caring for a client after cardiac surgery who has been prescribed protamine sulfate.
Which finding indicates that the treatment is having the intended effect?
A The international normalized ratio (INR) is trending down.
B The bleeding from the surgical site has slowed.
C The client reports decreased chest pain.
D The respiratory rate is increased.

Question Explanation
Correct Answer is B
Rationale: Protamine sulfate is the antidote for standard heparin and low molecular weight
heparins (LMWHs). Protamine is typically given for bleeding that may not respond to merely
withdrawing the heparin or when hemorrhaging is present. INR is used to determine the
therapeutic level of warfarin, not coumadin. Chest pain would be treated with nitroglycerin but
not protamine. The respiratory rate would be increased by naloxone if opiates were prescribed.
Concepts tested

Question 1848
The nurse is monitoring a client who is taking prescribed nitroglycerin for angina. Which finding
indicates the medication has a therapeutic effect?
A The client’s blood pressure is 150/80 mm/Hg.
B The client’s heart rate is 110.
C The client reports a decrease in chest pressure.
D The client reports a headache.

Question Explanation
Correct Answer is C
Rationale: Nitroglycerin acts to decrease myocardial oxygen consumption. Dilatation of the
veins reduces the amount of blood returning to the heart (preload), so the chambers have a
smaller volume to pump resulting in decreased oxygen needs. Decreased oxygen demand
reduces pain caused by dilating coronary blood flow. While blood pressure may decrease slightly
due to the vasodilatory effects of nitroglycerin, it is a secondary effect and not the desired
therapeutic effect of this drug. Increased blood pressure and increased preload would mean the

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heart would work harder, increasing oxygen demand and thus angina. Decreased heart rate is not
an effect of nitroglycerin.
Concepts tested

Question 1849
A nurse is providing discharge instructions on the use of an EpiPen to a client with a severe food
allergy. Which statement will the nurse include in the teaching?
A “Remove the autoinjector immediately after administering the medication.”
B “Inject the medication into your outer thigh.”
C “Do not massage the area after injecting the medication.”
D “The medication needs to be injected into bare skin.”

Question Explanation
Correct Answer is B
Rationale: Epinephrine supplied as an EpiPen should be administered into the outer thigh. The
thigh has a rich supply of blood and helps to promote medication absorption. The autoinjector
should remain in place for 10 seconds before removing it from the thigh. The injection site
should be massaged for 10 seconds after administration to decrease tissue irritation. The EpiPen
may be administered over clothing if necessary.
Concepts tested

Question 1850
A nurse is providing education on the use of pregabalin to a client with a seizure disorder. Which
client statement indicates further teaching is required?
A “I will record the number of seizures I experience.”
B “I will hold the dose if my seizures are controlled.”
C “I will notify my healthcare provider if I have significant mood changes.”
D “I will report any weight gain to my healthcare provider.”

Question Explanation
Correct Answer is B
Rationale: Pregabalin is an anticonvulsant medication used to manage seizure disorders. The
client should take the medication as prescribed as abrupt discontinuation can lead to seizure
activity. Recording the number of seizures helps to evaluate the effectiveness of the medication.
Pregabalin can cause suicidal thoughts and behaviors. The client should promptly report
significant mood changes. Pregabalin can cause weight gain and peripheral edema. These side
effects should be reported to the healthcare provider.
Concepts tested

Question 1851
The nurse is administering docusate sodium to a postpartum client. Which of the following
should the nurse include in the medication teaching?
A “This medication will help with your uterine cramping.”
B “Breastfeeding is contraindicated while taking this medication.”

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C “Report to the healthcare provider if you experience diarrhea.”
D “This medication lowers your risk of hemorrhage.”

Question Explanation
Correct Answer is C
Rationale: Docusate sodium is a stool softener/laxative and should not be administered to a client
who is experiencing diarrhea. This medication does not directly affect breastfeeding or the risk
of hemorrhage. Docusate sodium does not affect uterine cramping.
Concepts tested

Question 1852
The nurse is teaching a client who has been diagnosed with recurrent genital herpes about newly
prescribed valacyclovir. Which statement by the client indicates understanding?
A “This medication is preferable because I can take it less often than other antivirals.”
B “I will be free of outbreaks from now on.”
C “This medication will prevent transmission of the virus to my partner.”
D “Starting the medication now will not help speed up healing.”

Question Explanation
Correct Answer is A
Rationale: Valacyclovir has greater bioavailability than acyclovir does and is administered less
frequently. It speeds up the healing process for lesions and reduces discomfort from the lesions,
even if they’ve already developed. While antivirals do reduce the risk of transmitting herpes
simplex to partners, it is not eliminated. The number of outbreaks may be reduced but also may
not be completed eliminated.
Concepts tested

Question 1853
The nurse is preparing to administer the next dose of prescribed vancomycin to the client being
treated for sepsis. Which of the following laboratory results would be the priority for the nurse to
review?
A Peak serum drug level
B Serum potassium level
C Serum creatinine level
D White blood cell count

Question Explanation
Correct Answer is C
Rationale: Vancomycin can lead to interstitial nephritis and therefore, serum creatinine should be
monitored. Prior to a dose, a trough level would be drawn to help assess minimum inhibitory
concentration; however, peak levels are not needed for this purpose and are drawn after
administration. Do not hold the next vancomycin doses while waiting for the results of
vancomycin levels unless there is a concern about renal function. Therefore, the priority is serum
creatinine. While the treatment of infection is the goal, assessing white blood count (WBC) prior
to administration is not necessary.

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Concepts tested

Question 1854
The nurse is preparing to administer simethicone orally to a postpartum client. Which of the
following actions should the nurse take first?
A Ask the client to state their name
B Place the medication into a pill cup
C Collect the medication from the pharmacy
D Verify the prescription in the medical record

Question Explanation
Correct Answer is D
Rationale: When administering any medication, the first thing the nurse should do is verify the
prescription in the medical record. Verifying the prescription first helps to avoid the possibility
of medication errors. In this case, once the prescription has been verified, the nurse can collect
the medication from the pharmacy, verify the client’s identification, and then place the tablet in
the pill cup for administration.
Concepts tested

Question 1855
A nurse is preparing to administer prescribed maintenance dose of digoxin to a client who has
heart failure. Which action should the nurse to take?
A Withhold the medication if the heart rate is above 100/min
B Instruct the client to eat foods that are low in potassium
C Measure apical pulse rate for 30 seconds before administration
D Evaluate the client for nausea, vomiting, and anorexia

Question Explanation
Correct Answer is D
Rationale: A client with heart failure who is prescribed digoxin should be assessed for digoxin
toxicity. Manifestations of digoxin toxicity include nausea, vomiting, and anorexia. Digoxin is
used to decrease heart rate and should be held if the heart rate is less than 60 beats per minute.
Digoxin toxicity can occur when the client has low potassium. When administering digoxin, the
nurse should measure the client’s apical pulse for a full minute.
Concepts tested

Question 1856
A nurse is reviewing prescriptions for a client with a history of rheumatoid arthritis and peptic
ulcer disease. The client has prescriptions for ibuprofen and ranitidine. Which action will the
nurse perform?
A Clarify the prescription for ibuprofen
B Administer the ibuprofen 30 minutes before the ranitidine
C Hold the ranitidine for 1 hour after meals
D Question the prescription for ranitidine

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Question Explanation
Correct Answer is A
Rationale: Ibuprofen is a non-steroidal anti-inflammatory drug (NSAID) that can cause
gastrointestinal (GI) bleeding. The client has a history of peptic ulcer disease. The nurse should
clarify the prescription for ibuprofen. Administering the ibuprofen before the ranitidine does not
address the issue of possible GI bleeding. Ranitidine can be administered without regard to
meals. The prescription for ranitidine is appropriate for the client’s condition and does not need
to be questioned.
Concepts tested

Question 1857
A nurse is providing care to a trauma client requiring significant fluid resuscitation. The nurse
will initiate venous access at which site?
A Forearm
B Scalp
C Subclavian
D Antecubital

Question Explanation
Correct Answer is D
Rationale: The nurse should initiate peripheral venous access at the antecubital fossa site. The
antecubital area contains large veins that can sustain large-bore IV catheters for rapid infusions.
The forearm has smaller diameter veins and is not the site of choice for fluid resuscitation. Scalp
veins are very small in diameter and are not indicated for rapid fluid infusion. The subclavian
area requires a central line, which is a skill not within the nurse’s scope of practice.
Concepts tested

Question 1858
A nurse is performing pain assessments on several clients. Which client would benefit the most
from the administration of intravenous PRN pain medication?
A A client eating breakfast verbalizing a headache
B A client with a fractured arm pending discharge
C A client post-abdominal surgery sitting in a chair
D A client pending bedside debridement of a wound

Question Explanation
Correct Answer is D
Rationale: Intravenous pain medication has a rapid onset. A bedside wound debridement is a
complex, painful procedure. This client would benefit the most from IV pain medication. A
client with a headache who is able to tolerate meals and a postoperative client who is able to
reposition may benefit from pain medication via a different route (oral). A client pending
discharge should no longer require intravenous pain medication. Discharge criteria include pain
management with less invasive options.
Concepts tested

Question 1859
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A nurse is evaluating a client who was prescribed 30 mg of codeine after oral surgery. Which
assessment finding indicates the expected outcome of the medication?
A Normoactive bowel sounds
B Absence of pain
C Decreased cough reflex
D Normal respiratory rate

Question Explanation
Correct Answer is B
Rationale: Codeine is an opioid analgesic used primarily in the treatment of mild to moderate
pain. The expected outcome of codeine taken after oral surgery is the absence of pain. Codeine
may cause constipation and respiratory depression. Normoactive bowel sounds and a normal
respiratory rate indicate the absence of side effects of codeine but do not suggest an expected
outcome. A decreased cough reflex is expected when codeine is used in smaller doses (10-20
mg) as an antitussive.
Concepts tested

Question 1860
The nurse is caring for a client with cachexia who has delayed wound healing and has been
prescribed total parenteral nutrition (TPN). Which of the following findings indicates that the
TPN is having the intended effect?
A Decreased wound measurements
B Dark red color around the edges
C Serous drainage from the wound
D Increased pain

Question Explanation
Correct Answer is A
Rationale: Decreasing wound measurements are one indication of wound healing. Normally, the
healing process occurs without assistance; however, a variety of factors affect wound healing,
including nutritional status. Wound healing requires adequate proteins, carbohydrates, fats,
vitamins, and minerals. Clients who are undernourished may lack the nutritional stores to
promote wound healing. TPN can support the nutritional needs of a client who cannot tolerate
enteral feeding and is experiencing the adverse effects of malnutrition. Dark red wound edges,
drainage, and pain are all indications of impaired wound healing.
Concepts tested

Question 1861
A nurse is preparing to withdraw insulin into a syringe in the medication room. The nurse notes
an open, full vial of regular insulin with no labeled expiration date. Which action does the nurse
take?
A Discard the vial and request a new one from the pharmacy
B Label the vial with the current date and withdraw the medication
C Withdraw the medication and discard the vial

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D Store the medication in the refrigerator and notify the pharmacy

Question Explanation
Correct Answer is A
Rationale: Opened vials of medication should have a labeled expiration date. Multi-dose vials
expire 28 days after being opened. The nurse should discard the vial and request a new one since
there is no way of knowing when the vial was opened. Labeling the medication with the current
date or withdrawing the medication are not safe practices. There is no way to verify how long the
medication has been opened. The vial should not be stored without an expiration date label.
Concepts tested

Question 1862
The nurse is reviewing the laboratory data for a client who is receiving prescribed intravenous
(IV) fluids to treat fluid volume deficit. Which result would indicate the fluid therapy has been
effective?
A Serum sodium level of 138 mEq/l
B Blood urea nitrogen (BUN) level of 26 mg/dl
C Hematocrit (Hct) level of 56%
D Urine specific gravity of 1.038

Question Explanation
Correct Answer is A
Rationale: For clients who are receiving prescribed IV fluids to treat fluid volume deficits,
laboratory data can be used to determine if the fluid therapy is effective. In fluid volume deficits,
the client will have low sodium levels and increased BUN, hematocrit, and urine osmolarity
levels. A serum sodium level of 138mEq/l is within the normal range (135-145), indicating that
the fluid therapy has been effective. Normal BUN is 6-20, normal hematocrit is 35%-47% for
females and 39%-50% for males, and normal specific gravity is 1.010-1.025. The elevated BUN,
Hct, and urine specific gravity levels indicate that the client is still experiencing fluid volume
deficit.
Concepts tested

Question 1863
The nurse is preparing to administer newly prescribed albumin IV to a client who is on bedrest
following surgery. Which statement should the nurse make to educate the client about the
medication?
A “This medication will prevent electrolyte imbalance.”
B “This medication will prevent tissue breakdown.”
C “This medication will prevent dehydration.”
D “This medication will prevent malnutrition.”

Question Explanation
Correct Answer is B

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Rationale: Becoming immobile and inactive causes pressure on the skin and can result in skin
breakdown. If pressure persists, tissue necrosis can occur, and pressure ulcers will develop.
Serum albumin levels less than 3g/dl are associated with tissue edema and an increased risk of
pressure ulcers. The infusion of albumin will help avoid tissue breakdown. Albumin IV will not
prevent dehydration or electrolyte imbalance. Serum albumin levels can indicate that the client is
experiencing malnutrition, but the medication will not prevent it.
Concepts tested

Question 1864
The nurse is caring for a client with osteomyelitis who is receiving IV infusion of prescribed
vancomycin. Which statement by the client would be a priority for the nurse to report to the
healthcare provider?
A “I fell some burning at the catheter site.”
B “I feel a little nauseous.
C ” “I have a ringing in my ears.”
D “I have a headache.”

Question Explanation
Correct Answer is C
Rationale: The nurse who is caring for a client with osteomyelitis who is receiving IV infusion of
vancomycin should assess the client for toxicity. The client who reports ringing in the ear could
be experiencing ototoxicity, which is an adverse effect of vancomycin and should be reported to
the healthcare provider. Headache, nausea, and burning at the IV site are side effects of the
medication but not a priority for the nurse to report to the healthcare provider.
Concepts tested

Question 1865
The nurse is preparing to administer blood products as a part of fluid resuscitation to a client in
shock. The nurse understands which of the following is necessary prior to the administration of
the blood products?
A Placement of a foley catheter to monitor output
B Placement of 2 large bore IV's
C Baseline lung assessment
D Suction equipment at the bedside

Question Explanation
Correct Answer is B
Rationale: When a client is in hypovolemic shock, multiple fluids need to be administered at one
time. Prior to giving blood, the nurse should ensure that two large bore IVs are in place in order
to ensure the blood products can be administered prior to them expiring. The baseline lung
assessment should be done but is not in relation to the fluid being administered. The Foley
catheter should be in place prior to administering any fluid, not just blood. Suction equipment is
not required.
Concepts tested

Question 1866
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The nurse is caring for a client receiving IV therapy. The nurse understands which of the
following techniques is the best way to assess for infiltration?
A Check for blood return
B Perform a flush
C Assess for erythema at the site
D Apply a tourniquet above the transfusion site

Question Explanation
Correct Answer is D
Rationale: Infiltration is the unintentional administration of solution or medication into
surrounding tissue. Checking for blood return could be a false indicator that the site is working
properly. The more reliable way to check for infiltration is to apply a tourniquet above the
infusion site. Assessing for erythema is not an indication of infiltration but could indicate several
abnormal instances. which could include allergy to the adhesive used to secure the site.
Performing a flush may indicate leaking.
Concepts tested

Question 1867
The nurse is educating a client with seizure disorder about newly prescribed phenytoin. Which
statement should the nurse include in the teaching?
A “Blood work will be required if you have a seizure while taking this medication.”
B “You will need to have routine visits with a dentist when taking this medication.”
C “It is normal to have a change in your gait when you first start this medication.”
D “Avoid grapefruit juice when taking this medication.”

Question Explanation
Correct Answer is B
Rationale: Phenytoin is the first-line medication for the treatment of seizures. Clients should be
instructed that they will need routine lab work to ensure that they are at a therapeutic level with
the medication, even if they have been seizure-free. This medication can cause gingival
hyperplasia, which will require routine dental visits. The client does not need to avoid grapefruit
juice with this medication. Difficulty with hand and gait coordination could indicate toxicity and
should be reported to the healthcare provider.
Concepts tested

Question 1868
A nurse is teaching a client with stable angina about newly prescribed SL nitroglycerin. Which
statement should the nurse include in the teaching?
A "Take this medication after each meal and at bedtime."
B "Take one tablet 30 minutes before any physical activity."
C "Take one tablet immediately when you experience chest pain."
D "Take this medication with 8 ounces of water."
"Take this medication with 8 ounces of water."

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Question Explanation
Correct Answer is C
Rationale: Nitroglycerin is a vasodilator used to treat angina or ischemic chest pain. When
teaching a client about SL nitroglycerin, the nurse should instruct the client to take one tab and
place it under their tongue immediately when experiencing chest pain. The client only takes this
medication when experiencing chest pain. The client should not eat or drink when taking this
medication.
Concepts tested

Question 1869
The nurse is caring for a client who needs IV insertion. The client expresses concern about pain
during the insertion. Which statement is the best response by the nurse?
A “Don’t worry; the needle is small.”
B “The pain is necessary but only last a few seconds.”
C “I will provide you with a distraction, so you will not feel it.”
D “A small amount of pain is expected but is not ongoing after the insertion.”

Question Explanation
Correct Answer is D
Rationale: When preparing a client for peripheral IV insertion, the nurse should advise the client
on what to expect including feeling some discomfort. Telling the client that the needle is small
dismisses if the client feels any pain. Distractions can aid a client to focus on something besides
the pain but do not indicate that pain will not be felt.
Concepts tested

Question 1870
The nurse is preparing to administer a prescribed dose of lactulose to a client who has cirrhosis.
Which lab value will the nurse monitor to evaluate the therapeutic effect of the medication?
A Glucose
B Ammonia
C Potassium
D Bicarbonate

Question Explanation
Correct Answer is B
Rationale: Hepatic encephalopathy is a manifestation of liver disease that has neurotoxic effects
of ammonia. Lactulose acidifies feces in the intestines, which traps ammonia that can be then
eliminated with defecation.
Concepts tested

Question 1871
The nurse is monitoring a client with hypomagnesaemia who is receiving electrolyte replacement
intravenously. Which finding observed by the nurse would require immediate follow-up?

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A The infusion rate is set at 200 mg/min.
B The infusion is being infused with primary fluids of 0.9% normal saline.
C The client has a potassium level of 3.5 meq/l.
D The client also has a prescription for IV antibiotics.

Question Explanation
Correct Answer is A
Rationale: Magnesium sulfate should be given via infusion pump and should not be given at a
rate that is higher than 150 mg/min. Magnesium sulfate is administered via a secondary line and
is compatible with 0.9% normal saline. A potassium level of 3.5 is expected with a client who
has hypomagnesemia. The prescription for IV antibiotics can be started after the magnesium is
infused.
Concepts tested

Question 1872
The nurse is caring for a client who is prescribed methicillin sodium 1.5 g. The label reads to
reconstitute with 5.7 ml of sterile water for a FINAL concentration of 500mg/ml. How many ml
will the nurse administer with each dose?

Question Explanation
Correct Answer is 3
Rationale: After the nurse reconstitutes the medication with sterile water, the supply available is
500 mg/ml. ml/dose = (1 ml / 500 mg) x (1000 mg / 1 g) x (1.5 g/dose) = 1500 / 500 = 3
Concepts tested

Question 1873
The nurse is preparing to administer acetaminophen 7.5 mg/kg PO to a pediatric client. The
client weighs 20 kg. How many milligrams per dose should the nurse administer to the client?

Question Explanation
Correct Answer: 150
Rationale: 7.5 mg x 20 kg = 150
Concepts tested

Question 1874
The nurse is preparing to administer to a client an IV heparin to infuse at 20 ml/hr. The heparin
bag reads 25,000 units/250 ml. How many units per hour should the client receive?

Question Explanation
Correct Answer is 2000
Rationale: units/hr = (25,000 units / 250 ml) x (20 ml/hr) = 500,000 / 250 = 2,000
Concepts tested

Question 1875
The nurse is preparing to administer levothyroxine 125 mcg to a client. The available supply is
50 mcg levothyroxine. How many tablets should the nurse administer to the client?

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Question Explanation
Correct Answer is 2.5
Rationale: tablets/dose = (1 tab / 50 mcg) x (125 mcg/dose) = 125 / 50 = 2.5
Concepts tested

Question 1876
The nurse is caring for a client who weighs 188 lbs. The nurse received a prescription for the
client to receive methylprednisolone 2 mg/kg. The label reads 125 mg / 2 ml. How many ml
should the nurse administer to the client with each dose? Round answer to the nearest tenth.

Question Explanation
Correct Answer is 2.7
Rationale: 188 lbs / 2.2 = 84.45 kg; 84.45 kg x 2 mg = 168.9 mg; ml/dose = (2 ml / 125 mg) x
(168.9 mg/dose) = 337.8 / 125 = 2.7024 = 2.7
Concepts tested

Question 1877
The nurse is caring for a client with pulmonary embolism that is to receive prescribed heparin
25,000 units in 250 ml of normal saline continuous infusion at 15 ml/hr. How many units per
hour will the nurse administer to the client?

Question Explanation
Correct Answer is 1500
Rationale: units/hr = (25,000 units / 250 ml) x (15 ml/hr) = 375,000 / 250 = 1,500
Concepts tested

Question 1878
The nurse is to administer erythromycin ethyl succinate 280 mg. The supply available is 400
mg/5 ml. How many ml would the nurse administer with each dose?

Question Explanation
Correct Answer is 3.5
Rationale: ml/dose = (5 ml / 400 mg) x (280 mg/dose) = 1,400 / 400 = 3.5
Concepts tested

Question 1879
The nurse has a prescription to administer dopamine 2 mcg/kg/min for a client who weighs 110
lbs. The supply available is 200 mg in 250 ml normal saline. How many ml/hr will the client
receive? Round answer to the nearest tenth.

Question Explanation
Correct Answer is 7.5

Rationale: 110 lbs / 2.2 = 50 kg; 50 kg x 2 mcg/min = 100 mcg/min; ml/hr = (250 ml / 200 mg) x
(1 mg / 1,000 mcg) x (100 mcg/min) x (60 min/hr) = 7.5

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Concepts tested

Question 1880
The nurse is admitting a client from a long-term care facility who has a history of dementia.
When obtaining the client’s medication records, which action would be most appropriate?
A Request a copy of the client’s medication list from the long-term facility
B Call the healthcare provider for a verbal report of the medication list
C Instruct a family member to bring a medication list
D Review the client’s medical records for a previous medication list

Question Explanation
Correct Answer is A
Rationale: When admitting a client with a history of dementia, the nurse will have to use
resources to obtain a current health history, including the list of current medications. The most
appropriate action would be to request that the long-term care facility provide a copy of the
client’s current medication list. Requesting a verbal report from the healthcare provider could
result in inaccurate information. Reviewing the client’s medical record may not provide the most
current medication list. Instructing the family to bring a list may not be as accurate.
Concepts tested

Question 1881
The nurse is caring for a client with sepsis receiving broad-spectrum antibiotics. Which finding
might indicate to the nurse the need for a dosage adjustment?
A Elevated creatinine level
B Elevated heart rate
C Decreased white blood cell count
D Decreased platelet count

Question Explanation
Correct Answer is A
Rationale: Septic shock is the most common type of distributive shock that threatens multi-
system organ failure with a rapid onset, which is the leading cause of death in noncoronary ICU
patients. Gram-negative bacteria have been the most implicated organism, and broad-spectrum
antibiotics are given to help increase the likelihood of increasing tissue perfusion. The majority
of broad-spectrum antibiotics are excreted through the kidneys, and an elevated creatine level
will indicate the need for dosage adjustments. Elevated lactic acid levels, heart rate, and white
blood cell (WBC) levels are all signs of sepsis and need to be monitored closely. Decreased
platelet counts are seen when the condition is exacerbated with blood loss but does not affect the
antibiotic dosage.
Concepts tested

Question 1882
A client received 40 mg of furosemide by mouth at 10 am. Which information is most important
for the nurse to provide to the next nurse in the change-of-shift report?
A The client lost two pounds in the last 24 hours.

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B The client's urine output was 1500 mL over nine hours
C The client is to receive another dose of furosemide at 10 pm.
D The client's potassium level was 4.0 mEq/L prior to administration.

Question Explanation
Correct Answer is B
Rationale: Although all of the information is important to include, a diuresis of 1,500 mL is a
very large amount and could cause hypokalemia, fluid volume deficit and hypotension.
Therefore, it is the most important information to provide to the nurse on the next shift.
Concepts tested

Question 1883
A client who is receiving a blood transfusion suddenly reports having a severe headache and
lower back pain. Which actions should the nurse take? Select all that apply.
A Stop the blood transfusion
B Flush the IV line with 30 mL of normal saline
C Obtain a urine specimen as soon as possible
D Complete an incident/occurrence report
E Notify the rapid response team
F Provide emotional support to the client

Question Explanation
Correct Answer is A, C, D, F
Rationale: Clients who are receiving a blood transfusion can develop any one of these
transfusion reactions: febrile, hemolytic, allergic or bacterial reactions, circulatory overload, or
transfusion-associated graft-versus-host disease (TA-GVHD). The client in this scenario appears
to be experiencing a hemolytic reaction, which is caused by blood type or Rh incompatibility.
Interventions for this type of reaction should include immediately stopping the transfusion and
removing the blood tubing. The nurse should not flush the contents of the blood transfusion
tubing, which would allow more of the reaction-causing blood to enter the client. Instead, a
second, new IV access is preferred, especially for the fluid resuscitation the client will most
likely require. Because of the high risk of kidney failure with this type of reaction, a urine
sample is collected. This situation will also require an incident report to be completed, and the
blood bank needs to receive all of the original blood product and tubing for analysis and to figure
out how this reaction happened. The client might feel anxious and the nurse should provide
emotional support. Notifying the rapid response team (RRT) is not indicated at this time.
Concepts tested

Question 1884
The nurse is caring for a client with diabetes mellitus. The client reports feeling hungry and
thirsty. The client's most recent blood glucose level was 175 mg/dL. Which type of insulin
should the nurse anticipate being prescribed for this client?
A Exenatide

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B Glucagon
C Sitagliptin
D Lispro

Question Explanation
Correct Answer is D
Rationale: The inpatient client with an elevated blood sugar is usually prescribed a short-acting
insulin such as lispro, aspart or regular (Humulin-R) insulin. Glucagon is a medication used to
treat hypoglycemia, not hyperglycemia. Exenatide and sitagliptin are not insulins.
Concepts tested

Question 1885
The oncology nurse is preparing to administer the initial dose of vincristine to a child diagnosed
with acute lymphocytic leukemia. Which interventions should the nurse include in the plan of
care? Select all that apply.
A Apply pressure to the injection site if extravasation occurs
B Select the appropriate catheter for intrathecal administration
C Monitor for numbness or tingling in the fingers and toes
D Monitor liver function tests regularly
E Verify blood return before, during, and after intravenous administration

Question Explanation
Correct Answer is C, D, E
Rationale: Acute lymphocytic leukemia (ALL) is the most common type of cancer in children
and treatment protocols include vincristine, an anticancer drug. Vincristine is for intravenous use
only; intrathecal (i.e., spinal) administration can be fatal. Vincristine is a vesicant that can cause
significant local damage if extravasation occurs; treatment includes subcutaneous injection of an
antidote and warm compresses, as topical cooling may worsen the effect. Peripheral neuropathy
is a major side effect associated with vincristine. The nurse should monitor for decreased hepatic
functioning because vincristine is metabolized in the liver.
Concepts tested

Question 1886
A client with a central line catheter is being discharged home. The nurse is teaching the client's
partner how to change the central line dressing. Which is the best method to determine if the
teaching was effective?
A The partner return demonstrates a dressing change.
B The partner verbalizes the steps for changing the dressing.
C The partner observes the nurse changing the dressing.
D The partner watches a video about dressing changes.

Question Explanation
Correct Answer is A

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Rationale: Return demonstration is the best method for determining if the teaching has been
effective. The other methods are not as effective in determining if the partner understood
correctly and is able to change the dressing. It is not appropriate to have the partner complete a
quiz.
Concepts tested

Question 1887
The nurse is reviewing a client's medication list and notes the client takes bupropion SR 150 mg
oral twice a day. Which question is appropriate for the nurse to ask concerning the purpose of
this medication?
A "After taking this medication, did your hallucinations lessen?"
B "Did your cravings for nicotine decrease after starting this medication?"
C "How much weight have you gained on this medication?"
D "Have you had any abnormal dreams while taking this medication?"

Question Explanation
Correct Answer is B
Rationale: It is important for the nurse to know the generic name of drugs and their mechanism
of action and therapeutic uses. Bupropion, when marketed as Zyban, is used as a nicotine-free
method used to aid with smoking cessation. It should be started slowly and the dosage increased,
but it should not be given for more than 12 weeks. Bupropion, when marketed as Wellbutrin, is
used to treat depression. Side effects of bupropion are the same for either brand and include
weight loss and insomnia. An alternative smoking cessation aid, varenicline, is associated with
abnormal dreams and nightmares. Bupropion is not used for the treatment of hallucinations.
Concepts tested

Question 1888
The nurse is collecting data about a 20-year-old female client who has been prescribed
isotretinoin for severe acne. The client states that she does not understand why she has to be seen
monthly in the office to obtain a refill. What is the best response from the nurse?
A "A monthly pregnancy test is required for all refills of this medication."
B "The medication is addictive and there is a maximum amount that can be dispensed."
C "After a month the medication will expire and will have decreased effectiveness if taken. "
D "When taking this medication, you must have your creatinine monitored monthly."

Question Explanation
Correct Answer is A
Rationale: Isotretinoin is highly teratogenic. The administration of isotretinoin is therefore
closely monitored by the iPledge program, which has rules for the client, prescriber, pharmacist
and wholesaler. The iPledge program is a pregnancy prevention program for isotretinoin, which
has been linked to serious birth defects such as facial malformation, hydrocephalus and cardiac
defects.
Concepts tested

Question 1889

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The nurse is preparing to administer medications to her assigned clients. In order to reduce
medication errors, which of the following rights of medication administration should the nurse
adhere to? Select all that apply.
A Place each client's medication on their bedside table during the beginning of shift rounds
B Check the medication against the medication administration record (MAR)
C Confirm the client's room number against the medication administration record (MAR)
D Maintain a distraction-free environment while administering medication
E Prepare injectable medications at the beginning of the shift before the shift becomes busy
F Verify the client's full name and date of birth in the medication administration record (MAR)
G Ensure the medication is in the right form as ordered by the health care provider (HCP)

Question Explanation
Correct Answer is B, D, F, G
Rationale: Medication safety includes maintaining a culture of safety and ensuring rigorous
verification prior to administration. Distraction-free medication administration is recommended
as well as checking three times to ensure the correct medication and the rights of medication.
The rights of medication include the right medication, client, dosage, form, route, timing, and
indication. Medication should be prepared at the time of administration and never left unattended
by the nurse. These safeguards help reduce medication errors.
Concepts tested

Question 1890
The nurse is preparing to administer an enoxaparin injection to a client who is immobilized after
a cerebrovascular accident. The client voices concern and refuses to take the medication. What
actions should the nurse take? Select all that apply.
A Ask the client's significant other for permission to give the medication
B Notify the pharmacist to discontinue the medication
C Ask the client if they prefer the medication in an oral form
D Ensure the client correctly understands the medication's purpose
E Confirm the client understands the risks associated with not taking the medication
F Clarify the reason why the client is refusing the medication

Question Explanation
Correct Answer is D, E, F
Rationale: The client has a right to refuse any medication or treatment. If the client refuses a
medication, the nurse should identify the reason for refusal and ensure the client understands the
purpose of the medication and the potential risks of not taking the medication. Refusing the
enoxaparin places the client at an increased risk for developing a venous thromboembolism
(VTE). The ordering health care provider (HCP) is the only person who can discontinue the
medication. Enoxaparin is only available to be given as a subcutaneous injection.
Concepts tested

Question 1891

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The nurse is providing discharge instructions to a client who is going home with a peripherally
inserted central catheter (PICC). Which statement by the client indicates that teaching was
effective?
A "I will be sure to place my arm with the catheter in a sling during the day."
B "I will change the catheter dressing at least daily."
C "I will not drive while the catheter is in place."
D "I will avoid carrying my child with the arm that has the catheter."

Question Explanation
Correct Answer is D
Rationale: A PICC is typically placed in the antecubital fossa or the basilic vein and allows the
client considerable freedom of movement. The client will be able to drive but should avoid heavy
lifting which can dislodge or occlude the catheter. Placing the arm in a sling and daily dressing
changes are not necessary. Generally, a PICC dressing should be changed once a week or when it
becomes wet, soiled or dislodged.
Concepts tested

Question 1892
After abdominal surgery, a client with protein calorie malnutrition is receiving total parenteral
nutrition (TPN). Which is the best indicator that the client's nutritional needs are being met?
A The client's surgical incision is healing normally.
B The client's fluid intake and output are balanced.
C The client's blood glucose is less than 110 mg/dL.
D The client's serum albumin level is 3.5 mg/dL.

Question Explanation
Correct Answer is A
Rationale: Because poor incision/wound healing is a possible complication of malnutrition for
this client, normal healing of the surgical incision is the best indicator of the effectiveness of the
TPN in providing adequate nutrition for this client. Blood glucose levels are monitored during
TPN administration to prevent hypo- and hyperglycemia but they do not indicate that the client's
nutrition is adequate. Intake and output should also be monitored but they do not indicate if the
TPN is effective. The albumin level is in the low-normal range, but it is not as good as an
indicator of nutritional status as a total serum protein level or the normal wound healing.
Concepts tested

Question 1893
The nurse observes that a client whose blood type is AB-negative is receiving a transfusion of O-
negative packed red blood cells. Which action should the nurse take?
A Stop the transfusion immediately.
B Administer prescribed diphenhydramine.
C Continue to monitor the client.
D Report the problem to the blood bank.

Question Explanation

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Correct Answer is C
Rationale: Clients with an AB-negative blood type can receive O-negative blood because they
do not have antibodies against this type of blood. O-negative blood is also called the "universal
donor" blood type. The transfusion can proceed and the nurse should continue to monitor the
client. The blood bank would not need to be called and diphenhydramine (Benadryl) would only
be given if the client is having an allergic reaction.
Concepts tested

Question 1894
The nurse administers medication to the wrong client. Which action(s) should the nurse take
when the medication error is identified? Select all that apply.
A Complete an incident report
B Administer ipecac syrup to the client
C Report the error to the board of nursing
D Document the error in the medical record
E Notify the health care provider
F Monitor the client for adverse effects

Question Explanation
Correct Answer is A, D, E, F
Rationale: When a medication error occurs, the nurse should notify the health care provider
(HCP) immediately. Giving the wrong medication to a client may cause adverse effects, and the
nurse should monitor the client closely for the appropriate length of time. The administration of
ipecac syrup to induce vomiting is not recommended after the occurrence of a medication error.
The nurse is required to document the medication error and follow-up interventions in the client's
medical record. An incident report regarding the medication error needs to be completed as well.
The report allows the nurse and health care facility to investigate the root cause for the
medication error and put measures in place to prevent future errors. Reporting the error to the
board of nursing (BON) is not required.
Concepts tested

Question 1895
The nurse is reviewing medication orders for a client who has requested something for pain. In
the process, the nurse finds a newly written order for pain medication. The health care provider
wrote, "Give APAP every six hours as needed for pain." Which part(s) of the medication order
should the nurse clarify before administering the medication? Select all that apply.
A The indication
B The mechanism of action
C The dosage
D The frequency
E The route
F The drug name

Question Explanation
Correct Answer is C, E, F

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Rationale: Medication orders must include the client, medication, route, dose, time, frequency,
and indication. Medication abbreviations increase the risk of errors and should be eliminated
from written orders. Not every nurse will know that APAP is an abbreviation for acetaminophen,
therefore, the order should spell out the full, generic drug name. The nurse functions as the
client's advocate and should collaborate with health care providers (HCPs) and pharmacists when
they identify potential medication concerns. When reviewing a new medication order, the nurse
must clarify each concern with the HCP prior to administration. It is not required to include how
the drug works and other pharmacokinetic information in the prescription.
Concepts tested

Question 1896
The nurse prepares to administer a liquid medication to an infant. At the bedside, the parent
states that the infant does not like to take medications. Which action should the nurse perform to
ease the medication administration?
A Give half the dose now and the remaining amount in an hour
B Use an oral syringe to administer the medication, alternating with a pacifier.
C Mix the liquid medication with a full bottle of formula.
D Ask the health care provider to switch the medication to an injection.

Question Explanation
Correct Answer is B
Rationale: Infants may struggle taking oral medications. Nurses should use a small syringe for
liquid medications and administer to the side of the mouth. To encourage sucking, a pacifier or
bottle nipple may be used intermittently with the medication. Liquid medications should never be
added to a full bottle because the infant may not complete the feeding and receive a partial dose.
Nurses should avoid stretching out medications as this will impact medication peak times.
Developmentally appropriate techniques should be used before switching to a more invasive
medication route.
Concepts tested

Question 1897
The nurse is reviewing medication safety with a client. Which statements by the client indicate a
need for additional teaching? Select all that apply.
A "Alcohol is safe to drink with my medication."
B "I should take the medication as ordered."
C "I need to call my doctor if I have an allergic reaction."
D "It will be safe to take vitamins and herbal supplements with the medication."
E "If I miss a dose, I can double up the next dose."
F "My diet will not affect the medication."

Question Explanation
Correct Answer is A, D, E, F
Rationale: Medication safety includes a number of concepts that the nurse should reinforce with
the client. Current medications and allergies should be reviewed for potential interactions.
Medications should be taken as prescribed without changing the dose or frequency. If a dose is

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missed, the client should avoid doubling up doses. Dietary choices, vitamins, herbal
supplements, and alcoholic beverages should be reviewed for potentially causing adverse
reactions or side effects. If an adverse reaction might occur, the client will need to make lifestyle
changes. The client should notify the health care provider (HCP) if allergic reactions arise
because the medication will need to be stopped.
Concepts tested

Question 1898
The nurse is caring for a client who is receiving regular insulin supplied in a glass vial. Which
step(s) should the nurse take to ensure the correct administration of the insulin? Select all that
apply.
A The nurse should rub the injection site after administering the insulin.
B The nurse should shake the insulin vial before drawing up the insulin.
C The nurse should only use an insulin syringe to administer insulin.
D The nurse should check the strength of the insulin before administering it.
E The nurse should store opened vials of insulin at room temperature.
F The nurse should store unopened vials of insulin in the freezer.
G The nurse should discard the vial 28 days after it was opened.

Question Explanation
Correct Answer is C, D, E, G
Rationale: Insulin is a medication that can be used to control blood glucose levels in clients with
both type 1 and type 2 diabetes. Although there are many types of insulin, the act of
administering insulin is similar regardless of the type. Unopened vials of insulin should be stored
in the refrigerator, not the freezer. The nurse should gently roll the insulin vial back and forth
prior to drawing up the medication. Shaking the vial could lead to the formation of bubbles in the
syringe. To prevent a medication error, the nurse should only use an insulin syringe to administer
insulin. Another way the nurse can prevent a medication error is to check the strength and dose
of the insulin before administration. The nurse should not rub the injection site after
administering the insulin, as it could alter the absorption of the medication. If necessary, lightly
wipe the site with a piece of gauze after the injection. The vial in current use can typically be
stored at room temperature for up to one month but must be kept out of direct sunlight and
extreme heat.
Concepts tested

Question 1899
The nurse has given discharge instructions to a client who suffers from sensory neuropathy due
to diabetes. The client was prescribed gabapentin. Which of the following statements indicates
that the client understands the nurse's instructions regarding the medication?
A "It is safe to take extra doses if my pain becomes worse."
B "I can stop taking the medication at any time."
C "My doctor prescribed it for the pain in my legs."
D "The medication might cause me to have insomnia."

Question Explanation

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Correct Answer is C
Rationale: Gabapentin is an anticonvulsant that can also be used for off-labeled purposes, such
as for neuropathic pain syndromes (e.g., sensory neuropathy, postherpetic neuralgia). Taking
gabapentin can lead to drowsiness and dizziness, not excitability and insomnia. Gabapentin
should not be suddenly discontinued because that could lead to a seizure. Gabapentin is
considered a first-line medication to treat neuropathic pain in people who suffer from sensory
neuropathy and postherpetic neuralgia. Although uncommon, it is possible to overdose on
gabapentin.
Concepts tested

Question 1900
The nurse in a long-term care facility is preparing to administer medications. Which
physiological changes does the nurse know will affect medication pharmacokinetics in older
adults?
A Due to a decrease in renal drug excretion, a greater risk for adverse medication effects exists.
B Due to an increase in glomerular filtration rates, medications are excreted more rapidly.
C Due to an increase in metabolism, medications are prescribed more frequently
D Due to a decrease in gastric emptying, higher medication doses are prescribed.

Question Explanation
Correct Answer is A
Rationale: Due to the physiological changes that occur as a person ages, older clients tend to be
more sensitive to medications. Therefore, older clients must be monitored more closely for both
desired and adverse responses, and their medication regimen must be adjusted accordingly.
Aging-related organ decline affects drug absorption, distribution, metabolism and (especially)
excretion. Although gastric acidity is reduced in older adults, altering the absorption of certain
drugs, prescribing higher doses would not be appropriate. Because rates of hepatic drug
metabolism tend to decline with age, prescribing a drug more frequently would lead to drug
toxicity and adverse drug effects (ADEs). Renal drug excretion progressively declines due to a
decrease (not an increase) in filtration rate as the person ages, placing elderly clients at greater
risk for drug accumulation and ADEs.
Concepts tested

Question 1901
The nurse is caring for a client who is receiving patient-controlled analgesia via an epidural
catheter. The infusion pump was started at 8 am and was set to deliver a basal rate of 1 mg per
hour. When the nurse evaluates the client’s pain level at 12 pm, the client reports that their pain
level is unchanged from the morning. Which action should the nurse perform first?
A Review pump settings and confirm proper functioning.
B Increase the basal rate to 5 mg per hour.
C Notify the health care provider as soon as possible.
D Encourage the client to use distraction and guided imagery.

Question Explanation
Correct Answer is A

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Rationale: A patient-controlled analgesia (PCA) pump via an epidural catheter allows the client
to receive a basal rate of pain medication, and also allows them to administer a dose of pain
medication to themselves intermittently (i.e., bolus). All of the listed interventions are
correct. However, the nurse should use the nursing process as a prioritization tool to first assess
and determine that the pump is functioning correctly and that the medication has been infusing as
it should have. Once the nurse has determined that the pump is functioning correctly, the health
care provider (HCP) should be notified to ask for a potential increase in the medication dosage or
change in medication. The nurse cannot just increase the rate without an order from the HCP.
Nonpharmacological interventions, such as guided imagery and distraction, would also be
appropriate for the client to use to help with pain management, but should not come first.
Concepts tested

Question 1902
A client recovering from hip replacement surgery is taking acetaminophen with codeine every
three hours for pain. For which side effect should the nurse monitor the client?
A Constipation
B Diffuse rash
C Hyperglycemia
D Wheezing

Question Explanation
Correct Answer is A
Rationale: Codeine is an opioid analgesic and antitussive (cough suppressant). For analgesic use,
codeine is formulated alone and in combination with non-opioid analgesics (either aspirin or
acetaminophen). Because codeine and non-opioid analgesics relieve pain by different
mechanisms, the combination can produce greater pain relief than either agent alone. Opioids
such as codeine slow down the function of the central nervous system. This can affect
involuntary movements in the body, such as peristalsis. As the movement of food through the
intestinal tract is slowed down, the walls of the intestine absorb more fluid. With less fluid in the
intestines, stool becomes hard and constipation develops. The other side effects are not usually
seen with codeine.
Concepts tested

Question 1903
The triage nurse at a health clinic receives a call from a client. The client states that they have
been experiencing flu-like symptoms for the past 24 hours. The client asks for a prescription for
zanamivir. How should the triage nurse respond?
A "We will call your pharmacy for an antibiotic prescription for you."
B "Do you have trouble swallowing big pills?"
C "Call back tomorrow when you are sure you have the flu."
D "Come in right away so we can start treating you."

Question Explanation
Correct Answer is D
Rationale: Antiviral influenza treatment with zanamivir should be initiated within 48 hours of
onset of symptoms, thus it is important to get treatment started as soon as possible. The
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medication won't cure the disease, it will only shorten the time frame that someone is sick and
may reduce the severity of the illness. It is administered by oral inhalation. Antibiotics are not an
appropriate treatment for the flu.
Concepts tested

Question 1904
The nurse is administering an osmotic diuretic to a client with a traumatic brain injury. Which
finding best indicates that the medication was effective?
A Intracranial pressure reading of 14 mmHg
B Bilateral ovoid pupils that are slow to constrict
C Clear bilateral lung sounds to posterior auscultation
D 250 mL clear, yellow urine output over four hours

Question Explanation
Correct Answer is A
Rationale: Osmotic diuretics, such as mannitol, are used to reduce intracranial or intraocular
pressure. Intracranial pressure (ICP) for a client with a head injury should be less than 20 mmHg
and the osmotic diuretic may be administered to reduce a high ICP. The osmotic diuretic will
reduce the amount of water normally reabsorbed by the renal tubules and loop of Henle, so
urinary output is increased, which is an expected occurrence, but does not indicate effectiveness
of the medication. Ovoid pupils may indicate the presence of cerebral hypertension. An osmotic
diuretic is not intended to reduce pulmonary edema, thus clear lung sounds are not an indicator
for effectiveness of the diuretic for this particular client.
Concepts tested

Question 1905
The nurse is providing care for a client after surgery. The client has an order for acetaminophen
with codeine. The client asks the nurse what to expect after taking this medication. Which is
the best response by the nurse?
A "This medication combination will allow healing to occur faster."
B "This medication will minimize any side effects from the codeine."
C "The combination medication will reduce the chance of addiction."
D "This combination medication will better help to manage your pain."

Question Explanation
Correct Answer is D
Rationale: A post-operative client experiencing pain may receive opioid or non-opioid pain
medication, in addition to non-pharmacologic comfort measures. The use of acetaminophen with
codeine potentiates the effect of the codeine, thus providing greater/better pain relief. The
presence of codeine doesn't alter the chance of addiction or reduce the chances of side effects.
The medication will not affect healing.
Concepts tested

Question 1906
A client with bipolar disorder is taking lithium. The nurse should notify the health care provider
when the client is prescribed which additional medication?
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A Furosemide
B Finasteride
C Amlodipine
D Insulin

Qustion Explanation
Correct Answer is A
Rationale: Lithium generally should not be taken with diuretics, especially a loop diuretic such
as furosemide. The use of a diuretic will narrow the safe range for the lithium and adding a
diuretic can lead to lithium toxicity. Additionally, side effects of lithium are polyuria and
polydipsia. The nurse should clarify the order before administering lithium and furosemide
together. Finasteride, amlodipine or insulin typically do not interact with lithium.
Concepts tested

Question 1907
The nurse is caring for a client who is experiencing excessive bleeding after receiving
unfractionated heparin sodium. Which orders should the nurse anticipate from the health care
provider? Select all that apply.
A Obtain activated partial thromboplastin time (aPTT).
B Administer vitamin K.
C Obtain prothrombin time (PT)/international normalized ratio (INR).
D Change prescription to enoxaparin.
E Administer protamine sulfate.

Question Explanation
Correct Answer is A, E
Rationale: Protamine sulfate is the antidote used to reverse the anticoagulant effects of heparin.
A serum aPTT or PTT lab test is used to evaluate the anticoagulation effect of heparin. Vitamin
K is the antidote for warfarin. A serum PT/INR lab test is used to monitor the therapeutic
effectiveness of warfarin. Enoxaparin is another type of heparin and would be contraindicated for
this client.
Concepts tested

Question 1908
The daughter of a client with Alzheimer's disease asks the nurse, "Will the medication my
mother is taking cure her dementia?" What is the best response by the nurse?
A "It will not improve dementia but can help control emotional responses."
B "It will help your mother live independently again."
C "It is used to halt the progression of Alzheimer's disease."
D "It will provide a steady improvement in memory."

Question Explanation
Correct Answer is A

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Rationale: Drug therapy for Alzheimer's disease such as memantine and donepezil produce
modest improvements in cognition, behavior, and function, and slightly delayed disease
progression. They do not reverse the dementia or halt the progression of Alzheimer's disease. At
best, drugs currently in use may slow loss of memory and improve cognitive functions (e.g.,
memory, thought, reasoning) and emotional lability. However, these improvements are modest
and last a short time and for many clients, even these modest goals are elusive.
Concepts tested

Question 1909
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 client's
care?
A Captopril
B Furosemide
C Sildenafil
D Losartan

Question Explanation
Correct Answer is C
Rationale: The nurse will need to avoid giving nitrates to the client because nitrate
administration, commonly prescribed for clients experiencing an acute MI, is contraindicated in
clients who are using sildenafil (a PDE5 inhibitor) because of the risk of severe hypotension
caused by vasodilation. The other medications the client is taking should also be documented and
reported to the health care provider (HCP) but do not have as immediate an impact on decisions
about the client's treatment.
Concepts tested

Question 1910
A client with major depression is prescribed the extended release form of venlafaxine. Which
statement by the client indicates a need for additional teaching?
A "I should swallow the pill whole."
B "I may feel nauseated and anorexic."
C "I can stop taking the drug when I start feeling better."
D "I will call my doctor if I experience impotence."

Question Explanation
Correct Answer is C
Rationale: Venlafaxine is a serotonin/norepinephrine reuptake inhibitor (SNRI) used for major
depression, panic disorders and social phobias. It blocks neuronal uptake of serotonin and
norepinephrine with minimal effects on other transmitters or receptors. Pharmacologic effects are
similar to those of SSRIs. The most common side effect is nausea (37% to 58%). Sexual
dysfunction may occur and can cause the client to stop taking the medication. Therefore, the
client should contact their provider for a possible alternate prescription. The client is prescribed
the extended release form and should not chew or break the pill, but swallow the pill whole. The
client is expected to feel less depressed and should not stop taking the medication. Abrupt
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discontinuation can cause an intense withdrawal syndrome. Symptoms include anxiety, agitation,
tremors, headache, vertigo, nausea, tachycardia and tinnitus. Worsening of pretreatment
symptoms may also occur.
Concepts tested

Question 1911
A client with diabetes is starting on insulin therapy. Which type of short-acting insulin will the
nurse discuss using for mealtime coverage?
A Detemir
B NPH
C Glargine
D Lispro

Question Explanation
Correct Answer is D
Rationale: When classified according to time course, insulin preparations fall into three major
groups: short duration, intermediate duration and long duration. Lispro is a rapid-acting insulin
with an onset of 15 to 30 minutes, a peak of 0.5 to 2.5 hours and duration of 3 to 6 hours. Rapid-
or short-acting insulin is commonly used for mealtime coverage for clients receiving insulin
therapy. NPH insulin, glargine or detemir will be used as the basal insulin for intermediate- and
long-duration blood sugar control.
Concepts tested

Question 1912
The nurse is evaluating the plan of care for a client with benign prostatic hyperplasia (BPH). For
which prescribed medication should the nurse notify the health care provider (HCP)?
A Finasteride
B Diphenhydramine
C Metoprolol
D Terazosin

Question Explanation
Correct Answer is B
Rationale: Diphenhydramine is a first generation histamine1 receptor antagonist or
antihistamine, commonly used for relief from symptoms of mild to moderate allergic disorders.
H1 blockers have anticholinergic effects or atropine-like responses and can cause urinary
hesitancy or retention. A client with BPH is already at risk for urinary retention and should not
receive an antihistamine such as diphenhydramine without clarification from the HCP first.
Metoprolol is a beta blocker, which does not affect the bladder. Finasteride and terazosin are
drugs commonly used to treat BPH.
Concepts tested

Question 1913
A client has been admitted for the second time to treat tuberculosis (TB). Which referral does the
nurse initiate as a priority?

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A Social worker to see if the client can afford the medications
B Infection control nurse to arrange testing for drug resistance
C Psychiatric nurse liaison to assess reasons for noncompliance
D Visiting nurses to arrange for directly observed therapy (DOT)

Question Explanation
Correct Answer is D
Rationale: Clients with TB must take multiple drugs for six months or longer, making adherence
a very real problem. Non-adherence is the most common cause of treatment failure and relapse.
This client has a risk of non-adherence, as evidenced because this is their second admission to
treat TB. When the client is discharged, they most likely will need to be placed on DOT to
ensure compliance. This is the priority referral in order to prevent transmission of TB to others in
the community. The other referrals may also be appropriate depending on the client's needs.
Concepts tested

Question 1914
Propranolol is prescribed for a client with coronary artery disease (CAD). The nurse should
consult with the health care provider (HCP) before giving this medication when the client reports
a history of which condition?
A Myocardial infarction
B Deep vein thrombosis
C Asthma
D Peptic ulcer disease

Question Explanation
Correct Answer is C
Rationale: Non-cardioselective beta-blockers such as propranolol block b1- and b2-adrenergic
receptors and can cause bronchospasm, especially in clients with a history of asthma. Beta-
blockers will have no effect on the client's peptic ulcer disease or risk for DVT. Beta-blocker
therapy is recommended after an MI.
Concepts tested

Question 1915
The nurse is evaluating the effectiveness of therapy for a client who received albuterol via
nebulizer during an acute episode of shortness of breath due to asthma. Which finding is
the best indicator that the therapy was effective?
A Oxygen saturation is greater than 90%
B No wheezes are audible.
C Respiratory rate is 16 breaths/minute.
D Accessory muscle use has decreased.

Question Explanation
Correct Answer is A

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Rationale: The goal for treatment of an asthma attack is to relieve bronchospasms and keep the
oxygen saturation greater than 90%. Albuterol is a short-acting inhaled beta2-adrenergic agonist
and the treatment of choice for an acute asthma attack. Pulse oximetry is an objective data point
that the nurse should use to determine oxygenation status of the client. The other client data may
occur when the client is too fatigued to continue with the increased work of breathing required in
an asthma attack and, therefore, should not be used to evaluate effectiveness of treatment.
Concepts tested

Question 1916
The nurse is preparing a client with rheumatoid arthritis (RA) for discharge to an assisted living
facility. Which statement about the prescribed oral glucocorticoid is correct?
A "The medication will reverse the joint deterioration of RA."
B "You will be taking the medication for several years."
C "The medication will be gradually tapered off over 5 to 7 days."
D "It is normal to experience some memory loss or hallucinations."

Question Explanation
Correct Answer is C
Rationale: RA is an autoimmune, inflammatory disease that affects the joints. It is a progressive
disease that causes joint deterioration and destruction, joint deformities and functional limitations
for affected clients. The main goal of pharmacotherapy for RA is symptom relief.
Glucocorticoids are anti-inflammatory drugs, which can relieve symptoms of RA and may also
delay disease progression. For generalized symptoms related to RA, oral glucocorticoids are
indicated. The most commonly employed oral glucocorticoids are prednisone and prednisolone.

Glucocorticoids can slow disease progression, but will not reverse it. Treatment with
glucocorticoids for RA is usually limited to short courses. Adverse psychological reactions such
as hallucinations, memory loss or other psychoses must be reported to the provider and may
require discontinuation of the glucocorticoid. To minimize adrenal insufficiency when
glucocorticoids are discontinued, doses should be tapered very gradually.
Concepts tested

Question 1917
The nurse is observing a new graduate nurse preparing to administer bumetanide 4 mg orally to a
client with heart failure. Which client finding requires the nurse to intervene immediately?
A The client has crackles in both lung bases.
B The client has 4+ pitting edema in both lower legs.
C The client's most recent blood pressure is 96/60 mmHg.
D The client's most recent serum potassium level is 2.9 mg/dL.

Question Explanation
Correct Answer is D
Rationale: Bumetanide is a powerful, potassium-wasting loop diuretic. It promotes diuresis in
clients suffering from heart failure (HF) and fluid retention. Prior to administration, the nurse
should verify that the client's potassium level is within normal range (3.5 to 5.0 mg/dL). A serum
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potassium level of 2.9 mg/dL is very low. The new graduate nurse should hold the bumetanide
and notify the health care provider (HCP) immediately. Bibasilar crackles and pitting edema are
expected findings for a client with HF and are indications for the use of diuretics. Although loop
diuretics can cause hypotension related to diuresis, a BP of 96/60 is within acceptable limits for a
client with HF.
Concepts tested

Question 1918
The nurse is reviewing the medical history of a client who is receiving weekly erythropoietin
injections. Which medical condition requires the use of this medication?
A Sickle-cell disease
B End-stage kidney disease (ESKD)
C Hemorrhagic fever (Ebola)
D Iron-deficiency anemia

Question Explanation
Correct Answer is B
Rationale: Erythropoietin is a hormone that stimulates production of red blood cells (RBCs) in
the bone marrow. The hormone is produced by cells in the proximal tubules of the kidneys.
Erythropoietin can partially reverse anemia associated with chronic or end-stage renal failure.
Initial effects can be seen within 1 to 2 weeks. Hemoglobin usually reaches acceptable levels (10
to 11 gm/dL) in 2 to 3 months. Erythropoietin is not used for iron-deficiency anemia, sickle cell
disease or Ebola.
Concepts tested

Question 1919
The nurse is evaluating a client post kidney transplant about the client's understanding of
mycophenolate mofetil. Which statement by the client indicates a need for further teaching?
A "I will take the medication on an empty stomach."
B "I will notify my doctor when I develop a sore throat and chills."
C "I will take Tylenol for minor aches and pains."
D "I will take milk of magnesia with it to prevent heartburn."

Question Explanation
Correct Answer is D
Rationale: Mycophenolate mofetil is a medication used to prevent transplant organ rejection.
Absorption of this medication can be decreased by antacids that contain magnesium and
aluminum hydroxides such as milk of magnesia. Accordingly, mycophenolate mofetil should not
be given simultaneously with these drugs. Taking acetaminophen (Tylenol) for minor pain is
acceptable, as long as the client remains within the FDA-recommended maximum daily dose of
3,900 mg. A sore throat and chills can be early symptoms of an infection in immunosuppressed
clients, so the client should notify their HCP. Taking the drug on an empty stomach will facilitate
complete absorption and is recommended.
Concepts tested

Question 1920
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A client has been diagnosed with hypothyroidism. Which medication should the nurse administer
to treat the client's bradycardia?
A Adenosine
B Epinephrine
C Levothyroxine
D Atropine

Question Explanation
Correct Answer is C
Rationale: The treatment for bradycardia from hypothyroidism is to treat the hypothyroidism
using levothyroxine sodium, a T4 replacement hormone. If the heart rate were so slow that it
causes hemodynamic instability, then atropine or epinephrine might be an option for short-term
management. Adenosine slows atrioventricular (AV) conduction in the heart and would be
contraindicated for a client with bradycardia
Concepts tested

Question 1921
The nurse is reinforcing teaching about levothyroxine for a client newly-diagnosed with
hypothyroidism. Which information should the nurse make sure to reinforce about this
medication?
A The medication will decrease the client's heart rate.
B The medication must be stored in a dark container.
C The medication may decrease the client's energy level.
D The medication should be taken in the morning.

Question Explanation
Correct Answer is D
Rationale: A thyroid supplement, such as levothyroxine, should be taken on an empty stomach
in the morning. Morning dosing minimizes the side effect of insomnia and an empty stomach
facilitates absorption. The medication does not need to be stored in a dark container.
Levothyroxine will cause an increase in the client's energy level and heart rate.
Concepts tested

Question 1922
A client recently diagnosed with heart failure has been prescribed digoxin and furosemide.
Which of the following foods should the nurse teach the client to eat at least one serving a day?
A Pear nectar
B Tomato juice
C Wheat cereal
D Blueberries

Question Explanation
Correct Answer is B

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Rationale: Digoxin, an antiarrhymic, and furosemide, a diuretic, are commonly prescribed for
clients with heart failure. A common side effect for furosemide is depletion of potassium. Of the
food choices, tomato juice is the highest in potassium. To reduce the risk of potassium depletion,
the client should be encouraged to drink at least 1/2 cup of tomato juice every day which is about
400 mg of potassium. The other choices are low in potassium which would be recommended for
clients diagnosed with chronic renal failure.
Concepts tested

Question 1923
The nurse is teaching a client diagnosed with depression about a new prescription of
nortriptyline. What information would be essential for the nurse to emphasize about this
medication?
A Symptom relief occurs in a few days
B The medication must be stored in the refrigerator
C The use of alcohol should be avoided
D Episodes of diarrhea can be expected

Question Explanation
Correct Answer is C
Rationale: Nortriptyline is a tricyclic antidepressant used to manage chronic neurogenic pain and
depression. Adverse reactions include central nervous system (CNS) side effects such as suicidal
thoughts, drowsiness, fatigue, lethargy, and confusion. Clients who are prescribed this
medication should be educated to avoid the use of alcohol consumption or other CNS depressant
drugs as this can worsen the adverse reactions of the medication and cause injury.
Concepts tested

Question 1924
The nurse is planning to administer a series of vaccines to a 4-year-old child including the DTap,
IPV, MMR, and VAR. Before administering the vaccines, what information should the nurse be
aware of? Select all that apply.
A A 5/8 inch needle length is often used for subcutaneous (SubQ) injections
B The vaccines all contain weakened live viruses
C Either the deltoid muscle of the arm or anterolateral thigh muscle can be used
D A 20 gauge needle is used to administer the varicella (VAR) vaccine intramuscularly (IM)
E Multiple immunizations should be administered a minimum of 1 inch apart
F The vaccines contain the preservative thimerosal

Question Explanation
Correct Answer is A, C, E
Rationale: Vaccinations for a 4 to 6 year-old child include diphtheria, tetanus, and whooping
cough (DTaP), Polio (IPV), measles, mumps, and rubella (MMR), and chicken pox (Varicella).
DTap is given intramuscularly (IM) and can be administered in either the deltoid muscle of the
arm or the anterolateral thigh muscle. The IPV can be administered either subcutaneously (subq)
or IM. If multiple vaccinations are to be administered, injections should be spaced a minimum of

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1-inch apart. The MMR and Varicella are administered subq using a 5/8 inch, 25-gauge needle.
Not all the vaccinations contain live viruses; IPV and DTaP. Vaccines no longer contain
thimerosal, which is a form of mercury.
Concepts tested

Question 1925
A 76 year-old client is prescribed an anticholinergic metered dose inhaler (MDI) for chronic
obstructive pulmonary disease (COPD). Why would the nurse suggest the client use a spacer?
A To help control the intake of the medication
B To increase client compliance to take the medication
C To enhance the administration of the medication
D To prevent further exacerbation of COPD

Question Explanation
Correct Answer is A
Rationale: An anticholinergic is used for maintenance therapy of airway obstruction due to
chronic obstructive pulmonary disorder (COPD) including bronchitis and emphysema. The
therapeutic effects are to cause bronchodilation and improve efforts of breathing. To improve the
administration of the medication the nurse should suggest the client to use a spacer. This will
help control the intake of the medication and reduce the amount of the medication that remains
on the throat or tongue.
Concepts tested

Question 1926
A client diagnosed with bipolar disorder is prescribed lithium. Which intervention would
be essential for the nurse to emphasize when teaching the client about this medication?
A . .Use antacids to prevent heartburn
B Maintain adequate daily salt intake
C Take the medication before meals
D Reduce fluid intake to minimize diuresis

Question Explanation
Correct Answer is B
Rationale: Lithium levels need to be regularly monitored. Clients should be advised to drink 8 to
10 glasses of water or other liquids every day and keep their salt intake the same because too
little salt may cause lithium levels to rise (and more salt may cause lithium levels to fall).
Lithium is a naturally occurring mineral with an electrical charge similar to salt.
Concepts tested

Question 1927
The nurse is teaching a group of clients who have been diagnosed with schizophrenia about
atypical antipsychotic medications. Which statement by the client would require further
education by the nurse?
A "I know I need to be patient but I wish it didn't take so long for this medication to really start
working."

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B "I'm so glad that this medication won't cause any of the tremors or tics I had when I was taking
my old medication."
C "I should be careful when I get out of bed because this medication can cause my blood
pressure to drop."
D "I'll probably gain a lot of weight on this medication and I may even develop diabetes."

Question Explanation
Correct Answer is B
Rationale: Although atypical antipsychotics may cause fewer extrapyramidal side effects, the
client should know that they may still cause some of the same symptoms, like tics, slow speech,
tremors or retarded movement. Most of these medications take two to four weeks or more to take
effect. In addition to weight gain and developing diabetes, there is a risk for higher cholesterol
and triglyceride levels.
Concepts tested

Question 1928
A client is being transfused with one unit of packed red blood cells. Within 15 minutes of the
transfusion, the client reports having chills and a headache. Which action should the nurse
take first?
A Notify the health care provider
B Obtain a set of vital signs
C Obtain a urine specimen
D Stop the transfusion

Question Explanation
Correct Answer is D
Rationale: The first action of the nurse should be to stop the blood transfusion. Based on the
client’s symptoms, they are having a hemolytic transfusion reaction. This could be caused by
mismatched blood types. Most frequent symptoms include fever, chills, itching, hives, and a
headache. It would be essential for the nurse to assess for this manifestations within the first 15
minutes of the transfusion, throughout, and 90 minutes after. After the nurse stops the infusion,
the health care provider and the blood bank should be notified for further evaluation and
treatment.
Concepts tested

Question 1929
There is an order to administer an intramuscular influenza vaccine to an adult client. What
actions should the nurse take before administration of the injection? Select all that apply.
A Record the client's reaction to the injection
B Have the client sign the vaccination consent form Correct Answer
C Provide the client with the a vaccine information statement Correct Answer
D Check the expiration date on the vaccination bottle Correct Answer
E Ask if the client ever had an adverse reaction to the flu vaccine Correct Answer
F Record the site and time of injection
G Record the site and time of injection

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Question Explanation
Correct Answer is B, C, D, E
Rationale: Prior to administration, the nurse should identify the expiration date on the bottle and
give a current copy of the vaccine information statement to the client. The nurse should also
verify any allergies or previous reactions to the vaccine, prior to administering the vaccine. A
signed consent is required for vaccinations. Observing for a reaction to the injection and
recording the site and time of injection should be performed after administering the vaccine.
Concepts tested

Question 1930
The nurse is caring for a client who is receiving a continuous intravenous heparin infusion. The
client's most recent activated partial thromboplastin time (aPTT) is 120 seconds. Which
medication should the nurse plan to administer?
A Protamine
B Naloxone
C Enoxaparin
D Vitamin K

Question Explanation
Correct Answer is A
Rationale: The client's aPTT is much higher than the typical desired therapeutic range of 1.5-2.5
the control value and places the client at great risk for uncontrolled bleeding. Protamine sulfate is
the medication used to reverse the effects of heparin; it is a heparin antagonist. Neutralization of
heparin occurs immediately and lasts for 2 hours, after which additional protamine may be
needed. Protamine is administered by slow IV injection (no faster than 20 mg/ min or 50 mg in
10 minutes). Dosage is based on the fact that 1 mg of protamine will inactivate approx. 100 units
of heparin. Vitamin K is used to reverse the effects of warfarin. Naloxone is used to reverse the
effects of opioids. Enoxaparin is another anticoagulant (low molecular weight heparin).
Concepts tested

Question 1931
A nurse is educating a client who was prescribed a monoamine oxidase inhibitor (MAOI) for
depression to avoid foods high in tyramine. Which foods should the client avoid?
A Apple juice, ham salad, fresh pineapple
B Hamburger, fries, strawberry shake
C Red wine, raspberries, aged cheese
D Fresh juice, carrots, vanilla pudding

Question Explanation
Correct Answer is C
Rationale: The body has two forms of MAO, named MAO-A and MAO-B. In the brain, MAO-A
inactivates norepinephrine (NE) and 5-HT, whereas MAO-B inactivates dopamine. In the
intestine and liver, MAO-A acts on dietary tyramine and other compounds. Although the MAOIs
normally produce hypotension, they can be the cause of severe hypertension if the client eats
food that is rich in tyramine. The client must be given a detailed list of tyramine-rich food and
Page | 789
beverages to avoid, including avocados, figs, smoked meats, liver, processed deli meat such as
salami and bologna, red wine, and practically all cheeses.
Concepts tested

Question 1932
The nurse is caring for a client who is receiving a continuous intravenous heparin infusion. The
client's most recent activated partial thromboplastin time (aPTT) is 120 seconds. Which
medication should the nurse plan to administer?
A Protamine
B Naloxone
C Enoxaparin
D Vitamin K

Question Explanation
Correct Answer is A
Rationale: The client's aPTT is much higher than the typical desired therapeutic range of 1.5-2.5
the control value and places the client at great risk for uncontrolled bleeding. Protamine sulfate is
the medication used to reverse the effects of heparin; it is a heparin antagonist. Neutralization of
heparin occurs immediately and lasts for 2 hours, after which additional protamine may be
needed. Protamine is administered by slow IV injection (no faster than 20 mg/ min or 50 mg in
10 minutes). Dosage is based on the fact that 1 mg of protamine will inactivate approx. 100 units
of heparin. Vitamin K is used to reverse the effects of warfarin. Naloxone is used to reverse the
effects of opioids. Enoxaparin is another anticoagulant (low molecular weight heparin).
Concepts tested

Question 1933
A nurse is educating a client who was prescribed a monoamine oxidase inhibitor (MAOI) for
depression to avoid foods high in tyramine. Which foods should the client avoid?
A Apple juice, ham salad, fresh pineapple
B Hamburger, fries, strawberry shake
C Red wine, raspberries, aged cheese
D Fresh juice, carrots, vanilla pudding

Question Explanation
Correct Answer is C
Rationale: The body has two forms of MAO, named MAO-A and MAO-B. In the brain, MAO-A
inactivates norepinephrine (NE) and 5-HT, whereas MAO-B inactivates dopamine. In the
intestine and liver, MAO-A acts on dietary tyramine and other compounds. Although the MAOIs
normally produce hypotension, they can be the cause of severe hypertension if the client eats
food that is rich in tyramine. The client must be given a detailed list of tyramine-rich food and
beverages to avoid, including avocados, figs, smoked meats, liver, processed deli meat such as
salami and bologna, red wine, and practically all cheeses.
Concepts tested

Question 1934

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The nurse is administering spironolactone for a client diagnosed with cirrhosis of the liver and
ascites. Which electrolyte should the nurse anticipate to be spared when giving this medication?
A Sodium
B Albumin
C Potassium Correct Answer
D Phosphate

Question Explanation
Correct Answer is C
Rationale: Spironolactone is a potassium-sparing diuretic. Indications for this medication include
edema associated with heart failure, cirrhosis, and nephrotic syndrome. The nurse should
anticipate that potassium is spared and should watch for signs of heart arrhythmias if the
potassium is too elevated. This type of diuretic inhibits the action of aldosterone on the kidneys,
which does not allow the body to reabsorb sodium. An adverse effect could be hyponatremia.
This medication has no effects on phosphate and albumin is not an electrolyte.
Concepts tested

Question 1935
The nurse receives an order to administer intravenous (IV) iron sucrose to a client with anemia.
Which statement best describes the purpose of administering this medication using the IV route?
A To ensure that the entire dose of medication is given
B To prevent the drug from causing tissue irritation
C To enhance absorption of the medication
D To provide more even distribution of the drug

Question Explanation
Correct Answer is B
Rationale: Iron sucrose is an iron supplement used to treat iron deficiency anemia. If given
subcutaneously or intramuscularly, the tissue can become irritated and may result in bleeding
into the muscle; therefore, the best route for this medication is intravenous (IV). The rate for
administration will vary on the dosage but is typically at a slower rate due to the risk of adverse
reactions. The other statements do not accurately describe the purpose for the IV route.
Concepts tested

Question 1936
The nurse is caring for a client who is receiving intravenous total parenteral nutrition (TPN).
Which action by the nurse would represent appropriate care of this client?
A Monitor for cardiac arrhythmias
B Sterile technique for dressing change at IV site
C Maintain strict intake and output records
D Record the number of stools per day

Question Explanation
Correct Answer is B

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Rationale: Clients receiving TPN are very susceptible to infection. The concentrated glucose
solutions are a good medium for bacterial growth. Strict sterile technique is crucial in preventing
infection at IV infusion site.
Concepts tested

Question 1937
The nurse is planning care for clients over the age of 70. Which consideration would be most
appropriate when planning care for older clients?
A Avoid drugs with side effects that impact cognition
B Review the drug regimen yearly
C Start with the smallest dose and increase slowly as needed
D Do not stop a medication entirely

Question Explanation
Correct Answer is C
Rationale: It would be most appropriate for the nurse to consider starting with the smallest dose
of the medication and slowly increasing as needed. Example: If a 70+ year old client is
requesting pain medications and the order is for one or two tablets, the nurse should first
administer one tablet and evaluate if the other tablet is needed. Due to physiological changes of
the older client, medications can accumulate to toxic levels and cause serious adverse reactions.
This could lead to altered mental status and risk for serious complications of the body’s systems.
The nurse should educate the client on their medications more frequently than just a year.
Concepts tested

Question 1938
The nurse is caring for a client who has been taking furosemide for the past week. Which
manifestation would indicate that the client may be experiencing a negative side effect?
A Decreased appetite
B Gastric irritability
C Edema of the ankles
D Weight gain of five pounds

Question Explanation
Correct Answer is A
Rationale: Furosemide (Lasix) causes a loss of potassium if a supplement is not taken. Findings
of hypokalemia include anorexia, fatigue, nausea, decreased gastrointestinal motility, muscle
weakness and dysrhythmias.
Concepts tested

Question 1939
Template

Question Explanation
Correct Answer is template

Question 1940
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The nurse is caring for a client who was recently prescribed atropine as a treatment for
symptomatic bradycardia. Which condition should the nurse question as a contraindication when
taking this medication?
A Urinary incontinence
B Increased intracranial pressure
C Right-sided heart failure
D Glaucoma

Question Explanation
Correct Answer is D
Rationale: The nurse should question the use of atropine with a client who has glaucoma.
Atropine is contraindicated in clients with angle-closure glaucoma because it can cause pupillary
dilation with an increase in aqueous humor. This can lead to an increase in optic pressure causing
blurred vision and ocular pain.
Concepts tested

Question 1941
The nurse is teaching a client with stable angina about their new prescription for nitroglycerin
transdermal patch. Which instructions should the nurse include? Select all that apply.
A Plan for patch-free time, usually overnight
B Remove the patch if ankle edema occurs
C Apply a second patch with chest pain
D Notify your provider for persistent dizziness or any fainting episode
E Apply the patch to a hairless area of the body
F Rotate the application area

Question Explanation
Correct Answer is A, D, E
Rationale: Nitroglycerin (NTG) acts directly on vascular smooth muscle to promote vasodilation.
It decreases the pain of exertional angina primarily by decreasing cardiac oxygen demand. NTG
comes in a variety of routes of administration. NTG patches contain a reservoir from which the
drug is slowly released. Following release, the drug is absorbed through the skin and then into
the blood. The rate of release is constant and, depending on the patch used, can range from 0.1 to
0.8 mg/ hr. Effects begin within 30 to 60 minutes and persist as long as the patch remains in
place (up to 14 hours). Patches are applied once daily to a hairless area of skin. The site should
be rotated to avoid local irritation. Tolerance develops if patches are used continuously (24 hours
a day every day). Accordingly, a daily “patch-free” interval of 10 to 12 hours is recommended.
This can be accomplished by applying a new patch each morning, leaving it in place for 12 to 14
hours, and then removing it in the evening. NTG can cause orthostatic hypotension and the client
should let their provider know if dizziness and lightheadedness persist or the client has a fainting
(syncopal) episode as these may indicate that the NTG dose needs to be adjusted/decreased. The
other instructions are not appropriate for this medication.
Concepts tested

Question 1942

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The nurse is providing discharge instructions to an older adult client with heart failure. The client
asks, "What is the purpose for taking the furosemide?" How should the nurse respond?
A It will protect your kidneys from chronic damage.
B It will reverse the damage to your heart muscle.
C It will help with reducing the risk for an irregular heart rhythm.
D It will help with decreasing fluid buildup in your lungs.

Question Explanation
Correct Answer is D
Rationale: Furosemide is a loop diuretic. Diuretics are the first-line drug of choice in older adults
with heart failure (HF) and fluid overload. These drugs enhance the renal excretion of sodium
and water by reducing circulating blood volume, decreasing preload, and reducing systemic and
pulmonary congestion, i.e., decreased fluid buildup in the lungs. The other actions do not pertain
to furosemide.
Concepts tested

Question 1943
The nurse is providing preoperative teaching for a client preparing for a thyroidectomy about the
medication saturated solution of potassium iodide (SSKI, ThyroSheild) drops. Which
information is important for the nurse to include?
A Store the medication in the refrigerator.
B The medication will enlarge the thyroid gland.
C Mix the medication with juice or milk.
D Take the medication on an empty stomach.

Question Explanation
Correct Answer is C
Rationale: For client’s with Grave’s disease, saturated solution of potassium iodide (SSKI) is
given to control the hyperthyroidism, but also to reduce the amount of blood loss during surgery.
The medication is in drop form, and the typical dosing is 1 to 2 drops three times a day mixed in
juice or milk for 10 days preoperatively. It is not necessary to take it on an empty stomach.
Storing it in the refrigerator may cause crystallization of the solution. The medication will not
enlarge the thyroid gland.
Concepts tested

Question 1944
The nurse is discharging a client on oral potassium replacement. Which of the following
statements requires further teaching by the nurse?
A "I will continue to use salt substitutes to flavor my food."
B "I will take my furosemide first thing in the morning."
C "I can still take my nonsteroidal anti-inflammatory medications occasionally for my arthritis
pain."

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D "I will read the food labels for added potassium."

Question Explanation
Correct Answer is A
Rationale: Salt substitutes are made using potassium. As the client is taking potassium
supplements, they should avoid salt substitutes to prevent hyperkalemia from occurring.
NSAIDS can be used occasionally. The furosemide should be taken in the morning. Some low-
sodium prepared foods may contain potassium, so reading the labels is important.
Concepts tested

Question 1945
The nurse is providing discharge instructions to a client with a prescription for sublingual
nitroglycerin. The nurse should inform the client to prepare for this most common side effect?
A Anorexia
B Dry mouth
C Headache
D Depression

Question Explanation
Correct Answer is C
Rationale: Nitroglycerin is a potent vasodilator and a headache is the most common side effect.
The headache comes on suddenly and can be severe, thus the client should be prepared for this
effect. The other side effects listed are common side effects of oral medications, but not
specifically to nitroglycerin.
Concepts tested

Question 1946
Which of the following instructions is most important for the nurse to include when discharging
a client with an infection caused by staphylococcus?
A Complete the full course of the antibiotic
B Visit the provider in a few weeks
C Schedule follow-up blood cultures
D Monitor for signs of recurrent infection

Question Explanation
Correct Answer is A
Rationale: Staphylococcus is a bacteria and to rid the body of the infection, it is most important
to instruct the client to complete the full course of antibiotics. Not completing the full course of
antibiotics can lead to antibiotic resistant infections. At this point, there is no indication for the
need for blood cultures. The client will need a follow-up appointment with the provider, and will
need to monitor for signs of recurrent infections, but these are not as high a priority as
completing the full course of antibiotics.
Concepts tested

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Question 1947
A client calls the clinic and states to the triage nurse: "I had an upset stomach and took Pepto-
Bismol and now my tongue looks black. What’s happening to me?" What would be the nurse’s
best response?
A "This is a common and temporary side effect of this medication."
B "Come to the clinic so you can be seen by the health care provider."
C "How long have you had an upset stomach?"
D "Are your stools also black?"

Question Explanation
Correct Answer is B
Rationale: The best response would be to explain that a dark tint of the tongue is a common and
temporary side effect of bismuth subsalicylate (Pepto-Bismol). Although it may also turn stools a
darker color, do not confuse this with black, tarry stools, which is a sign of bleeding in the
intestinal tract. After addressing the client’s initial concern and the reason for the call, the nurse
can ask about the upset stomach and then ask the client to come to the clinic if necessary.
Concepts tested

Question 1948
The nurse is preparing to start a peripheral venous access device on an alert and oriented adult
client. Which supplies should the nurse select? Select all that apply.
A Adhesive tape
B An arm board
C Transparent dressing
D Soft wrist restraint
E An appropriate size IV catheter
F Antiseptic skin swab
G Saline flush syringe

Question Explanation
Correct Answer is A, C, E, F, G
Rationale: When preparing to start a peripheral venous access device, the nurse should select a
catheter that is appropriate in size for the client and medication or IV fluid administration. Most
facilities provide "IV start kits" that contain the necessary supplies including a transparent
dressing, adhesive tape and an antiseptic skin swab. A soft wrist restraint or arm board which can
be considered a "restraint" if it limits movement, are not indicated for this client.
Concepts tested

Question 1949
The nurse is preparing to teach a client with type 2 diabetes mellitus about their newly prescribed
exenatide (Byetta) pen. Which instructions should the nurse include? Select all that apply.
A You may experience some weight loss.
B Take any oral medications 1 hour before the exenatide.

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C After use, store the injector pen in the refrigerator.
D Take the exenatide immediately after meals.
E Inject yourself in the abdominal or thigh area.

Question Explanation
Correct Answer is A, B, E
Rationale: Exenatide (Byetta) is a non-insulin, incretin mimetic used for the treatment of
diabetes. It works by lowering blood glucose by slowing gastric emptying, stimulating glucose-
dependent insulin release, suppressing postprandial glucagon release, and reducing appetite.
Some initial, minor weight loss is common. Exenatide comes in pre-filled, injector pens.
Injections are made subcutaneously into the thigh, abdomen, or upper arm. Exenatide should be
administered 0 to 60 minutes before the morning and evening meals — never after the meal.
Exenatide delays gastric emptying and hence can slow the absorption of oral drugs; this is of
particular concern with oral contraceptives and antibiotics. To minimize this interaction, the
client should take oral drugs at least 1 hour before exenatide. Common side effects include
nausea and vomiting. The pen should be stored at room temperature after first use.
Concepts tested

Question 1950
The nurse is providing instructions to a client with a new prescription for levothyroxine 50 mcg
daily to treat hypothyroidism. Which of the following is important for the nurse to include in the
discharge instructions?
A It must be stored in a dark container.
B It may decrease the client's energy level.
C It can be taken with an antacid if stomach upset occurs.
D It should be taken in the morning.

Question Explanation
Correct Answer is D
Rationale: A thyroid supplement should be taken in the morning on an empty stomach with 8
ounces of water to maximize effects. Also, the client should avoid foods high in fiber, iron or
soybeans within four hours of taking this medication because they may interfere with this drug's
absorption. The medication should not be given in the evening or prior to bedtime because it may
cause insomnia. It is not necessary to keep in a dark container. As the medication replaces
thyroid hormone the client's energy level should be improved not decreased.
Concepts tested

Question 1951
The nurse is providing care for a client admitted to the hospital with a diagnosis of digoxin
toxicity. The client reports more than usual urine output over the previous 48 hours, because of
the prescribed diuretic. Which assessment finding does the nurse anticipate?
A Blood in the urine
B Tinnitus

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C Hypertension
D Muscle weakness or cramping

Question Explanation
Correct Answer is D
Rationale: The client with heart failure on digoxin and a diuretic is at risk for hypokalemia. The
digoxin binds to the potassium receptor of the sodium/potassium ATPase pump. The increased
urine output makes hypokalemia likely and thus it is more likely for digoxin toxicity to occur.
Symptoms of hypokalemia include muscle weakness and cramping. The digoxin toxicity will not
cause blood in the urine, or tinnitus or hypertension.
Concepts tested

Question 1952
The home health nurse evaluates a caregiver's technique for administering a rectal suppository to
a client. The caregiver turns the client to the left side, pushes the lubricated suppository in with
one finger, up to the second knuckle, removes the finger and then waits 10 minutes before
turning the client to the right side. Which feedback from the nurse is most appropriate?
A "Did you feel any stool in the intestinal tract?"
B "Let's check to see if the suppository is in far enough."
C "That was done correctly. Did you have any problems with the insertion?"
D "Why don't we now have the client turn back to the left side."

Question Explanation
Correct Answer is C
Rationale: Left side-lying position is the optimal position for clients to receive rectal
medications. Due to the position of the descending colon, left side-lying allows the medication to
be inserted and move along the natural curve of the intestine and facilitates retention of the
medication. The suppository should be somewhat melted after 10 to 15 minutes and the client
can move into any position of comfort.
Concepts tested

Question 1953
The caregiver of a client with Alzheimer's disease asks the nurse for information about different
treatment options that can help with memory or behavior problems. Which of the following
responses by the nurse are correct? Select all that apply.
A "Music therapy has been found to help some clients."
B "Donepezil (Aricept) may help slow cognitive decline."
C "Garlic may help with this disease."
D "Ginkgo biloba may help with memory."
E "Acupuncture may be very relaxing."

Question Explanation
Correct Answer is A, B, D
Rationale: Some complementary and integrative health therapies may help with the symptoms
of Alzheimer's disease. Music, art and dance therapies can help with behavior issues. Ginkgo

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biloba may be used to improve memory. Acupuncture may be a frightening experience for
someone with Alzheimer's disease. Garlic is not a treatment for Alzheimer's disease. Donepezil
(Aricept) is used to ease the symptoms associated with Alzheimer's disease.
Concepts tested

Question 1954
The nurse is teaching a client with rheumatoid arthritis about etanercept. Which of the following
statements by the client indicates no further teaching is needed?
A "If you keep the medication in a refrigerator, be sure to allow it to warm to room temperature
before injecting it."
B "The medication needs to be mixed well. You can shake the bottle to mix it."
C "You will need to come into the clinic every 6 weeks to receive an intravenous infusion."
D "Take the medication daily, first thing in the morning on an empty stomach."

Question Explanation
Correct Answer is A
Rationale: Etanercept is in a class of medications called tumor-necrosis factor inhibitors and is
used alone or with other medications to relieve the symptoms of some autoimmune disorders. It
usually comes in a prefilled syringe and an automatic injection device. The medication is
injected subcutaneously once a week. Besides knowing how and where to inject the medication,
the client should be instructed never to shake the vial and, if the medication has been
refrigerated, the nurse should reinforce that the client should simply place the medication on a
flat surface (like a countertop) and allow it to warm to room temperature for about 30 minutes
but never heat it in a microwave or place it in hot water.
Concepts tested

Question 1955
A nurse is administering an intravenous piggyback infusion of penicillin. Which client statement
would require the nurse's immediate attention?
A "I have a burning sensation when I urinate."
B "I am itching all over."
C "I have cramping in my stomach."
D "I have soreness and aching in my muscles."

Question Explanation
Correct Answer is B
Rationale: Allergic reactions to medications can include itching all over. This can be further
supported by the presence of hives or welts. Abdominal pain or cramping could indicate a side
effect of the penicillin. The other symptoms of muscle soreness and painful urination are not as
urgent as the itching.
Concepts tested

Question 1956
A client is diagnosed with rheumatoid arthritis (RA). Which types of drugs might the nurse
expect to be ordered as a combination drug therapy regimen? Select all that apply.

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A Anti-inflammatory drugs
B Antimicrobial agents
C Glucocorticoids
D Diuretics
E Biological-response modifiers

Question Explanation
Correct Answer is A, C, E
Rationale: Rheumatoid arthritis is a chronic, systemic autoimmune disorder that results in
symmetric joint destruction. Research shows that multiple drug therapy is most effective in
protecting against further destruction and promoting function. Analgesics and anti-inflammatory
drugs are used. Disease-modifying anti-rheumatic drugs (DMARDs) such as methotrexate help
slow or stop progression of RA. Biological response modifiers are used to help stop
inflammation. Glucocorticoids can also be used for severe RA or when RA symptoms flare to
ease the pain and stiffness of affected joints. Because RA is not an infectious disease,
antimicrobials are ineffective. Although there is swelling in the joints, it is not fluid, so diuretics
are not part of the treatment plan.
Concepts tested

Question 1957
A nurse is preparing to administer morning medications to a client with heart failure. The
morning lab values are: sodium 142 mEq/L (142 mmol/L), potassium 2.9 mEq/L (2.9 mmol/L),
digoxin level 1.4 ng/mL. Which of the following medications should the nurse not administer
until after speaking with the health care provider?
A Spironolactone
B Carvedilol (Coreg)
C Ferrous sulfate
D Digoxin (Lanoxin)

Question Explanation
Correct Answer is D
Rationale: Because the potassium levels are low (normal is 3.5 to 5 mEq/L or 3.5 to 5 mmol/L),
the nurse should not give the digoxin; hypokalemia can predispose a person to digoxin toxicity.
The other medications can be administered. Although carvedilol can increase plasma digoxin
concentration, the digoxin level is normal. Spironolactone is a potassium-sparing diuretic and
because the potassium level is low, this too can be given. Ferrous sulfate does not affect the
given lab values.
Concepts tested

Question 1958
The client is newly diagnosed with type 1 diabetes mellitus. Which of these approaches would be
the best strategy for the nurse to use when teaching insulin injection techniques?
A Ask questions during practice
B Give written pre and post tests

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C Allow another diabetic to assist
D Observe a return demonstration

Question Explanation
Correct Answer is D
Rationale: Learning to inject oneself is a challenging task and the nurse should first demonstrate
the injection and then ask for a return demonstration from the client. Giving a written test is not
appropriate for this teaching. Asking questions during practice is important, but the nurse still
needs to see the client self-inject. Asking another diabetic to assist is not appropriate
Concepts tested

Question 1959
The nurse is reviewing the medical record of a client with bipolar disorder. The client is
prescribed aripiprazole (Abilify) 10 mg once a day but reports that they have not taken the
medication in several weeks. Which action should the nurse take?
A Instruct the client's partner to make sure the medication is taken every day.
B Inform the client that they will have to be admitted to an inpatient psychiatric facility.
C Educate the client on the importance of taking their medications as prescribed.
D Request for the medication to be changed to a once monthly injection.

Question Explanation
Correct Answer is D
Rationale: Aripiprazole (Abilify) is the first representative of a unique class of antipsychotic
drugs, referred to as dopamine system stabilizers (DSSs). Approved indications are
schizophrenia, acute bipolar mania, major depressive disorder, agitation associated with
schizophrenia or bipolar mania. Aripiprazole is available in standard tablets, orally disintegrating
tablets and extended-release injections that can be given monthly. For clients who struggle with
adherence, a once a month injection is a good alternative to a daily oral dose. The other actions
are not appropriate, helpful or necessary.
Concepts tested

Question 1960
The nurse is assessing a client with suspected aspirin overdose. Which assessment findings
would support this diagnosis? Select all that apply.
A Jaundice
B Serum pH 7.31
C Tinnitus
D Headache
E Hypoglycemia
F Respiratory rate of 28

Question Explanation
Correct Answer is B, C, D, F
Rationale: Aspirin belongs to a chemical family known as salicylates. All members of this group
are derivatives of salicylic acid. Aspirin is produced by substituting an acetyl group onto

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salicylic acid and is commonly known as acetylsalicylic acid, or simply ASA. Low therapeutic
doses of aspirin produce plasma salicylate levels less than 100 mcg/ mL. Anti-inflammatory
doses produce salicylate levels of about 150– 300 mcg/ mL. Signs of salicylism (toxicity) begin
when plasma salicylate levels exceed 200 mcg/ mL. Severe toxicity occurs at levels above 400
mcg/ mL. Salicylism is a syndrome that begins to develop when aspirin levels climb just slightly
above therapeutic. Overt signs include tinnitus (ringing in the ears), sweating, headache, and
dizziness. Acid-base disturbance (metabolic acidosis) may also occur. The respiratory rate will
increase in an effort to 'blow off' CO2 to compensate for the acidosis. Hypoglycemia and
jaundice are not typically seen with salicylate overdose.
Concepts tested

Question 1961
A client has received a prescription for nitrofurantoin to treat a urinary tract infection. Which of
the following statements made by the client indicates the need for additional teaching about the
medication?
A "I'll call my primary health care provider immediately if I develop a rash after taking the
medication."
B "I will spend extra time in the sun to get plenty of vitamin D."
C "I will be sure to finish taking the antibiotics, even if I start feeling better."
D "I will take the medication with food."

Question Explanation
Correct Answer is B
Rationale: Clients taking nitrofurantoin should avoid exposure to sunlight while taking the
medication. Exposure to sunlight while taking this medication can lead to damage to the skin. A
client planning to spend extra time in the sun while taking nitrofurantoin should be informed of
the dangers of sun exposure and counseled to avoid sun exposure while taking the medication.

Client statements reflecting the importance of taking the complete course of antibiotics, notifying
the health care provider if a rash develops and taking the medication with food demonstrate
correct understanding of important considerations while taking this antimicrobial therapy.
Concepts tested

Question 1962
A client received hydromorphone orally one hour ago. When the nurse enters the client's room,
the client is unresponsive to verbal stimuli and has a respiratory rate of six breaths per minute.
Which action should the nurse take next?
A Administer supplemental oxygen.
B Prepare to administer naloxone.
C Prepare for endotracheal intubation.
D Begin cardiopulmonary resuscitation.

Question Explanation
Correct Answer is B
Rationale: Hydromorphone is an opioid analgesic. The client seems to be experiencing central
nervous system and respiratory depression related to the medication. The antidote for opioids is
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naloxone. The nurse should first administer naloxone to reverse the effects of the
hydromorphone. The other actions are not appropriate for the client at this time.
Concepts tested

Question 1963
A client has been taking isoniazid and rifampin for several months. Which laboratory test should
the nurse monitor with this client?
A Liver enzymes
B Sputum culture
C Cardiac enzymes
D Creatinine clearance

Question Explanation
Correct Answer is A
Rationale: INH and rifampin are used to treat tuberculosis and both are hepatotoxic. Isoniazid
can cause hepatocellular injury and multilobular necrosis and is believed to result from the
production of a toxic isoniazid metabolite. Rifampin is also toxic to the liver, posing a risk of
jaundice and even hepatitis. Asymptomatic elevation of liver enzymes occurs in about 14% of
patients. Hepatotoxicity is most likely in people who abuse alcohol and in clients with pre-
existing liver disease. These individuals should be monitored closely for signs of liver
dysfunction. Tests of liver function (serum aminotransferase levels) should be made before
treatment and every 2 to 4 weeks thereafter. The other lab tests are not specific to the
medications the client is taking.
Concepts tested

Question 1964
The nurse is reviewing the client's medical record and notes that the client has been taking an
oral contraceptive for several years. For which potential complications should the nurse monitor
the client? Select all that apply.
A Depression
B Colon Cancer
C Osteoporosis
D Breast cancer
E Deep Vein Thrombosis (DVT)
F Anemia

Question Explanation
Correct Answer is A, D, E
Rationale: Oral contraceptives contain both advantages and disadvantages for clients.
Advantages include shortening menstrual cycles, decreasing anemia and protecting against bone
loss. Clients have decreased risks for ovarian, colorectal and endometrial cancers. Potential
complications include increased risks for breast cancer, depression and a DVT. Women who
smoke may have an increased risk for myocardial infarction, stroke and hypertension.
Concepts tested

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Question 1965
The nurse is reviewing the client's medical record and notes that the client has been taking an
oral contraceptive for several years. For which potential complications should the nurse monitor
the client? Select all that apply.
A Depression
B Colon cancer
C Osteoporosis
D Breast cancer
E Deep Vein Thrombosis (DVT)
F Anemia

Question Explanation
Correct Answer is A, D, E
Rationale: Oral contraceptives contain both advantages and disadvantages for clients.
Advantages include shortening menstrual cycles, decreasing anemia and protecting against bone
loss. Clients have decreased risks for ovarian, colorectal and endometrial cancers. Potential
complications include increased risks for breast cancer, depression and a DVT. Women who
smoke may have an increased risk for myocardial infarction, stroke and hypertension.
Concepts tested

Question 1966
The nurse in the urgent-care clinic is reviewing discharge instructions with a client who is
prescribed doxycycline. Which statement by the client indicates understanding of the
instructions?
A "I will take this medication with an antacid to prevent an upset stomach."
B "I will not wear my contact lenses while taking this medication."
C "I will apply sunscreen when outside to prevent a sunburn."
D "I will carry glucose tablets with me in case I experience low blood sugar."

Question Explanation
Correct Answer is C
Rationale: Doxycycline is a tetracycline antibiotic. All tetracyclines can increase the sensitivity
of the skin to ultraviolet light. The most common result is a sunburn. Clients on these types of
medications should prevent sunburn by avoiding prolonged exposure to sunlight, wearing
protective clothing and applying sunscreen to exposed skin while outdoors. This drug should be
taken two hours before or after antacids, not with them. Hypoglycemia is not a common side
effect of doxycycline. Wearing contact lenses is not contraindicated with this medication.
Concepts tested

Question 1967
The nurse is caring for a client newly diagnosed with generalized anxiety disorder (GAD) who
has been prescribed alprazolam by the health care provider (HCP). Which of the following
statements best describes this medication in the treatment of GAD?
A Alprazolam provides short-term treatment but is less effective than other drug therapy.
B There is no risk for developing a dependency to alprazolam.

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C Alprazolam will become more effective over time.
D Alprazolam is the only recommended drug for GAD.

Question Explanation
Correct Answer is A
Rationale: The most effective pharmacological treatment for generalized anxiety disorder is
considered to be SSRI or SNRI therapy. Benzodiazepines like alprazolam may be used for fast-
acting pharmacological treatment. However, SSRIs or SNRIs are considered to be more effective
than benzodiazepines.

Clients can develop a chemical dependency to benzodiazepines, and these medications can
become less effective over time because clients can develop a tolerance to its therapeutic effect.
Concepts tested

Question 1968
Which of the following statements by a client taking lithium for bipolar disorder indicates the
need for additional teaching?
A "I should let my health care provider (HCP) know if I have a lot of vomiting or diarrhea.”
B "I will be sure to drink about 6 to 8 glasses of water every day."
C "I will need to have my blood drawn once a year to check the lithium level."
D "I will call my health care provider (HCP) if I have blurred vision or ringing in my ears."

Question Explanation
Correct Answer is C
Rationale: Lithium levels should be checked more frequently than once per year, with some
sources recommending routine monitoring as often as every 1 to 2 months. The nurse would
need to inform the client that it will be necessary to monitor lithium levels more often than once
per year and coordinate with the HCP to identify the appropriate monitoring schedule for this
client.

Blurred vision, tinnitus, slurred speech and confusion could indicate a dangerous condition called
lithium toxicity and the HCP would need to be notified immediately. Similarly, vomiting or
diarrhea could increase the risk of dangerous levels of lithium in the blood. It is appropriate for
clients taking lithium to drink 6 to 8 glasses of water each day.
Concepts tested

Question 1969
A client who is taking duloxetine asks the nurse if the medication treats depression or diabetes.
Which is the best response from the nurse?
A "Duloxetine is used to treat depression but can also be used to lower blood sugar levels."
B "Duloxetine is not prescribed for either depression or diabetes."
C "Duloxetine is used to treat diabetes but can also be used to treat depression."
D "Duloxetine is used to treat depression but can be used to treat pain that can occur in people
with diabetes."

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Question Explanation
Correct Answer is D
Rationale: Duloxetine is a selective serotonin and norepinephrine reuptake inhibitor (SNRI) that
can be used to treat depression but also can be used to treat pain associated with diabetic
neuropathy. Duloxetine is not used to lower blood glucose levels.

While it is a true statement that duloxetine is an antidepressant, it is not the best response from
the nurse since it does not fully address the client's question. The best response is to confirm the
use of duloxetine in the treatment of depression and to explain its additional role in treating
diabetic neuropathy in some situations.
Concepts tested

Question 1970
The nurse in a hematology clinic is reviewing home medications for a child with hemophilia.
Which medication should the nurse clarify with the health care provider?
A Acetaminophen
B Naproxen
C Prednisone
D Diphenhydramine

Question Explanation
Correct Answer is B
Rationale: Hemophilia is a group of inherited bleeding disorders caused be a deficiency in
clotting factors. Management is focused on replacing the missing clotting factor and prevention
and control of bleeding. Naproxen is an NSAID that can affect platelet function and lead to an
increased risk for bleeding. Clients should be educated not to take this medication when they
have hemophilia. Corticosteroids, acetaminophen or diphenhydramine do not increase the risk
for bleeding and are not contraindicated for a child with hemophilia.
Concepts tested

Question 1971
The nurse in an emergency department is caring for a 3-week-old infant. During the initial
assessment, the infant is crying and displaying furrowed brows and clenched fists. Which
additional finding would indicate that the infant might be in pain?
A Increased muscle tone
B Hyperglycemia
C Constricted pupils
D Ruddiness

Question Explanation
Correct Answer is A
Rationale: Evaluation of acute pain in an infant is partly based on physiological changes because
the baby is unable to verbally self-report pain. The nurse should assess physiological
manifestations in order to effectively assess and manage pain. Categories of physiologic
responses noted during acute pain in a neonate include changes in vital signs, oxygenation, and

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others such as dilated pupils and increased muscle tone. Constricted pupils, ruddiness or
hyperglycemia are not typical findings in a neonate experiencing pain.
Concepts tested

Question 1972
A client at risk for a stroke has been prescribed clopidogrel. Which information
is most important for the nurse to reinforce with the client?
A "You must take the medication on an empty stomach."
B "You must have your lab tests checked weekly."
C "If you miss a dose, take a double dose the next day."
D "You must stop the medication a week before your surgery."

Question Explanation
Correct Answer is D
Rationale: Clopidogrel is an oral antiplatelet drug with similar effects to aspirin. The drug is
taken for secondary prevention of myocardial infarction, ischemic stroke and other vascular
events. Clopidogrel prevents platelet aggregation. Like all other antiplatelet drugs, clopidogrel
poses a risk of serious bleeding. Clopidogrel should be discontinued 5 to 7 days before elective
surgery.

The drug's effects begin two hours after the first dose and plateau after 3 to 7 days of treatment.
Platelet function and bleeding time return to baseline 7 to 10 days after the last dose. It can be
taken with or without food. No weekly lab tests are required with clopidogrel. Clients should not
be instructed to double up when missing a dose.
Concepts tested

Question 1973
The nurse is reinforcing the correct use of a metered-dose inhaler (MDI) for a client newly-
diagnosed with asthma. The client asks, "how will I know the canister is empty?" What is
the best response by the nurse?
A "Drop the canister in water to observe if it floats."
B "Count the number of doses as the inhaler is used."
C "Contact your pharmacy to find out when to obtain a refill."
D "Shake the canister and listen for any fluid movement."

Question Explanation
Correct Answer is B
Rationale: Floating an MDI in water, or shaking it to listen for fluid movement to determine
how much medication is left, is not recommended. MDIs that count down the number of
remaining doses are available, however, these mechanisms are not always accurate. Therefore, it
is best to calculate how long the inhaler will last by dividing the number of doses in the container
by the number of doses the client takes per day. For example, a client who needs to take two
puffs of albuterol, four times a day, will take a total of eight puffs per day. The MDI contains a
total of 200 puffs. Divide 200/8 = 25 days. The inhaler in this example will last 25 days. To
ensure that the client does not run out of medication, the client should obtain a refill at least 7 to
10 days before it runs out. The pharmacy would not be able to determine if the canister is empty.
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Concepts tested

Question 1974
The nurse administers cimetidine to a 75-year-old client diagnosed with a gastric ulcer. The
nurse should monitor the client for which adverse reaction?
A Hearing loss
B Increased liver enzymes
C Mental status change
D Constipation

Question Explanation
Correct Answer is C
Rationale: Cimetidine is a histamine H2-receptor antagonist used to treat gastric ulcers. It has
been found to cause confusion in susceptible clients, such as the elderly and debilitated clients.
Clients over age 50 or who are severely ill may become temporarily confused while taking
H2 blockers, especially cimetidine.
Concepts tested

Question 1975
A client is prescribed furosemide and digoxin for heart failure. The nurse should monitor the
client for which potential adverse drug effect?
A Acute arterial occlusion
B Pulmonary hypertension
C Acute kidney injury
D Cardiac dysrhythmias

Question Explanation
Correct Answer is D
Rationale: Digoxin is a cardiac glycoside, or positive inotrope that increases myocardial
contractility. By increasing contractile force, digoxin can increase cardiac output in clients with
heart failure (HF). Furosemide is a potassium-wasting (loop) diuretic, prescribed to prevent fluid
overload in clients with HF. Clients who take furosemide are at risk for developing hypokalemia.
Potassium ions compete with digoxin and a low potassium level can cause digoxin toxicity,
leading to lethal cardiac dysrhythmias. Therefore, it is imperative that potassium levels be kept
within normal range (3.5 to 5 mEq/L) while taking digoxin.
Concepts tested

Question 1976
The nurse is reinforcing medication interactions with a client who is taking warfarin. Which
over-the-counter (OTC) medication should the nurse remind the client to avoid?
Question 16 Answer Choices
A Pantoprazole
B Naproxen
C Acetaminophen
D Diphenhydramine

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Question Explanation
Correct Answer is B
Rationale: Warfarin is an anticoagulant. OTC medications that interact with warfarin should be
avoided. Naproxen, a nonsteroidal anti-inflammatory drug (NSAID), is a commonly used OTC
analgesic. Naproxen can prolong bleeding time and should therefore be avoided by clients who
take anticoagulants. The other medications are not contraindicated when taking warfarin.
Concepts tested

Question 1977
The nurse is preparing to administer an antibiotic intramuscularly (IM) to a 2-year-old child. The
total volume of the injection is 2 mL. Which is the best approach for the nurse to take when
administering this medication?
A Substitute an oral form of the medication.
B Inject the medication in the deltoid muscle.
C Split the medication into two separate injections.
D Call the provider and request a smaller dose.

Question Explanation
Correct Answer is C
Rationale: Recommendations for intramuscular (IM) medication administration for an
infant/toddler (1 month to 2 years) include using a 1 inch, 22 to 25 gauge needle. The vastus
lateralis muscle is preferred. The deltoid muscle should only be used if the muscle mass is
adequately developed. IM injections for small children should not exceed a volume of 1 mL. For
medication doses that exceed this volume, it is best to split the dose into two separate injections
of 1 mL each. The other actions are not appropriate in this situation.
Concepts tested

Question 1978
The nurse is teaching a client with systemic lupus erythematosus about methotrexate. Which
statement by the client indicates an understanding of the medication?
A “I should not use contraception that contains estrogen.”
B “I will not take any vitamin that contains folic acid.”
C “I will avoid interacting with people in large crowds.”
D “Lab work won’t be necessary while I take this medication.”

Question Explanation
Correct Answer is C
Rationale: Methotrexate is an immunosuppressant medication that is used to treat systemic lupus
erythematosus (SLE). Due to immunosuppression, clients taking methotrexate should avoid large
crowds of people to prevent becoming ill. Methotrexate should be taken with folic acid to
decrease gastrointestinal and hepatic toxicity. Clients who are taking this medication should have
a complete blood count test done regularly to monitor for decreased white blood cells and
platelets, which can indicate bone marrow suppression. Methotrexate is teratogenic, therefore,
pregnancy should be avoided while taking this medication. Oral contraceptives that contain
estrogen are not contraindicated with this medication or disease.
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Concepts tested

Question 1979
The nurse assesses a client who has been taking haloperidol for several months. Which of the
following statements made by the client should be reported to the health care
provider immediately?
A "I occasionally have a dry, harsh cough."
B "I'm having jerky movements with my arms that I can't control."
C "I'm having difficulties with falling asleep at night."
D "My bowel movements have become harder and less frequent."

Question Explanation
Correct Answer is B
Rationale: Haloperidol is an anti-psychotic medication that blocks the effects of dopamine. It is
used to treat schizophrenia, schizoaffective disorders and aggressive and agitated behaviors.
Some of the most common side effects caused by this medication include nausea, vomiting,
diarrhea, dry mouth, insomnia and blurred vision. Extrapyramidal side effects may also occur
with the long-term administration of haloperidol. Of these effects, tardive dyskinesia is the most
concerning because it is difficult to treat and may be irreversible. Tardive dyskinesia may result
in tongue protrusions, muscle rigidity, and involuntary movements of the face and limbs. It
typically resolves after the medication is discontinued. Severe tardive dyskinesia may affect the
larynx and diaphragm, and may be life-threatening. Suspicions of tardive dyskinesia must be
immediately reported to the health care provider.
Concepts tested

Question 1980
The nurse in an urgent care clinic is preparing discharge instructions for the parents of a 15-
month-old child with a first episode of otitis media. Which information is the priority to
include?
A Provide a written handout describing the care of myringotomy tubes
B Describe the tympanocentesis most likely needed to clear the infection
C Explain that the child should complete the full 10 days of antibiotics
D Offer information on recommended immunizations around the child's second birthday

Question Explanation
Correct Answer is C
Rationale: Otitis media, an inner ear infection, commonly occurs in young children. Although
not always caused by bacteria, many ear infections are treated with oral antibiotics. If a client is
prescribed antibiotics, the priority is to make sure that they take the full prescription for the
prescribed number of days to prevent recurrence or antibiotic resistance.
Concepts tested

Question 1981
The nurse has provided instructions to a client on the use of warfarin. Which statement by the
client requires further teaching?

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A "If I catch a cold, I will use guaifenesin to make my cough better"
B "If I develop an itchy rash, I will use a cream with diphenhydramine."
C "If I become constipated, I can take laxatives containing magnesium salts."
D "If I develop a headache, I should take ibuprofen to help my pain."

Question Explanation
Correct Answer is D
Rationale: Warfarin is an anticoagulant that prolongs bleeding time and is used to treat and
prevent blood clots. One of the most serious side effects of warfarin is excessive bleeding and
hemorrhage. Warfarin interacts with a number of other drugs. Clients taking warfarin should not
take nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen at the same time due to
an increased risk for bleeding. There are no known drug interactions between warfarin and
laxatives containing magnesium salts, guaifenesin, or diphenhydramine cream. As a result, they
may be taken together.
Concepts tested

Question 1982
The nurse is caring for a client on a behavioral health unit. The client has received several doses
of haloperidol for agitation and aggression related to acute psychosis. Before administering the
next dose of haloperidol, the nurse assesses the client. Which findings indicate that the client is
experiencing an adverse reaction to the drug? Select all that apply.
A Hyperthermia
B Muscular rigidity
C Sedation
D Diaphoresis
E Redness at the site of injection

Question Explanation
Correct Answer is A, B, D
Rationale: Haloperidol is a typical or first-generation antipsychotic. Neuroleptic malignant
syndrome (NMS) is one dangerous, life-threatening adverse drug effect associated with typical
antipsychotics. Signs of NMS include muscular rigidity, hyperthermia, altered mental status and
diaphoresis. Thus, these findings indicate that the client is experiencing an adverse reaction to
the drug and the nurse should not give the medication and notify the health care provider.
Redness at the site of injection is a common side effect but does not indicate a possible medical
emergency. Sedation is a common side effect of typical antipsychotics and also does not indicate
a possible medical emergency.
Concepts tested

Question 1983
A client is prescribed eye drops for treatment of glaucoma. What assessment is required before
the nurse can begin teaching proper administration of the medication?
A Determine the client's third-party payment plan
B Evaluate the client's manual dexterity
C Identify the client's proximity to health care services

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D Assess the client's use of visual assistive devices

Question Explanation
Correct Answer is B
Rationale: Eye drops are prescribed to treat acute and chronic eye conditions, such as glaucoma.
Eye drops are the mainstay of treatment, as they are administered directly at the site of action.
Clients must become self-sufficient with eye drop administration. Often, ophthalmic
administration of medications is more effective than oral administration of the same medication.
Client education on proper instillation of eye medications is important. After a review of the
procedure, a return demonstration by the client should be performed. The client's insurance has
no relation to their ability to self-administer eye drops. Making sure that the client has ample
support services is important, but it is not the most important aspect prior to learning how to self-
administer eye drops. Clients must have adequate manual dexterity when self-administering eye
drops. The drops need to be administered in an exact location and with aseptic technique.
Although clients who suffer from visual disturbances need to use visual assistive devices,
assessing their use of a device is not a higher priority than evaluating their manual dexterity.
Concepts tested

Question 1984
The nurse on a cardiac unit is caring for a client who is receiving nitroglycerin intravenously for
unstable angina. During administration of the medication, which assessment is the priority?
A Cardiac enzymes
B Respiratory rate
C Cardiac rhythm
D Blood pressure

Question Explanation
Correct Answer is D
Rationale: Nitroglycerin is a drug that is used to provide relief from myocardial chest pain and
treat hypertensive emergencies. Nitroglycerin causes vasodilation. Common adverse effects of
nitroglycerin include hypotension, headache and dizziness; therefore, monitoring the client's
blood pressure is the priority. Nitroglycerin does not affect respirations, cardiac enzyme levels
or heart rhythm.
Concepts tested

Question 1985
The nurse is assessing a client who began taking omeprazole a month ago. Which finding by the
nurse, indicates that the drug has had the desired effect?
A Feelings of depression are not as severe
B Blood pressure readings are lower
C Chronic pain level is markedly decreased
D Heartburn discomfort is lessened

Question Explanation
Correct Answer is D

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Rationale: Omeprazole is a proton pump inhibitor used to decrease stomach acid and relieve
symptoms of gastroesophageal reflux disorder (GERD), such as heartburn. Omeprazole is also
used to treat gastric ulcers and esophagitis. Omeprazole does not affect blood pressure. A lower
blood pressure reading in this client would not be related to administration of medication.
Omeprazole is not indicated for depression. Although omeprazole can alleviate abdominal pain
in an individual who has a gastric ulcer or suffers from gastric bleeding, the option does not
specify what type of pain is being discussed. Secondly, omeprazole is not typically indicated for
chronic pain. The desired outcome for this client is to have a decrease in symptoms of GERD
within 4 weeks.
Concepts tested

Question 1986
The nurse is caring for a client with a new prescription for a selective serotonin reuptake
inhibitor (SRRI) to treat depression. In reviewing the admission history and physical, which
finding should the nurse clarify with the health care provider?
A History of morbid obesity
B Diagnosis of peripheral vascular disease
C Reported frequent use of antacids
D Prescribed monoamine oxidase (MAO) inhibitor

Question Explanation
Correct Answer is D
Rationale: Selective serotonin reuptake inhibitors (SSRIs) are indicated for treatment of
depression, panic attacks, bulimia, social phobias and social anxiety disorders. The medication
blocks the uptake of serotonin and increases its level in the synaptic cleft. Examples of SSRIs
include fluoxetine, sertraline and escitalopram. Clients should not take monamine oxidase
inhibitors (MAOIs) concurrently with SSRIs because serious, life-threatening reactions (i.e.,
serotonin syndrome) may occur with this combination of drugs. The nurse should notify the
provider about this finding. The other findings do not represent a contraindication for taking
SSRIs.
Concepts tested

Question 1987
The inpatient hospital nurse is caring for a client with hypokalemia. The health care provider
prescribed a potassium intravenous (IV) infusion of 40 mEq potassium chloride in 250 mL
normal saline to be infused over 4 hours. The nurse receives the infusion from the pharmacy.
Which action should the nurse take next?
A Notify the health care provider of the inappropriate dose of the prescribed IV potassium
B Ask another nurse to verify the prescription, IV solution and serum potassium level
C Confirm patency of the peripheral venous access device and start the infusion
D Ask another nurse to witness the addition of the prescribed potassium to the IV solution

Question Explanation
Correct Answer is B

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Rationale: Since potassium chloride is considered a high alert medication, especially when given
IV, having two nurses verify the order and IV bag is recommended. The nurses should compare
the supplied IV bag to the prescriber's order. If potassium IV is infused too rapidly or in too high
a dose, it can cause dysrhythmias and cardiac arrest. In addition, the second nurse should also
verify the client's most recent serum potassium level to ensure that the prescription is
appropriate. The prescribed dose and amount of IV solution is within normal range for IV
potassium replacement therapy. Potassium should never be added by a nurse to an IV bag.
Concepts tested

Question 1988
The nurse is preparing to administer an intramuscular injection to a 1-year-old child. Where
should the nurse give the injection?
A Deltoid muscle
B Dorso gluteal muscle
C Vastus lateralis muscle
D Gastrocnemius muscle

Question Explanation
Correct Answer is C
Rationale: An intramuscular (IM) injection is an injection that is administered directly into the
muscle. The vastus lateralis muscle is the preferred site for infants due to the large muscle mass
at this location. The muscle lies along the lateral aspect of the thigh and is large enough to
tolerate larger volumes of medication. The muscle is also not located near any nerves or blood
vessels. Although the deltoid muscle is an option for IM injections, it is not the preferred site for
infants. The other muscles are no longer recommended or appropriate for an IM injection.
Concepts tested

Question 1989
The nurse is teaching a client with asthma about albuterol. How should the nurse best describe
the action of this medication?
A "The medication will help to relax smooth muscles in the airways."
B "The medication is given to reduce secretions that block airways."
C "The medication will stimulate the respiratory center in the brain."
D "The medication will help to prevent pneumonia."

Question Explanation
Correct Answer is A
Rationale: Albuterol is a bronchodilator and rescue drug of choice to treat asthma. It is a short-
acting beta-adrenergic agonist that is used to prevent and treat wheezing, difficulty breathing,
and chest tightness. Albuterol works by relaxing and opening the airways to make breathing
easier. The medication comes as a tablet, syrup, inhaler and nebulizer. Albuterol does not reduce
secretions, stimulate the respiratory center in the brain or prevent pneumonia.
Concepts tested

Question 1990

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The nurse is reviewing medication instructions with a client who is taking digoxin. The nurse
should reinforce to the client to report which of the following side effects?
A Rash, dyspnea, edema
B Polyuria, thirst, dry skin
C Hunger, dizziness, diaphoresis
D Nausea, vomiting, fatigue

Question Explanation
Correct Answer is D
Rationale: Digoxin is considered an antidysrhythmic and inotrope, that is used to treat atrial
dysrhythmias and congestive heart failure. The medication produces a positive inotropic effect,
prolongs the refractory period and slows conduction through the sinoatrial (SA) and
atrioventricular (AV) nodes. Overall, digoxin increases cardiac output and slows the heart rate.
The effects of digoxin produce many side effects and clients who take digoxin are at risk for
digoxin toxicity. Because digoxin improves cardiac output, side effects of the medication would
not include dyspnea or edema. Rashes are also not considered a side effect of digoxin. Common
manifestations of digoxin toxicity include nausea, vomiting and fatigue. Hunger, dizziness and
diaphoresis, together, are not considered side effects of digoxin. Although dizziness could occur
with another side effect of digoxin, such as bradycardia. Polyuria, thirst and dry skin are not
considered side effects of digoxin.
Concepts tested

Question 1991
The labor and delivery nurse is caring for a 34-weeks gestation client with gestational
hypertension who is receiving a continuous intravenous infusion of magnesium sulfate. What is
the purpose of the infusion?
A Increase the frequency of contractions
B Maintain adequate respiratory function
C Prevent preeclamptic seizures
D Help speed up fetal lung maturity

Question Explanation
Correct Answer is C
Rationale: Gestational hypertension can progress to preeclampsia and eclampsia. Eclampsia is
defined as the development of convulsions in a woman with pre-eclampsia. Eclampsia can be
prevented by giving magnesium sulfate. Magnesium sulfate is a central nervous system
depressant that is used to prevent seizures. The literature has found that magnesium sulfate
reduces the occurrence of eclampsia by 50%. The other actions are not related to magnesium
sulfate.
Concepts tested

Question 1992
The nurse is providing discharge instructions to a client with a prescription for chlorpromazine.
Which finding should the nurse teach the client to report immediately?

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A Insomnia
B Fever
C Breast enlargement
D Alopecia

Question Explanation
Correct Answer is B
Rationale: Chlorpromazine is used to treat schizophrenia and psychosis. The medication exhibits
anticholinergic activity and alters the effects of dopamine in the central nervous system (CNS).
A fever may indicate an infection due to agranulocytosis, a serious side effect of chlorpromazine.
If white blood cell counts are low, the treatment should be stopped and antibiotic therapy started.
Other common side effects of chlorpromazine include dry mouth and nasal congestion,
extrapyramidal reactions, motor restlessness and hypotension. The other findings are not
typically associated with this medication.
Concepts tested

Question 1993
The nurse is admitting a client to the hospital with findings of liver failure and ascites. A health
care provider (HCP) orders spironolactone. The nurse understands that the pharmacological
effects of the medication, are which of the following?
A Increases aldosterone levels
B Combines safely with antihypertensives
C Depletes potassium reserves
D Promotes sodium and chloride excretion

Question Explanation
Correct Answer is D
Rationale: Spironolactone is considered a diuretic that is indicated for individuals with
hypertension, edema, congestive heart failure and potassium loss. Spironolactone promotes
sodium and chloride excretion while sparing potassium and decreasing aldosterone levels.
Spironolactone is often combined with other diuretics and anti-hypertensive agents. Kidney
function and electrolytes should be monitored more closely when spironolactone is used in
combination with other medications. The medication is considered a potassium-sparing diuretic,
because as aldosterone levels decrease and sodium and water is excreted, potassium is spared. A
major side effect of spironolactone is hyperkalemia.
Concepts tested

Question 1994
The nurse is preparing to administer eye drops to a 6-year-old child. Which of the following is
the correct method the nurse should use when instilling eye drops to the client?
A In the corner where the lids meet
B On the anterior surface of the eyeball
C Under the upper lid as it is pulled upward
D In the conjunctival sac as the lower lid is pulled down

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Question Explanation
Correct Answer is D
Rationale: When administering eye drops, the nurse should position the client either sitting or
lying down with the head supported. They should wash their hands before instilling eye drops to
prevent cross infection. Before administration, they should establish that they have the correct
eye drops and that they have not expired. The nurse should agitate the bottle before use to make
sure the drug is properly mixed. The nurse should instill the eye drops into the space created by
gently pulling down the lower lid. The client should look up to make sure the eye drops do not
land directly onto the sensitive cornea. Once the eye drops are instilled, the nurse should release
the eyelid, and use a tissue or swab to dab any excess from the cheek.
Concepts tested

Question 1995
The nurse is preparing to administer a liquid medication orally to a 9-month-old infant. Which of
the following administration methods would be appropriate for the nurse to use?
A Administer the medication with a syringe next to the tongue
B Mix the medication with the infant's formula in the bottle
C Allow the infant to drink the liquid from a medicine cup
D Hold the child upright and administer with a spoon

Question Explanation
Correct Answer is A
Rationale: Giving oral medications to an infant requires skill. The use of appropriate
administration techniques is essential to prevent aspiration of liquid. Infants usually receive elixir
or suspension forms that are administered using an oral syringe. First, the nurse should place the
infant in an upright position. The nurse opens the infant's mouth by applying gentle pressure to
the cheeks. The nurse should place the syringe in the infant's mouth along the side of the cheek,
and then push the medication in slowly as the infant sucks. Using a needless syringe to slowly
give liquid medicine to an infant is often the safest method. If the nurse directs the medicine
toward the side or the back of the mouth, gagging will be decreased.
Concepts tested

Question 1996
The nurse is caring for a client with Parkinson's disease. Which finding indicates that the client
might be experiencing an adverse side effect from the dopamine-enhancing drugs?
A Hypertensive urgency
B Urinary retention
C Kidney failure
D Hallucinations

Question Explanation
Correct Answer is D
Rationale: Carbidopa-levodopa-entacapone is the treatment of choice for clients with Parkinson's
disease. Common side effects include dyskinesia, confusion and dizziness. Serious side effects
include hallucinations, paranoia and agitation. Hallucinations may be relieved by decreasing the

Page | 817
dose of levodopa, but this may decrease the effect of the drug on the motor symptoms of
Parkinson's disease.
Concepts tested

Question 1997
The nurse has administered fentanyl, atropine, cefazolin and benzocaine to a client for an
endoscopic procedure. The nurse is monitoring the client and notes that the heart rate has
increased from the pre-procedure baseline. The nurse knows that which of the following
medications is most likely responsible for the client's increased heart rate?
A Atropine
B Cefazolin
C Fentanyl
D Benzocaine

Question Explanation
Correct Answer is A
Rationale: Procedural sedation is used in endoscopic procedures as an effective way to provide
an appropriate degree of pain and anxiety control; memory loss; and decreased awareness. The
most commonly used medication regimen for gastrointestinal endoscopic procedure is still the
combination of benzodiazepines, opioids, anticholinergics and topical anesthetics. Atropine is an
anticholinergic drug that is used to dry secretions during the procedure. However, it can also
increase the heart rate and dilate the pupils and is the most likely cause for the increased heart
rate. Fentanyl is an opioid analgesic and short-term central nervous system (CNS) depressant and
tends to slow breathing and lower heart rate and blood pressure. Benzocaine is a topical
anesthetic and cefazolin is an antibiotic; neither should affect the heart rate.
Concepts tested

Question 1998
The nurse is caring for a client with acute pain and realizes a medication error has occurred. The
client received twice the ordered dose of morphine an hour ago. Which nursing problem is
the priority at this time?
A Chronic pain
B Constipation
C Tolerance
D Respiratory depression

Question Explanation
Correct Answer is D
Rationale: Opioids (e.g., morphine) are indicated for the treatment of moderate to severe pain.
An opioid is a medication that relieves pain by binding to receptors in the nervous system.
Respiratory depression is a life-threatening risk in an opioid overdose. The priority problem is
ineffective respirations/respiratory depression due to central nervous system depression.
Concepts tested

Question 1999

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The nurse is teaching a client diagnosed with asthma about the medication albuterol. Which
statement by the nurse demonstrates appropriate teaching?
A "Use this medication at bedtime to promote rest."
B "Call your doctor's office if you need to use the drug more often."
C "Discontinue the inhaler if you feel dizzy."
D "Use this medication after other asthma inhalers."

Question Explanation
Correct Answer is B
Rationale: Albuterol is a bronchodilator used for the relief of bronchospasm. It is considered a
rescue medication for a client during an asthmatic attack. If the client notices the need to use the
inhaler more frequently, the health care provider (HCP) should be notified. The client may need
to seek emergency medical care, as the medication is no longer effective. In addition, clients
should not exceed the recommended dosage, as adverse effects may occur. Be sure the client
understands how to correctly use this medication. The client may experience side effects of
dizziness, headache, nausea, vomiting, rapid heart rate, anxiety, sweating, flushing and insomnia.
Using albuterol at bedtime may lead to insomnia. Albuterol should be used before all other
inhalers, as it dilates the bronchi or bronchioles and allows more of the other medication to reach
the lower respiratory tract. It would not be appropriate to suddenly discontinue taking a
bronchodilator.
Concepts tested

Question 2000
The nurse is teaching the client how to properly use a dry powder capsule inhaler. How should
the nurse instruct the client to use this type of inhaler?
A Seal lips tightly around mouthpiece and inhale rapidly and deeply
B Breathe in medicine slowly and deeply for about 3-5 seconds
C Rinse mouthpiece in hot soapy water after using
D Shake inhaler before putting it in mouth

Question Explanation
Correct Answer is A
Rationale: The client should breathe in quickly and deeply for up to 10 seconds when using a dry
powder capsule inhaler. The client should not shake this type of inhaler. The mouthpiece can be
rinsed with warm water but without soap or detergent.
Concepts tested

Question 2001
A client has been taking rosuvastatin for six weeks as part of a treatment plan to reduce
hyperlipidemia. The clinic nurse is reviewing and reinforcing information about the medication
with the client. Which statements by the client indicates an understanding about the
medication? Select all that apply
A "I will need to come back to have my liver and kidney labs checked."

Page | 819
B "I need to be careful when I get up because this medication can make my blood pressure
drop."
C "I will need to call my doctor if I have any muscle weakness or pain, especially in my legs."
D "This medication has to be taken first thing in the morning, before I eat breakfast."
E "I add some nuts and fresh fruit to my oatmeal in the morning and I can't remember when I
last ate a steak."

Question Explanation
Correct Answer is A, C, E
Rationale: Clients taking rosuvastatin need to be monitored for alteration in liver function. An
adverse effect of rosuvastatin is muscle pain and weakness (rhabdomyolysis). Left untreated,
rhabdomyolysis can lead to renal impairment. The medication does not affect blood pressure or
cause orthostatic hypotension. The client should be taught to follow a low-cholesterol diet, which
includes increasing intake of whole grains and limiting intake of foods high in saturated fats,
trans fats and dietary cholesterol. The medication is ordered once a day. The client can take it at
any time of day, preferably at the same time of day each day, before or after eating.
Concepts tested

Question 2002
A 32-year-old female with human epidermal growth factor receptor 2-positive (HER2-positive)
metastatic breast cancer is scheduled to begin therapy with pertuzumab. What information is
important for the nurse to reinforce and discuss with the client? Select all that apply.
A Use contraception during and for 6 months following the use of this drug.
B Take the medication at the same time every day on an empty stomach.
C Other therapies for cancer treatment are no longer needed.
D Report shortness of breath, lightheadedness, dizziness, cough or swelling of the feet.
E Report chills, fatigue, or headache during treatment

Question Explanation
Correct Answer is A, D, E
Rationale: Pertuzumab (Perjeta) is used in combination with trastuzumab (Herceptin) as a
targeted therapy for HER2+ metastatic breast cancer; these medications are used in combination
with chemotherapy and radiation. The most common side effects are fatigue, loss of taste,
muscle pain and vomiting; sometimes slowing the infusion rate can help. It is best to eat a small
meal before receiving the infusion. Serious side effects include birth defects and fetal death;
women of child-bearing age must use a form of effective contraception during and for 6 months
following treatment. Drugs that block HER2+ activity decrease left ventricular ejection fraction
(LVEF) and will worsen symptoms of congestive heart failure; heart function must be tested
before and monitored during treatment.
Concepts tested

Question 2003
The nurse is talking with a client who was admitted with an acute myocardial infarction due to
coronary artery disease. The clients asks what the purpose for the prescribed carvedilol is. How
should the nurse respond?

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A "A beta blocker will prevent postural hypotension."
B "Most people develop hypertension after a heart attack."
C "Beta blockers will help to increase your heart rate."
D "This drug will decrease the workload on your heart."

Question Explanation
Correct Answer is D
Rationale: One action of beta blockers is to decrease systemic vascular resistance by dilation of
the arterioles. This is useful for clients with coronary artery disease and will reduce the risk of
another MI or a sudden cardiac event. Some of the more commonly prescribed beta blockers
include metoprolol and carvedilol (Coreg). The other responses are incorrect.
Concepts tested

Question 2004
The nurse is monitoring a client who is receiving the thrombolytic agent alteplase for treatment
of an acute myocardial infarction (AMI). What outcome indicates the client is receiving adequate
therapy within the first few hours of treatment?
A Absence of cardiac arrhythmias
B Reduction of ST-segment elevation on a 12-lead ECG
C Stabilization of blood pressure
D Cardiac enzymes are within normal limits

Question Explanation
Correct Answer is B
Rationale: Alteplase (a t-PA) is used in the management of AMI with ST-segment elevation
(STEMI). If thrombolytic therapy was successful, a follow-up ECG will show a reduction of
50% or more in the ST segment. This indicates a return in blood flow to the injured myocardium;
however, the ST segment may not return to baseline due to myocardial damage. The other
responses are incorrect: successful thrombolysis can cause a variety of cardiac arrhythmias;
cardiac enzymes peak 8 hours or more after an AMI; and blood pressure may be unstable.
Concepts tested

Question 2005
A very active 2-year-old child pulls out a tunneled central venous catheter. What initial nursing
action is most appropriate?
A Obtain emergency equipment.
B Assess heart rate, rhythm and all pulses.
C Use cold packs at the exit incision site.
D Apply pressure to the vessel insertion site.

Question Explanation
Correct Answer is D
Rationale: If a central venous catheter is accidentally removed, pressure should be applied to the
vein exit site and chest area above it with gauze dressing or a clean washcloth. The primary care

Page | 821
provider should be notified. Cold packs are not indicated at this time. At this point, emergency
equipment is not required. The assessments are all done routinely.
Concepts tested

Question 2006
The nurse is discharging a client with a new prescription for tiotropium to help manage the
symptoms of chronic obstructive pulmonary disease. What information should the nurse include
in the discharge teaching?
A A common side effect is nausea and loose stools.
B It may be a few days before you feel the full effects of tiotropium.
C This medication cannot be used to relieve sudden breathing problems.
D Be sure to swallow the capsules with a full glass of water.

Question Explanation
Correct Answer is C
Rationale: Tiotropium is a long-acting anticholinergic bronchodilator. The medication comes as
a capsule to use with a specially designed inhaler – clients should never swallow the capsules.
For new prescriptions, it's important to tell the client that they may start breathing better with the
full dose but it may take a few weeks to feel the full effects. It cannot be used as a fast-acting
inhaler. Due to its anticholinergic properties, it may cause constipation (not loose stools).
Concepts tested

Question 2007
A nurse is assessing a 9-year-old child after several days of treatment for a documented strep
throat. Which statement is incorrect and suggests that further teaching is needed?
A "Sometimes I take my medicine with fruit juice."
B "I am feeling much better than I did last week."
C "Sometimes I take the pills in the morning and other times at night."
D "My mother makes me take my medicine right after school."

Question Explanation
Correct Answer is C
Rationale: Strep throat is a bacterial infection that is treated with antibiotics. It is important to
take antibiotics on a regular schedule and at approximately the same time each day. Depending
on the medication, it is OK to take it with food or juice. The client should be feeling better after
several days of antibiotics —however should be cautioned to complete the prescribed amount.
Concepts tested

Question 2008
The nurse is caring for a post-surgical client who is using patient controlled analgesia (PCA)
with morphine for pain management. The client reports that the pain is severe and does not get
better, even after "pushing the PCA button". Indicate the sequence of actions the nurse should
take in the correct order.
1. Verify that the client is using the PCA equipment correctly.
2. Check the MAR for adjuvant medications.
3. Confirm that the pump is working and the tubing is patent.
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4. Offer non-pharmacological interventions.
5. Consult with the health care provider.
A 1, 3, 2, 4, 5
B 1, 2, 3, 4, 5
C 5, 4, 1, 2, 3
D 4, 5, 1, 2, 3

Question Explanation
Correct Answer is A
Rationale: The nurse should implement the interventions/actions in the following order: (1)
Verify that the client understands how to use the PCA equipment correctly, (2) assess if the PCA
pump is functioning properly and medication is being delivered, (3) determine if the client is able
to receive additional or adjuvant medication for pain management, (4) offer non-pharmacological
interventions such as repositioning, diversional activities and rest. Lastly, (5) the nurse should
notify the health care provider if the client's pain level does not improve.
Concepts tested

Question 2009
The nurse is teaching a client about some of the side effects of fluoxetine. What information
should the nurse be certain to include?
A Tachycardia, blurred vision, hypotension, anorexia
B Orthostatic hypotension, vertigo, hunger, reactions to tyramine-rich foods
C Photosensitivity, seizures, edema, hyperglycemia
D Drowsiness, dry mouth, changes in weight or appetite, reduced libido

Question Explanation
Correct Answer is D
Rationale: Fluoxetine (Prozac) is an antidepressant in a group of drugs called selective serotonin
reuptake inhibitors (SSRIs). Commonly reported side effects include drowsiness and yawning,
dry mouth, changes in weight or appetite, and sexual dysfunction; other reported side effects
include insomnia and strange dreams, stuffy nose or tremors. People taking MAOIs should avoid
foods containing tyramine. Tricyclic antidepressants (TCAs) can cause photosensitivity and TCA
toxicity can cause hypotension and cardiac dysrhythmias.
Concepts tested

Question 2010
The nurse is teaching a client with intractable hiccups about chlorpromazine. Which information
should the nurse include?
A Avoid tyramine-containing foods.
B Avoid dairy products that contain lactose.
C Avoid direct sunlight.
D Take on an empty stomach.

Question Explanation
Correct Answer is C

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Rationale: Chlorpromazine is an antipsychotic medication in a group of phenothiazines. Principal
indications for use are schizophrenia and other psychotic disorders. Other uses include
suppression of emesis and relief of intractable hiccups. The most common adverse effects are
sedation, orthostatic hypotension, and anticholinergic effects (dry mouth, blurred vision, urinary
retention, photophobia, constipation, tachycardia). Photosensitivity reactions are possible;
therefore, the client should be advised to avoid direct exposure to sunlight. The other instructions
do not apply to this medication.
Concepts tested

Question 2011
The health care provider has prescribed tetracycline for a 28-year-old female client with severe
acne. When teaching the client about this medication, which information is important for the
nurse to include?
A It may decrease the effectiveness of oral contraceptives.
B It should be taken with food or milk.
C It may cause staining of the teeth.
D It may cause hearing loss.

Question Explanation
Correct Answer is A
Rationale: Tetracycline, a broad-spectrum antibiotic, can decrease the effectiveness of oral
contraceptives; therefore, it is important to recommend use of an additional form of
contraception such as a condom when taking this medication. Tetracycline should be taken on an
empty stomach and never with milk. It is not given to children younger than 8 years old because
it can stain developing teeth. Tetracycline is not known to cause hearing loss
Concepts tested

Question 2012
A nurse administers cimetidine to a 79-year-old male with a gastric ulcer. Which parameter may
be affected by this drug and should be closely monitored by the nurse?
A Blood pressure
B Hemoglobin
C Mental status
D <span style="font-weight: 400;">Liver enzymes</span>
Liver enzymes

Question Explanation
Correct Answer is C
Rationale: Cimetidine is an H2 receptor blocker used in treatment of gastric ulcers. Cimetidine
should be used cautiously in the elderly, as it is known to cause a change in mental status such as
confusion in the elderly population. Cimetidine does not impact the blood pressure, liver
enzymes, or hemoglobin.
Concepts tested

Question 2013

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A 42-year-old male client diagnosed with hypertension tells the nurse he no longer wants to take
the prescribed propranolol. Which client statement best explains the reason why he does not
want to take this medication?
A "I'm having problems with my stomach."
B "I feel so tired all the time."
C "I'm experiencing decreased sex drive."
D "I have difficulty falling asleep."

Question Explanation
Correct Answer is C
Rationale: Propranolol is a beta-blocker used to treat many conditions, such as essential tremors,
angina, hypertension and heart rhythm disorders. Common side effects of this drug include
nausea, diarrhea, constipation, stomach cramps, rash, tiredness, dizziness, sleep problems and
vision changes. Additionally, propranolol may cause decreased sex drive, impotence or difficulty
having an orgasm in men. The clients can be switched to an alternative antihypertensive, such as
an angiotensin-converting enzyme (ACE) inhibitor or a calcium channel blocker.
Concepts tested

Question 2014
The nurse is providing teaching to a client who has been prescribed cyclophosphamide for breast
cancer treatment. Which of the following statements made by the client would indicate that
additional teaching is needed?
A "I will probably need to plan on using a wig to cover my hair loss."
B "I may have trouble getting pregnant due to the damaging effects of the medication."
C "I will need to stay away from children when my white blood cell count is low."
D "I should limit the amount of fluids I drink while taking this medication."

Question Explanation
Correct Answer is D
Rationale: Cyclophosphamide is a chemotherapeutic medication. Some of the side effects of this
medication include hair loss, low white cell count and infertility. The client is encouraged to
drink about 2 to 3 liters of fluid per day to aid in eliminating the chemotherapy from the body.
Concepts tested

Question 2015
The nurse is providing discharge instructions to a client with pernicious anemia. Which
statement by the client demonstrates correct understanding of the at-home medication regimen?
A "I will need vitamin B12 injections weekly for a month and then I can switch to an oral form
of vitamin B12."
B "Initially, I will need weekly injections of vitamin B12 and then monthly injections for
maintenance, which will be a lifelong requirement."
C "When I start to feel weak, I will need to schedule an appointment at my provider's office for a
vitamin B12 infusion."
D "I will require one injection every 12 months until my vitamin B12 levels are therapeutic and
then I'm done."

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Question Explanation
Correct Answer is B
Rationale: A client with pernicious anemia cannot absorb vitamin B12 through the GI system,
due to the lack of intrinsic factor needed to absorb B12. So taking supplements of vitamin
B12 orally would not help with pernicious anemia. Therefore, the typical regimen for a client
with pernicious anemia is to receive vitamin B12 through injections. Typically, the client will
receive weekly injections until the hemoglobin is normal and then monthly, as maintenance.
Clients with this type of anemia usually require lifelong treatment.
Concepts tested

Question 2016
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?
A The child should return to the clinic to evaluate effectiveness of the treatment.
B The child may be given acetaminophen or ibuprofen drops for pain.
C The child must complete the entire course of the prescribed antibiotic.
D The child may be given a decongestant to relieve pressure on the tympanic membrane.

Question Explanation
Correct Answer is C
Rationale: Acute otitis media (AOM) is an inflammation of the middle ear space with a rapid
onset of the signs and symptoms of acute infection, namely, fever and otalgia (ear pain). It is one
of the most prevalent early childhood illnesses. Treatment for AOM is one of the most common
reasons for antibiotic use in the ambulatory setting. When antibiotics are necessary, it is most
important to complete the entire course to prevent antibiotic resistance. The child should be seen
after antibiotic therapy is complete to ensure that the infection has resolved. Supportive care of
AOM includes treating the fever and pain. Decongestants or antihistamines are not
recommended for children with ear infections.
Concepts tested

Question 2017
A 2 year-old child is being treated with amoxicillin suspension, 200 milligrams per dose, for
acute otitis media. The child weighs 33 lb (15 kg) and the daily dose range is 20 to 40 mg/kg of
body weight, in three divided doses every eight hours. Using principles of safe drug
administration, what should a nurse do next?
A Hold the medication because the dosage is too low
B Recognize that antibiotics are over-prescribed
C Call the health care provider to clarify the dose
D Give the medication as ordered

Question Explanation
Correct Answer is D

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Rationale: Amoxicillin continues to be the drug of choice in the treatment of acute otitis media.
The dose range is 20 to 40 mg/kg/day divided every eight hours; 15 kg x 40 mg = 600 mg,
divided by 3 = 200 mg per dose. The prescribed dose is correct and should be given as ordered.
Concepts tested

Question 2018
The nurse obtains a new order to infuse 20 mEq of potassium chloride IV piggyback for a client
with a serum potassium of 3.2 mEq/L (3.2 mmol/L). While reviewing the client’s cardiac
monitor, which ECG finding best indicates that the infusion of potassium should be stopped?
A Tall, peaked T waves
B Shortened PR interval
C Narrowed QRS complex
D Prominent U waves

Question Explanation
Correct Answer is A
Rationale: Tall, peaked T waves are a finding in hyperkalemia, and would necessitate a change
in IV solution, to eliminate the potassium. If the potassium infusion were to continue it could
cause worsening hyperkalemia and possible cardiac arrhythmias. The nurse should notify the
health care provider of the ECG finding, and should request an order for a different IV solution
without potassium. In addition, a stat serum potassium should be done to assess the severity of
the hyperkalemia and to determine whether further intervention to reduce the potassium level is
required. In conjunction with this, a serum creatinine should be checked to determine whether
worsening renal function may have reduced potassium excretion, contributing to this new
electrolyte abnormality.
Concepts tested

Question 2019
The nurse is caring for a client diagnosed with deep vein thrombosis who is receiving a
continuous intravenous heparin infusion. The client's baseline activated partial thromboplastin
time (aPTT) prior to starting the heparin infusion was 24 seconds. The most recent aPTT result
was 55 seconds. What action should the nurse take?
A Maintain the current heparin infusion rate
B Administer a heparin antagonist (protamine)
C Decrease the heparin infusion rate
D Increase the heparin infusion rate

Question Explanation
Correct Answer is A
Rationale: For clients on a heparin drip, the therapeutic aPTT goal is generally 1.5 to 2.5 times
the client's baseline. The client's baseline aPTT was 24 seconds and the therapeutic range for this
client should be between 36 to 60 seconds. Since the client’s aPTT is 55 seconds, within the
therapeutic range, the nurse should maintain the current heparin infusion rate. The other actions
would not be appropriate for this client.
Concepts tested

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Question 2020
The nurse on an inpatient hospital unit is preparing to administer insulin aspart per sliding scale
to a client whose most recent blood glucose level is 180 mg/dL. Which is the best time in
relation to eating to give the insulin?
A Administer the insulin right before the client is about to start eating
B Administer the insulin immediately after checking the blood glucose level
C Administer the insulin at any time before or after the meal
D Administer the insulin 2 hours after the client has finished eating the meal

Question Explanation
Correct Answer is A
Rationale: Sliding scale insulin coverage typically consists of a short or rapid acting insulin and
is generally prescribed to be given "AC" (ante cibum) or before meals. The client should begin
eating within minutes of receiving the insulin due to the rapid onset of insulin aspart (ranging
from 10 to 20 minutes) to prevent hypoglycemia. Therefore, the nurse should first determine that
the client's meal has arrived and the client is about to start eating. If the client receives the insulin
but the meal is delayed for some reason, the client may become hypoglycemic. Insulin aspart
peaks at around 1 to 3 hours after administration. The other times are not appropriate to
administer the insulin.
Concepts tested

Question 2021

A client is taking diphenhydramine for seasonal allergic rhinitis. The nurse should reinforce
teaching for the client about which possible side effects? Select all that apply.
A Dry mouth
B Urinary frequency
C Constipation
D Drowsiness
E Urinary retention

Question Explanation
Correct Answer is A, C, D, E
Rationale: Diphenhydramine is an over-the-counter (OTC) drug commonly used for allergic
rhinitis and the common cold. It is a first-generation H1 antagonist or antihistamine. Sedation and
sleepiness are the most common side effects of this antihistamine. Due to the anticholinergic
effects of H1 blockers, constipation, dry mouth, and urinary retention are potential side effects.
Urinary frequency is not an expected finding.
Concepts tested

Question 2022
The nurse is reinforcing teaching for a client diagnosed with asthma. Which statement indicates
that the client understands the use of the prescribed long-acting beta2 agonist medication?
A "I will take this medication daily to prevent an acute attack."
B "I will take this medication when I experience acute shortness of breath."

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C "I will take this medication as needed during allergy season."
D "I will eventually be able to stop using this medication."

Question Explanation
Correct Answer is A
Rationale: Long-acting beta2 agonists (LABA), such as salmeterol, cause bronchodilation by
relaxing bronchiolar smooth muscle and binding to and activating pulmonary beta2 receptors.
Their onset of action is slow with a long duration. They are primarily used for the prevention of
an asthma attack. The client will take this medication every day for the best effect. This is not the
medication the client will use during an acute asthma attack because it does not have an
immediate onset of action. The client will be required to take this medication long-term.
Concepts tested

Question 2023
A client diagnosed with iron deficiency anemia is prescribed ferrous sulfate suspension orally.
Which instruction would be most appropriate for the nurse to give to the client regarding this
medication?
A "Diarrhea is a common side effect when taking this medication."
B "Taking this medication will turn your urine dark orange in color."
C "You should use a straw when taking this medication."
D "You should take the medication with food to enhance absorption."

Question Explanation
Correct Answer is C
Rationale: Iron deficiency anemia is the most common type of anemia. Treatment includes
nutritional therapy, oral iron supplementation, and blood transfusions. Although diarrhea is a
potential side effect of iron supplementation, the more common side effect of iron
supplementation is constipation. Clients should take iron on an empty stomach for better
absorption. Only in rare circumstances should clients take iron with food. Because liquid iron
can stain the teeth, the most appropriate instruction is to use a straw. Iron medications do not
cause discoloration of urine, but they can cause stool to turn black.
Concepts tested

Question 2024
The nurse is evaluating a client's adherence to the prescribed regimen of antihypertensive
medications. Which finding is most indicative of effective hypertension management?
A There is no indication of lower extremity edema.
B There is no indication of renal impairment.
C The client's weight has been stable for the past two weeks.
D The client's blood pressure reading is 148/94 mmHg.

Question Explanation
Correct Answer is B
Rationale: The most common complications of hypertension (HTN) are target organ diseases
including of the kidneys. Uncontrolled HTN is the most significant risk factor for the

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development of chronic kidney disease. Therefore, the absence of renal impairment is a good
indicator that the client is adhering to the prescribed medication regimen. A blood pressure of
148/94 is higher than recommended and indicates that the medication regimen may need to be
adjusted. A stable weight and absence of edema are indicators often used to evaluate the
management of heart failure, not HTN.
Concepts tested

Question 2025
Nadolol is prescribed for a client with chronic stable angina. To evaluate whether the drug is
effective, the nurse will monitor for which finding?
A Fewer complaints of having cold hands and feet
B The ability to do daily activities without chest pain
C Decreased blood pressure and heart rate
D Improvement in the strength of the distal pulses

Question Explanation
Correct Answer is B
Rationale: Nadolol is a first-generation, non-selective beta-adrenergic antagonist (i.e., beta-
blocker). Because the medication is ordered to improve the client's angina, it is considered
effective when the client is able to accomplish daily activities without chest pain. Blood pressure
and heart rate may decrease, but these data do not indicate that the goal of decreased angina has
been met. Non-cardioselective b-adrenergic blockers can cause peripheral vasoconstriction, so
the nurse would not expect an improvement in distal pulse quality or skin temperature.
Concepts tested

Question 2026
The nurse is caring for a client with chronic atrial fibrillation. Which drug does the nurse expect
to administer to prevent a common complication of this condition?
A Lidocaine
B Diltiazem
C Warfarin
D Carvedilol

Question Explanation
Correct Answer is C
Rationale: Atrial fibrillation puts clients at risk for developing emboli and is a major risk factor
for an ischemic, i.e., thrombotic stroke. Clients at risk for emboli due to atrial fibrillation are
treated with anticoagulants such as warfarin. The other drugs might be used for rate control of
atrial fibrillation and as a "cardioprotective" medication, but they do not help prevent the
development of a thrombus or embolus.
Concepts tested

Question 2027

Page | 830
The nurse is caring for a client admitted with sickle cell crisis. Which medication is the drug of
choice for pain management with this client?
A Hydromorphone
B Ibuprofen
C Meperidine
D Acetaminophen

Question Explanation
Correct Answer is A
Rationale: Sickle cell disease (SCD) is a genetic disorder that is characterized by hemolysis and
sickling of red blood cells. A sickle cell crisis is considered an acute, severe exacerbation of the
disease. During a crisis, individuals can develop severe pain and necrosis from the sickled cells
that are accumulating within their blood vessels. As a result, clients should be treated with opioid
pain medications during a crisis preferably administered intravenously. Hydromorphone
(Dilaudid) is a strong opioid agonist indicated for moderate to severe pain. The other
medications are indicated for more minor to moderate pain. Use of meperidine (Demerol) should
be avoided so as to prevent the accumulation of normeperidine, a toxic metabolite.
Concepts tested

Question 2028
The nurse administered furosemide to a client with acute pulmonary edema. Which observation
by the nurse would indicate that the client is experiencing an adverse side effect of the
medication?
A The client exhibits exertional dyspnea with walking.
B The client's weight decreased by 2 lbs. in two days.
C The client's blood pressure is 104/60 mmHg.
D The client reports muscle cramps in both legs.

Question Explanation
Correct Answer is D
Rationale: Pulmonary edema is a condition that can occur secondary to left-sided heart failure or
volume overload. Pulmonary edema can happen very quickly as fluid accumulates in the lung
fields (i.e., interstitial area and alveoli) due to an increase in hydrostatic pressure. Manifestations
of acute pulmonary edema include dyspnea, tachypnea, cough, tachycardia, jugular venous
distention, and hypertension. The hallmark treatment for pulmonary edema is diuretic therapy
with a loop diuretic (i.e., furosemide). Furosemide, a potassium-wasting diuretic, can
significantly decrease intravascular volume, thus leading to hypotension, dehydration, and/or
hypokalemia. A blood pressure of 104/60 mmHg is considered a normal value. Weight loss of 2
lbs. in two days is considered normal for a client receiving a diuretic for pulmonary edema.
Dyspnea with exertion is not a medication side effect and is to be expected until the pulmonary
edema has resolved. Muscle cramps and spasms while receiving diuretic therapy could indicate
hypokalemia, an adverse drug effect of furosemide.
Concepts tested

Question 2029

Page | 831
The nurse is teaching a client about precautions while taking warfarin. The nurse should instruct
the client to avoid foods with excessive amounts of which nutrient?
A Vitamin E
B Calcium
C Iron
D Vitamin K

Question Explanation
Correct Answer is D
Rationale: Vitamin K is an essential vitamin required for blood clotting. Eating foods with
excessive amounts of vitamin K may alter anticoagulant effects. Foods highest in vitamin K
include (dried and fresh) herbs, dark leafy greens, scallions, Brussel sprouts, broccoli, chili
powder, prunes, asparagus, and cabbage.
Concepts tested

Question 2030
The nurse is reinforcing teaching to a 24-year-old woman receiving acyclovir for a herpes
simplex virus type 2 infection. Which instructions should the nurse provide the client with?
A Stop treatment if she thinks she may be pregnant
B Complete the entire course of the medication for an effective cure
C Begin treatment with acyclovir at the onset of symptoms of recurrence
D Continue to take prophylactic doses for at least five years after the diagnosis

Question Explanation
Correct Answer is C
Rationale: When the client is aware of early symptoms, such as pain, itching, or tingling,
treatment is very effective. Medications for herpes simplex do not cure the disease. They simply
decrease the intensity of the symptoms. Acyclovir (Zovirax) is not known to have an impact on
the fetus. Acyclovir should not be taken for preventive purposes regardless of the date of
diagnosis.
Concepts tested

Question 2031
The nurse is providing education to the parents of a 10-year-old child who is diagnosed with
diabetes insipidus (DI) and has been prescribed vasopressin. What priority information should
the nurse include regarding this medication?
A The child will need intravenous therapy for several weeks.
B The family must monitor the child for arrhythmias.
C The child should be observed for dehydration.
D Parents should administer the daily intramuscular injections.

Question Explanation
Correct Answer is B
Rationale: Diabetes insipidus is characterized by a decreased secretion of antidiuretic hormone
(ADH). Decreased ADH results in polyuria and polydipsia; the person is unable to concentrate

Page | 832
urine. Vasopressin is the drug of choice to treat central DI. At home, it can be administered 2-3
times a day, either IM, subQ, or intranasally. Not drinking enough fluids can cause arrhythmias,
fatigue, and muscle pain. Other serious side effects include chest pain, skin discoloration, and
paresthesia.
Concepts tested

Question 2032
The nurse is teaching a client who has a new prescription for sublingual nitroglycerin. Which
point should the nurse emphasize?
A Carry the nitroglycerine with you at all times
B Take the medication at the same time each day
C Rest in bed for an hour after taking medication
D Keep the medication bottle in the refrigerator

Question Explanation
Correct Answer is A
Rationale: The medication should be kept in its original dark-colored glass container.
Nitroglycerin should be carried by the client at all times, so it can be used when anginal pain
occurs. When needed, the client should sit and place a tablet under his or her tongue. Sitting is
safe because the drug can cause lightheadedness or dizziness, but it's not necessary to rest in bed.
The client should never pack this and any other medications in a checked bag when traveling.
Concepts tested

Question 2033
The nurse is teaching a client with migraine headaches about almotriptan. Which statement by
the client indicates that the teaching was effective?
A "I will take the medication as soon as I notice migraine symptoms."
B "If the first dose does not help, I can take two more doses 15 minutes apart."
C "I will take a dose every morning to make sure to prevent an acute attack."
D "I will wait to take the medication until the pain has become unbearable."

Question Explanation
Correct Answer is A
Rationale: Almotriptan and other triptans are serotonin receptor agonists that work by causing
vasoconstriction of intracranial arteries. The drug is most effective when taken as soon as
migraine symptoms start but before the onset of acute pain. It will not prevent headaches or
reduce the number of attacks. One of the most common side effects of this medication is dry
mouth. After taking a dose, if the headache goes away and comes back, it is acceptable to take a
second dose. The client should not take more than two doses of any triptan in 24 hours.
Concepts tested

Question 2034
The nurse is caring for a client who is actively dying and has been receiving high doses of opioid
analgesics. The client has become unresponsive to verbal stimuli. What action should the nurse
take?

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A Stop giving the analgesic
B Give an extra dose of the analgesic
C Continue the analgesic at the current dose
D Decrease the analgesic dosage by half

Question Explanation
Correct Answer is C
Rationale: Clients who are actively dying and have been experiencing chronic pain will probably
continue to experience pain even though they cannot communicate this. Pain medication should
be continued at the same dose as long as it is effective at that dose; some adjustments may be
needed based on the client's physical manifestations of pain, such as grimacing or moaning.
Concepts tested

Question 2035
The nurse is teaching a school-aged child and family members about the use of inhalers
prescribed for asthma. Which statement made by a family member indicates an understanding of
the nurse's instructions?
A "Skin color changes in our child are an early warning sign for airway constriction."
B "Monitoring our child's pulse rate is not necessary."
C "We will keep a chart of daily peak flow meter results."
D "We can rely on our child's self-report of symptoms."

Question Explanation
Correct Answer is C
Rationale: The peak flow meter can help determine if the symptoms of asthma are in control or
are worsening. It works by measuring how fast air comes out of the lungs when the client
forcefully exhales (the peak expiatory flow or PEF). The client should record the highest of three
readings in an asthma diary daily. Children ages 4 and up should be able to use a peak flow
meter. A decrease in PEF is an early warning sign for airway constriction and should be
immediately addressed. Family members should monitor the child's pulse rate, and changes in
skin color are a late sign.
Concepts tested

Question 2036
The nurse works in an assisted living facility and cares for older adults. The nurse understands
that older adults are at a greater risk for drug toxicity than younger adults due to which
physiological change associated with aging?
A Drugs are absorbed more readily from the gastrointestinal tract.
B Older adults have a more rapid hepatic metabolism.
C Older adults are often malnourished and anemic.
D Older adults have less body water and more fat.

Question Explanation
Correct Answer is D

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Rationale: Because older adults have decreased lean body tissue and water in which to distribute
medications, more drug remains in the circulatory system creating a potential for drug toxicity.
Increased body fat results in greater amounts of fat-soluble drugs being absorbed, leaving less
medication in circulation and thus increasing the duration of action of the drug.
Concepts tested

Question 2037
A client is prescribed heparin therapy for deep vein thrombosis (DVT). Which laboratory value
should the nurse monitor closely?
A Bleeding time
B D-dimer
C Activated partial thromboplastin time
D Platelet count

Question Explanation
Correct Answer is C
Rationale: Heparin is used to prevent further clots from being formed and to prevent the present
clot from enlarging. The activated partial thromboplastin time (APTT) test measures the time it
takes blood to clot and is used to monitor the effectiveness of heparin therapy. The therapeutic
range is about 1 1/2 to 2 or 2 1/2 times the normal values. D-dimer is used to evaluate blood clot
formation. Platelet counts are used to evaluate abnormal bleeding times. Bleeding time refers to
the time it takes for a pinprick to stop bleeding (normally about 2 1/2 minutes).
Concepts tested

Question 2038
The nurse is caring for a client who has been prescribed atropine preoperatively. The nurse
understands the intended purpose for administering this preoperatively is to induce which effect?
A Elevate blood pressure
B Decrease secretions
C Enhance sedation
D Reduce heart rate

Question Explanation
Correct Answer is B
Rationale: Atropine is a common anesthesia adjunct. It decreases the number of secretions
which, in turn, decreases the risk of aspiration during the operative procedure.
Concepts tested

Question 2039
The nurse is reviewing the medical record of a client who received a new prescription for
benztropine. For which condition in the client's record should the nurse clarify the prescription
with the health care provider?
A Glaucoma
B Cataracts
C Schizophrenia

Page | 835
D Parkinson's disease

Question Explanation
Correct Answer is A
Rationale: Benztropine is an anticholinergic medication used to treat extrapyramidal disorders
caused by antipsychotic medications or Parkinson's disease. The use of benztropine or other
anticholinergics is contraindicated for individuals diagnosed with glaucoma, ileus, and prostatic
hypertrophy. Adverse effects include tachycardia, urinary retention, and increased intraocular
pressure.
Concepts tested

Question 2040
An 80-year-old client who is taking digoxin reports nausea, vomiting, abdominal cramps, and
halo vision. Which laboratory result should the nurse evaluate first?
A Blood urea nitrogen
B Blood pH
C Potassium levels
D Magnesium levels

Question Explanation
Correct Answer is C
Rationale: Nausea, vomiting, abdominal cramps, and halo vision are classic signs of digitalis
toxicity. The most common cause of digitalis toxicity is a low potassium level. Clients are to be
taught that it is important to have adequate potassium intake, especially if taking loop or thiazide
diuretics that enhance the loss of potassium.
Concepts tested

Question 2041
The nurse is planning to administer otic drops to a 6-year-old child. Which action is part of the
correct procedure?
A Insert cotton in the inner ear after giving medication
B Place several drops in the outer ear
C Assist the child to lie on the affected side afterward
D Hold the pinna up and back to instill the drops

Question Explanation
Correct Answer is D
Rationale: The external auditory canal should be straightened by gently pulling the pinna up and
back for otic drop administration. In children who are under three years of age, the pinna should
be pulled down and back.
Concepts tested

Question 2042

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The nurse is caring for a client who is prescribed an antipsychotic medication. Which statement
correctly identifies why it is important for the nurse to monitor the client's blood pressure?
A Rising trends in blood pressure will indicate when an antiparkinsonian medication is needed
B Most antipsychotic medications cause wide fluctuations in blood pressure throughout the day
C Orthostatic hypotension is a common side effect
D Blood pressure will determine if dietary restrictions should be implemented

Question Explanation
Correct Answer is C
Rationale: Clients should be made aware of the possibility of dizziness and syncope from
postural hypotension for about an hour after taking antipsychotic medication. Clients should be
advised to get up slowly from a sitting or lying position.
Concepts tested

Question 2043
The nurse is developing a plan of care for a client who has developed blisters and sores in the
mouth after receiving chemotherapy. Which interventions should the nurse include? Select all
that apply.
A Examine your mouth frequently
B Visit a dental hygienist weekly
C Drink 2 or more liters of water per day
D Suck on ice chips during chemotherapy
E Avoid spicy or acidic foods
F Use strong mouthwashes to kill bacteria

Question Explanation
Correct Answer is A, C, D, E
Rationale: Mucositis is a complex, multiphase process at the cellular level started in response to
cytotoxic chemotherapy. The epithelial cells in the mouth are very sensitive to chemotherapy due
to their high rate of cell turnover. Oral cryotherapy using ice water or ice chips can be used for
the prevention of mucositis. It is believed that vasoconstriction caused by the cold temperature
decreases exposure of the oral mucous membranes to the mucositis-causing agents. Frequent
mouth assessment and good and frequent oral hygiene are key in managing mucositis. The client
should avoid the use of "strong" mouthwashes that often contain alcohol. Mucositis can be
managed at home and does not require seeing a dental hygienist. Increased hydration is generally
recommended.
Concepts tested

Question 2044
The nurse is giving instructions to the parents of a child who has cystic fibrosis. Which
information should the nurse emphasize about the administration of pancreatic enzymes?
A Crush the tablet and sprinkle on food three times a day
B They are to be taken with every meal or snack
C Dispense once daily with breakfast
D Administer each time a high-carbohydrate meal is eaten

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Question Explanation
Correct Answer is B
Rationale: Pancreatic enzymes are necessary for digesting fat, starch, and protein. They should
be taken with each meal and most snacks to allow for the proper digestion of the food. If taken
on an empty stomach, they may cause gastric irritation and possibly ulcers. Enzyme capsules
should be swallowed whole, not crushed or chewed, and the microspheres should not be
sprinkled on or mixed with the whole meal.
Concepts tested

Question 2045
A client is prescribed digoxin 0.25 mg by mouth daily. The health care provider has written a
new order to give metoprolol tartrate 25 mg twice a day by mouth. In assessing the client prior to
administering the medications, which finding should the nurse report to the health care provider?
A Respiratory rate of 16
B Heart rate of 76 BPM
C Urine output of 50 mL/hour
D Blood pressure of 94/60

Question Explanation
Correct Answer is D
Rationale: Both medications decrease the heart rate. Metoprolol (Lopressor) affects blood
pressure. Therefore, the heart rate and blood pressure must be within the normal range (HR 60 to
100 BPM and systolic BP greater than 100 mmHg) in order to safely administer both
medications.
Concepts tested

Question 2046
The nurse is preparing to administer medications through a gastrostomy tube. The nurse should
contact the health care provider before giving which drugs through the gastrostomy tube? Select
all that apply.
A Aspirin EC
B Metoprolol XL
C Acetaminophen
D Terazosin IR
E Calcium carbonate
F Diltazem SR

Question Explanation
Correct Answer is A, B, F
Rationale: Sustained-release (SR), extended-release (ER), or long-acting (XL) drug formulations
are designed to release the drug over an extended period of time. If crushed, as would be

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required for gastrostomy tube (G-tube) administration, sustained-release properties and blood
levels of the drug will be altered. Enteric-coated (EC) drugs should also not be crushed. "IR"
stands for immediate release, and those medications can be crushed. Absent any quantifier such
as "ER" or "IR" with the drug name, the nurse should assume that the medication can be crushed
and given through a G-tube.
Concepts tested

Question 2047
A client with a history of heart disease has been prescribed prophylactic aspirin daily. Which
action should the nurse implement to help prevent aspirin toxicity?
A Teach the client that tinnitus is an expected side effect
B Measure daily protein intake
C Monitor serum albumin
D Assess serum potassium level

Question Explanation
Correct Answer is C
Rationale: Aspirin and salicylic acid are bound to serum albumin. A low serum albumin level
may result in altered salicylate binding thereby increasing the availability of the unbound (active)
drug for toxic effects. The effect is more evident in the elderly, especially someone with heart
disease taking other medications that may be albumin-bound. Although aspirin can cause tinnitus
and hearing loss, educating the client that this is an expected side effect is incorrect and would
not prevent toxicity.
Concepts tested

Question 2048
A newly admitted client reports taking phenytoin for several months. Which assessment should
the nurse include in the admission report? Select all that apply.
A Report of unsteady gait, rash, and diplopia
B Serum phenytoin levels
C Report of anorexia, numbness, and tingling of the extremities
D Report of any seizure activity

Question Explanation
Correct Answer is A, B, D
Rationale: Serious adverse outcomes of antiseizure medications, such as phenytoin, are unsteady
gait, slurred speech, extreme fatigue, blurred vision, or feelings of suicide. Clients who are
prescribed phenytoin should have their levels monitored on a routine basis. The nurse should
include any seizure activity as this may demonstrate a lack of a therapeutic level. Increased
hunger (not anorexia), increased thirst, or increased urination are additional serious side effects.
Concepts tested

Question 2049
A client who was prescribed sertraline to treat depression informs the nurse that they stopped
taking the sertraline and began taking their partner's tranylcypromine. The client reports

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experiencing "muscle twitches" and a "racing heart rate". Which adverse reaction should the
nurse immediately assess for?
A Mental status changes
B Atrial fibrillation
C Muscle weakness
D Pulmonary edema

Question Explanation
Correct Answer is A
Rationale: Use of serotonergic agents may result in serotonin syndrome with confusion, nausea,
palpitations, increased muscle tone with twitching muscles, and agitation. Serotonin syndrome is
most often reported in clients taking two or more medications that increase CNS serotonin levels
by different mechanisms. The most common drug combinations associated with serotonin
syndrome involve MAOIs, SSRIs, and tricyclic antidepressants.
Concepts tested

Question 2050
A client diagnosed with an aplastic sickle cell crisis is within the initial 10 minutes of receiving a
blood transfusion. The client reports "feeling hot." Almost immediately, the client begins to have
audible wheezes. Which action should the nurse take first?
A Stop and disconnect the blood infusion
B Notify the health care provider
C Send blood samples to the lab
D Take and record vital signs

Question Explanation
Correct Answer is A
Rationale: If a reaction of any type is suspected during the administration of blood products, stop
the infusion immediately, disconnect the blood product line and connect a line with 0.9% normal
saline at a keep open rate, notify the health care provider, monitor the vital signs and any other
changes, and then send a urine and blood sample to the lab.
Concepts tested

Question 2051
A client who recently had a heart attack has been prescribed low-dose (81 mg) aspirin at
bedtime. The client states "Why am I supposed to take a 'baby aspirin' instead of a regular 325
mg tablet?" Which statement represents the nurse's best response?
A "The higher dose will cause you to have heartburn."
B "Taking a higher dose will affect your hearing."
C "Taking 325 mg of aspirin daily will increase your risk of bleeding."
D "The higher doses may interfere with your normal sleep patterns.”

Question Explanation
Correct Answer is C

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Rationale: Aspirin is a nonsteroidal anti-inflammatory drug and is prescribed to help keep blood
clots from forming after a heart attack. Lower-dose aspirin therapy is just as effective in reducing
the risk of secondary heart attacks as higher doses of aspirin but with less risk of bleeding
(including gastrointestinal bleeding.) This is especially important for the client to understand
since he may also be prescribed an anticoagulant after his heart attack. Common side effects of
aspirin therapy include rash, upset stomach, heartburn, drowsiness, and headache. Many drugs,
including aspirin, can affect hearing; usually, much larger daily doses would be needed to affect
hearing.
Concepts tested

Question 2052
A client is newly diagnosed with bipolar disorder and has a prescription for lithium. Which point
should the nurse be sure to emphasize?
A Take other medication as usual
B Maintain a salt-restricted diet
C Report vomiting or diarrhea
D Substitute generic form if desired

Question Explanation
Correct Answer is C
Rationale: If dehydration results from vomiting, diarrhea, or excessive perspiration, the client
may experience findings of toxicity due to a build-up of the drug. Lithium has a relatively
narrow therapeutic index. Clients with serum lithium levels higher than 2 mEq/L should be
admitted to the hospital.
Concepts tested

Question 2053
A client is prescribed alendronate. Which instruction should the nurse emphasize when teaching
about this medication?
A "Be sure to take this medication on an empty stomach."
B "Take the medication with a full glass of milk two hours after meals."
C "It is recommended that you take this medication with calcium and a glass of juice."
D "You may take this medication after any meal at the same time every day."

Question Explanation
Correct Answer is A
Rationale: Alendronate (Fosamax) is used to treat and prevent osteoporosis. It should be taken
first thing in the morning with 6 to 8 ounces of plain water at least 30 minutes before other
medication or food. Food and fluids (other than water) greatly decrease the absorption of this
medication. The client must also be instructed to remain in the upright position for 30 minutes
following the dose to facilitate passage into the stomach and minimize irritation of the
esophagus.
Concepts tested

Question 2054

Page | 841
The nurse is caring for a client undergoing chemotherapy for colon cancer. Which of the
following statements made by the client should the nurse be most concerned about?
A "I pray several hours a day to God to help me deal with this cancer."
B "I think the green tea I'm drinking is helping me to fight the cancer."
C "I am using relaxation techniques to help cope with the stress of having cancer."
D "I take 10 different types of vitamins daily to help my immune system fight the cancer."

Question Explanation
Correct Answer is D
Rationale: The client's statement of taking 10 different vitamins daily should be cause for
concern. While other complementary and integrative health therapies may or may not have a
direct beneficial effect on cancer, the multitude of vitamins may interfere with chemotherapeutic
medications and may have toxic effects. The client should speak with their oncologist for further
evaluation of the continuation of the vitamins.
Concepts tested

Question 2055
A client has been prescribed cholestyramine (Questran) in addition to other medications for
coronary artery disease and hyperlipidemia. When should the nurse instruct the client to take the
cholestyramine?
A Early in the morning on an empty stomach
B Anytime is acceptable
C At least 1 to 2 hours after other medications
D At least 1 hour before meals

Question Explanation
Correct Answer is C
Rationale: Cholestyramine is a bile-acid sequestrant used to reduce LDL cholesterol levels. They
are used primarily as adjuncts to statin therapy. Benefits derive from blocking cholesterol
synthesis in the liver. The bile-acid sequestrants can form insoluble complexes with other drugs.
Medications that undergo binding cannot be absorbed and hence are not available for systemic
effects. Drugs known to form complexes with the sequestrants include thiazide diuretics,
digoxin, warfarin, and some antibiotics. To reduce the formation of sequestrant-drug complexes,
oral medications that are known to interact should be administered either 1 to 2 hours before the
sequestrant or 4 hours after. Cholestyramine works best when taken with meals.
Concepts tested

Question 2056
The nurse is teaching a client who is receiving a monoamine oxidase inhibitor (MAOI) for
clinical depression about potential side effects. Which intervention should the client implement
to prevent potential adverse effects of the medication?
A Avoid walking without assistance
B Avoid chocolate and cheese
C Take the medication with milk
D Take frequent naps

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Question Explanation
Correct Answer is B
Rationale: MAO inhibitors are anti-depressants that affect neurotransmitters (chemical
messengers between neurons). MAO inhibitors prevent the synthesis of monoamine oxidase,
which eliminates the neurotransmitters dopamine, serotonin, and epinephrine from the brain. Due
to the higher levels of these neurotransmitters, the client may experience an enhanced mood.
MAO inhibitors impede the breakdown of tyramine. Tyramine is an amino acid that regulates
blood pressure. Higher levels of tyramine can lead to a hypertensive crisis. An important
intervention to stress for clients taking MAO inhibitors is to ensure that they limit the intake of
tyramine-rich foods. Foods that are high in tyramine include chocolate, wine, and cheese. It is
not necessary for a client to take MAO inhibitors with milk. Additional side effects from MAO
inhibitors may include dizziness, weakness, and blurred vision. Although side effects may occur
from these medications, it is not general practice to encourage clients to not walk without
assistance or to take frequent naps.
Concepts tested

Question 2057
The nurse is preparing to administer diltiazem to a client with heart disease. Which action should
the nurse take first?
A Assess the client's urine output and potassium level
B Assess the client's blood pressure and apical pulse
C Auscultate the abdomen for bowel sounds
D Assess the client's lung sounds and monitor for wheezing

Question Explanation
Correct Answer is B
Rationale: Diltiazem is a calcium channel blocker that is used to treat hypertension, angina, and
tachyarrythmias. The medication works by causing systemic vasodilation and lowering the
client's heart rate. Common side effects of diltiazem include hypotension, orthostatic
hypotension, bradycardia, edema, and headaches. It is not necessary to auscultate the client's
lung sounds prior to administering the medication. Wheezing is not considered a side effect of
diltiazem. Because the medication can lead to hypotension and bradycardia, it is essential to
assess the client's blood pressure and apical pulse prior to administration. It is not necessary to
check the client's urine output or potassium level prior to administering the medication.
Diltiazem does not affect a client's renal status or potassium level. It is not necessary to check the
client's bowel sounds prior to administering the medication. Diltiazem does not affect a client's
gastrointestinal system.
Concepts tested

Question 2058
The nurse is caring for a client who received the first dose of fluphenazine two hours ago. The
client suddenly experiences torticollis and involuntary spastic muscle movement. After
administering the ordered anticholinergic drug, which of the following actions should the nurse
implement?
A Immediately place the client in a seclusion room

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B Administer a prn dose of an anti-psychotic medication
C Assess the client for anxiety and agitation
D Have respiratory support equipment available

Question Explanation
Correct Answer is D
Rationale: Clients who receive neuroleptic medication and experience torticollis and involuntary
muscle movement are demonstrating side effects that could lead to respiratory failure.
Concepts tested

Question 2059
The nurse is preparing to administer digoxin to a client with recurring atrial fibrillation. Which
laboratory value should be of the highest concern for the nurse?
A Serum potassium level of 3.1 mEq/L
B Serum creatinine level of 1.9 mg/dL
C Hemoglobin level of 9.4 g/dL
D B-type natriuretic peptide level of 140 pg/mL

Question Explanation
Correct Answer is A
Rationale: Digoxin is a cardiac glycoside used to treat atrial dysrhythmias and heart failure.
Because digoxin competes with potassium ions, digoxin should not be given when the client's
potassium level is below the normal range. Giving digoxin to a client with hypokalemia can
cause digoxin toxicity and life-threatening cardiac dysrhythmias. Although all of the lab values
are outside of the normal range, the low potassium level (normal range 3.5-5.0 mEq/L) should be
of highest concern for the client at this time. The nurse should hold the digoxin and notify the
health care provider.
Concepts tested

Question 2060
The nurse is caring for a client who has a prescription for an insulin sliding scale to manage the
client's hyperglycemia. At 11 am, the client's blood glucose level was 285 mg/dL. According to
the following sliding scale parameters, how many units of insulin should the nurse administer?
For glucose less than 140, give 0 units of insulin aspart.
For glucose between 140 to 180, give 2 units of insulin aspart.
For glucose between 181 to 220, give 4 units of insulin aspart.
For glucose between 221 to 260, give 6 units of insulin aspart.
For glucose between 261 to 300, give 8 units of insulin aspart.
For glucose greater than 300, notify the health care provider.
A 2 units
B 4 units
C 6 units
D 8 units

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Question Explanation
Correct Answer is D
Rationale: According to the prescribed sliding scale, for a blood glucose level of 285 mg/dL, the
nurse should administer 8 units of insulin aspart.
Concepts tested

Question 2061
At the client's request, the nurse performs a fingerstick to test the client's blood glucose and the
results are 322 mg/dL. Following the insulin sliding scale orders, the nurse administers 3 units of
insulin lispro at 11:00 AM. When does the nurse anticipate the insulin lispro will begin to act?
A 3:00 pm
B 1:00 pm
C 12:00 PM
D 11:15 am

Question Explanation
Correct Answer is D
Rationale: The onset of action for insulin lispro, which is a rapid acting insulin, is 10 to 15
minutes after administration. It was administered at 11:00 AM, so it will begin to act at 11:15
AM.
Concepts tested

Question 2062
The nurse is caring for a client with breast cancer who received chemotherapy one week ago.
Which finding is the priority to report to the health care provider?
A Fever and chills
B Depressed mood
C Skin tenting of the forearm
D <span style="font-weight: 400;">Discomfort in both breasts</span>
Discomfort in both breasts

Question Explanation
Correct Answer is A
Rationale: Chemotherapy causes myelo or bone marrow suppression, resulting in neutropenia,
the reduction in neutrophils (white blood cells) that fight off infections. Neutropenic, i.e.,
immunocompromised, clients are at an increased risk for infection, sepsis and septic shock and
the nurse has to be extra vigilant in monitoring for early signs of infection. A fever and chills are
indicative of a possible infection and take priority to be reported to the HCP. The other findings
are also important to note and should be addressed by the nurse after notifying the HCP of the
fever and chills.
Concepts tested

Question 2063
The nurse is reviewing a new prescription for a client with conjunctivitis that reads: Administer
ciprofloxacin solution 1 gtt OD Q4H. Which action should the nurse take next?
Page | 845
A Squeeze one drop of the medication in the client's left eye every 4 hours.
B Apply one drop of the medication in the client's right ear every 4 hours.
C Contact the prescriber to clarify and rewrite the order.
D Ask another nurse for their interpretation of the order.

Question Explanation
Correct Answer is C
Rationale: Abbreviations, symbols and dose designations can be misinterpreted and lead to
medication errors. "OD" can mean "right eye" (oculus dexter) or "once daily"; it should never be
used when communicating medical information. The abbreviation "Q" should be written out as
"every". Although "gtt" is not on the official "Do Not Use List", it is best to use "drop" instead.
Asking other nurses to interpret an order is a potentially dangerous workaround. The next action
the nurse should take is to call the primary health care provider (HCP) who prescribed the
medication and clarify the order.
Concepts tested

Question 2064
A client who has been receiving chemotherapy through a central venous access device (CVAD)
at home, is admitted to the intensive care unit with a diagnosis of septicemia. Which nursing
intervention is the priority?
A Prepare the client for insertion of a new CVAD.
B Change the dressing over the site of the existing CVAD.
C Place the client on contact precautions.
D Insert an indwelling urinary catheter.

Question Explanation
Correct Answer is A
Rationale: Many cases of sepsis occur in immunocompromised clients and clients with chronic
and debilitating diseases. Since it is likely that the existing CVAD is the source of the blood
stream infection, it should be removed and the tip sent for culture and sensitivity testing. The
nurse should anticipate this action and the priority is to prepare the client for insertion of a new
CVAD. The other interventions are not indicated or appropriate for this client.
Concepts tested

Question 2065
The nurse working in an intensive care unit is caring for a client diagnosed with acute angina.
The client is receiving an intravenous infusion of nitroglycerin. What is the priority assessment
for this client?
A Neurologic status
B Heart rate
C Urine output
D Blood pressure

Question Explanation
Correct Answer is D

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Question 2066
Today's prothrombin time for a client receiving warfarin is 20 seconds. The normal range listed
by the lab is 10 to 14 seconds. What is an appropriate nursing action?
A Recognize that this is a therapeutic level.
B Notify the primary health care provider immediately.
C Observe the client for hematoma development.
D Assess for bleeding gums or IV sites.

Question Explanation
Correct Answer is A
Rationale: For the client on warfarin therapy, this prothrombin level is within the therapeutic
range. Therapeutic levels for warfarin are usually one and a half to two times the normal level.
Concepts tested

Question 2067
The nurse is teaching a client with chronic renal failure about their medications. The client
questions the purpose of taking aluminum hydroxide. How should the nurse respond?
A "It decreases your blood's phosphate levels."
B "It is taken to control gastric acid secretions."
C "It increases your urine output."
D "It will reduce your blood's calcium levels."

Question Explanation
Correct Answer is A
Rationale: Aluminum binds to phosphates that tend to accumulate in the client with chronic
renal failure due to decreased filtration capacity of the kidneys. Antacids such as aluminum
hydroxide are commonly used in clients with chronic renal failure to decrease serum phosphate
levels. Aluminum hydroxide will not increase urine production, control gastric acid secretions or
lower serum calcium levels.
Concepts tested

Question 2068
The nurse receives an order to administer intravenous gentamicin to a client. For which finding
should the nurse contact the health care provider to clarify the order?
A Low serum albumin
B Low serum blood urea nitrogen
C High serum creatinine
D High gastric pH

Question Explanation
Correct Answer is C
Rationale: Gentamicin is an aminoglycoside antibiotic that is excreted primarily by the kidneys.
If there is reduced renal function as evidenced by the elevated serum creatinine level, the client is
at greater risk for drug toxicity and further renal damage.

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Concepts tested

Question 2069
The nurse is providing information to a client about propranolol. Which statement by the client
indicates the teaching has been effective?
A "I can have a heart attack if I stop this medication suddenly."
B "I should expect to feel nervousness during the first few weeks."
C "I could have an increase in my heart rate for a few weeks."
D "I may experience seizures if I stop the medication abruptly."

Question Explanation
Correct Answer is A
Rationale: Propranolol is commonly used to treat hypertension, abnormal heart rhythms, heart
disease and certain types of tremors. It is in a class of medications called beta blockers. Suddenly
discontinuing a beta blocker can cause angina, hypertension, dysrhythmias, or even a myocardial
infarction (i.e., heart attack).
Concepts tested

Question 2070
A client who is taking isoniazid for tuberculosis asks the nurse about the possible side effects of
this medication. The nurse informs the client to report which side effect of this medication to the
primary health care provider (HCP)?
A Confusion and light-headedness
B Double vision and visual halos
C Extremity tingling and numbness
D Photosensitivity and photophobia

Question Explanation
Correct Answer is C
Rationale: Peripheral neuropathy is a common side effect of isoniazid and other anti-tubercular
medications. Extremity tingling and numbness should be reported to the primary health care
provider (HCP). Daily doses of pyridoxine (vitamin B6) may lessen or even reverse peripheral
neuropathy due to isoniazid use.
Concepts tested

Question 2071
The nurse is teaching a client with cardiac disease who is taking furosemide and digoxin about
foods rich in potassium. Which food choice best indicates the client understands the teaching?
A A baked potato
B An apricot
C A small orange
D A small banana

Question Explanation
Correct Answer is A

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Rationale: A baked potato contains approximately 610 mg of potassium. Apricots, oranges and
bananas are also sources of potassium, but because of their size, they are not the highest in
potassium. A baked potato is the highest in potassium of the given options and is the best choice.
Concepts tested

Question 2072
A client with severe iron-deficiency anemia is prescribed a parenteral form of iron (i.e., iron
dextran). Which intervention does the nurse prepare to implement before administering the
medication?
A Administer a small test dose.
B Obtain informed consent.
C Obtain the client's vital signs.
D Use the Z-track administration method.

Question Explanation
Correct Answer is A
Rationale: The most serious adverse effect of iron dextran is an anaphylactic reaction. Although
anaphylactic reactions are rare, their possibility demands that iron dextran be used only when
clearly required. To reduce this risk, each dose must be preceded by a small test dose and the
client must be closely monitored while receiving the test dose. The nurse should be aware that
even the test dose can trigger anaphylactic and other hypersensitivity reactions. In addition, even
when the test dose is uneventful, patients can still experience anaphylaxis. The medication does
not require informed consent and obtaining the client's vital signs does not prevent an
anaphylactic reaction. If the medication is ordered to be administered intramuscularly, the Z-
track technique should be used to minimize discomfort, leakage and surface discoloration.
Concepts tested

Question 2073
The nurse is preparing to administer an albuterol nebulizer treatment to an 11-year-old child with
asthma. Which assessment finding should be brought to the health care provider's attention prior
to administering the medication?
A Respiratory rate of 28
B Heart rate of 116 bpm
C Lower extremity edema
D Temperature of 101 F (38.3 C)

Question Explanation
Correct Answer is B
Rationale: One of the more common adverse effects of beta-adrenergic medications, such as
albuterol, is an increase in heart rate. Normal resting heart rate for children 10-years-old and
older is the same as adults: 60 to 100 bpm. The nurse should report the heart rate to the health
care provider prior to administering the medication.
Concepts tested
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Question 2074
The nurse on a surgery unit is evaluating which client would be appropriate for patient-controlled
analgesia (PCA). Which client would not be appropriate for PCA?
A A 71-year-old client with numerous arthritic nodules on their hands.
B A 16-year-old client who reads at a fourth-grade level.
C A 25-year-old client with a history of Down syndrome.
D A 4-year-old client with intermittent episodes of alertness.

Question Explanation
Correct Answer is D
Rationale: The 4-year-old client (preschool-aged) is most likely to have difficulty with the use
or understanding of a patient-controlled analgesia (PCA) pump. The preschooler also has a
decreased level of consciousness and would not be able to fully benefit from the use of a PCA
pump. School age children, ages 6 and up, are better candidates for PCA electronic pumps.
Concepts tested

Question 2075
A client is started on long-term corticosteroid therapy for an autoimmune disorder. Which
statement by the client indicates the need for more teaching by the nurse?
A "I will be sure to eat foods that are high in potassium."
B "I will keep a record of my weight each week."
C "The medication needs to be taken with food."
D "For 1 week each month I will stop taking the medication."

Question Explanation
Correct Answer is D
Rationale: Corticosteroids should never be stopped abruptly, they should always be weaned. To
suddenly stop this medication may result in a sudden drop in the blood pressure from a loss in
fluid volume associated with adrenal crisis. Clients should be warned not to abruptly stop taking
the medication. Corticosteroids can lower the amount of potassium in the body so the client
should eat more potassium rich foods. Weight gain is an expected effect of corticosteroid
therapy. Clients should regularly keep track of their weight. Generally, corticosteroid
medications are taken with breakfast.
Concepts tested

Question 2076
The nurse in a pediatrician's office is speaking with the parent of an 8-year-old child who is
concerned about the child receiving the annual flu vaccine due to an egg allergy. How should the
nurse respond?
A "We can premedicate the child to prevent an allergic reaction."
B "Your child should not be receiving the flu vaccine."
C "We have new types of flu vaccines where an egg allergy does not matter."
D "You can schedule an appointment to have the vaccine administered in our office."

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Question Explanation
Correct Answer is D
Rationale: The Centers for Disease Control and Prevention (CDC) states that people with egg
allergies can receive any licensed, recommended age-appropriate influenza (flu) vaccine (IIV,
RIV4, or LAIV4) that is otherwise appropriate. People who have a history of severe egg allergy
(those who have had any symptom other than hives after exposure to egg) should be vaccinated
in a medical setting, supervised by a health care provider who is able to recognize and manage
severe allergic reactions. The other responses are not correct.
Concepts tested

Question 2077
A client who previously had a stroke and is refusing to take the daily aspirin prescribed by their
health care provider. Which statements should the nurse include in her response to the
client? Select all that apply.
A "Do you experience any nausea when you take the aspirin?"
B "If you don't take aspirin every day, you might die."
C "Do you take your other medications as prescribed by your provider?"
D "Would you like to take the aspirin at another time of day?"
E "Can you tell me what concerns you have about the aspirin?"

Question Explanation
Correct Answer is A, C, D, E
Rationale: Although clients have the right to refuse medications, the nurse should still try to
determine the underlying reasons for the client's refusal. Aspirin is a platelet aggregate inhibitor
that is often prescribed for clients with cardiovascular disease (CVD) and stroke to prevent
another thrombotic event and future stroke. Aspirin can cause gastrointestinal (GI) irritation and
should be taken with food. The nurse can increase the client's adherence to their prescribed
medication regimen by investigating their reasons for refusal, exploring any misconceptions
about the drug and reinforcing the importance of the medication in preventing another stroke. In
addition, involving the client in making decisions about when to take the medication can help the
client accept the regimen. Stating that the client might die if they do not take the medication is
nontherapeutic, inappropriate and violates the client's right to autonomy.
Concepts tested

Question 2078
The nurse is completing a health history of a client diagnosed with Alzheimer's disease. The
nurse reviews a list of the client's medications and supplements routinely taken at home. Which
treatment should be a cause for concern by the nurse?
A Coconut oil
B Ginkgo biloba
C Omega-3 fatty acids
D Donepezil

Question Explanation
Correct Answer is A

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Rationale: Donepezil, rivastigmine, and galantamine are most commonly used in the treatment
of Alzheimer's disease (AD). Complementary and integrative therapies use to treat AD include
Gingko biloba (a plant extract) and omega-3 fatty acids. While there isn't sufficient research to
support using these treatments, continued use won't necessarily be harmful. However, coconut
oil, which is a source of caprylic acid, is a concern. While there has been limited research on
Katasyn (an experimental drug containing caprylic acid), there is no scientific evidence that
coconut oil is safe and effective or prevents cognitive decline.
Concepts tested

Question 2079
The nurse is providing discharge teaching to the parents of a 15-month-old child diagnosed with
Kawasaki disease. The child received intravenous immunoglobulin therapy during the
hospitalization. Which information should the nurse include?
A Active range of motion exercises should be done frequently.
B The measles, mumps and rubella vaccine should be delayed.
C High doses of aspirin will be continued for some time.
D Complete recovery is expected within several days.

Question Explanation
Correct Answer is B

Question 2080
A nurse is teaching an 80-year-old client how to use a metered dose inhaler. The nurse is
concerned that the client is unable to coordinate the release of the medication during the
inhalation phase. Which intervention should improve the delivery of the medication?
A Request a home health nurse to visit the client at home.
B Ask a family member to assist the client with the inhaler.
C Add a spacer device to the inhaler canister.
D Use nebulized treatments at home instead.

Question Explanation
Correct Answer is C
Rationale: Use of a spacer is especially useful with older adults because it allows more time to
inhale and requires less eye-hand coordination. If the client is not using the metered dose inhaler
(MDI) properly, the medication can get trapped in the upper airway and lead to dry mouth and
throat irritation. Using a spacer will allow more drug to be deposited in the lungs and less in the
mouth.
Concepts tested

Question 2081
The nurse is reviewing the medical record of a client with a new prescription for lovastatin for
hyperlipidemia. Which finding requires the nurse to notify the health care
provider immediately?
A Alanine aminotransferase level of 90 U/L Correct Answer
B Serum creatinine level of 1.2 mg/dL

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C Total cholesterol level of 320 mg/dL
D Hemoglobin A1c level of 10.2%

Question Explanation
Correct Answer is A
Rationale: Lovastatin is an HMG-CoA reductase inhibitor, commonly called a "statin," which is
used for the treatment of hyperlipidemia and other cardiovascular diseases. Statins can be
hepatotoxic and liver injury, as evidenced by elevations in serum transaminase levels, can
develop. Normal alanine aminotransferase (ALT) levels range from 10 to 40 U/L. An ALT level
of 90 is above normal and the nurse should notify the prescriber immediately. An elevated
cholesterol level is an indication for treatment with lovastatin. The hemoglobin A1c level is also
high but pertains to diabetes management, not the medication prescribed in this scenario. The
creatinine level is normal.
Concepts tested

Question 2082
A child is treated with succimer for lead poisoning. Which of these assessments is the priority?
A Check the client's blood calcium level.
B Check the client's complete blood count with differential.
C Test the client's deep tendon reflexes.
D Check the client's serum potassium level.

Question Explanation
Correct Answer is B
Rationale: Succimer is used in the management of lead or other heavy metal poisoning.
Although it is generally well-tolerated and has a relatively low toxicity, it may
cause neutropenia. Succimer therapy should be withheld or discontinued if the absolute
neutrophil count (ANC) is below 1,200/mm3. The normal range for an ANC is 1.5 to 8.0 (1,500
to 8,000/mm3). Therefore, the assessment priority in this scenario is checking the complete
blood count (CBC) with differential which includes an ANC value.
Concepts tested

Question 2083
A client with angina has been instructed about the use of sublingual nitroglycerin. Which
statement by the client indicates the need for additional teaching?
A "I understand that the medication should be kept in the dark bottle."
B "I can swallow two or three tablets at once if I have severe pain."
C "I will rest briefly right after taking one tablet."
D <span style="font-weight: 400;">"I'll call the health care provider if pain continues after three
tablets five minutes apart."</span>
"I'll call the health care provider if pain continues after three tablets five minutes apart."

Question Explanation
Correct Answer is B

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Rationale: Clients must understand that just one sublingual tablet should be taken at a time.
Clients must also understand that they should rest when experiencing angina. Two or three
tablets should not be used at once, even in the setting of severe pain, as this can lead to
significant hypotension. The client should notify their primary healthcare provider should they
not have a relief of symptoms with nitroglycerin use.
Concepts tested

Question 2084
The nurse is caring for a client who had a central venous catheter inserted at the bedside. Which
of these findings requires immediate intervention by the nurse?
A Pallor in the extremities
B Increased temperature by one degree
C Dyspnea at rest
D Involuntary coughing spells

Question Explanation
Correct Answer is C
Rationale: Complications of central catheter insertion include pneumothorax and hemothorax.
Air embolism is another potential complication. Dyspnea, shallow respirations, sudden sharp
chest pain that worsens with coughing or deep breathing are indications of pneumothorax. Other
potential complications of central catheters may include thrombosis, local or systemic infection,
or even cardiac tamponade (if the central line perforates the heart). When considering the options
listed, the client who is dyspneic after central line insertion would be the greatest concern for the
nurse.
Concepts tested

Question 2085
The home care nurse is reviewing the medical record of a new client with a history of chronic
obstructive pulmonary disease, atrial fibrillation and gout. After reviewing the client's
medication list, for which medications should the nurse arrange to monitor blood levels? Select
all that apply.
A Theophylline
B Allopurinol
C Beclomethasone
D Montelukast
E Digoxin

Question Explanation
Correct Answer is A, E
Rationale: It is necessary to monitor blood levels for theophylline and digoxin to prevent
toxicity. Both of those drugs can accumulate in the blood and reach toxic levels. The other
medications are not known to accumulate and cause toxicity if taken as prescribed.
Concepts tested

Question 2086

Page | 854
A one-year-old child is receiving temporary total parental nutrition (TPN) through a central
venous line. This is the first day of TPN therapy. Although all of the following nursing actions
must be included in the plan of care of this child, which one would be a priority at this time?
A Use aseptic technique during dressing changes
B Monitor serum glucose levels
C Check results of liver enzyme tests
D Maintain central line catheter integrity

Question Explanation
Correct Answer is B
Rationale: Hyperglycemia may occur during the first day or two as the child adapts to the high-
glucose load of the TPN solution. Thus, a priority nursing responsibility is blood glucose testing.
Concepts tested

Question 2087
A client who has returned from surgery reports feeling nauseated and later has an emesis. The
nurse administers promethazine per standing orders. In addition to relief from nausea, what other
effects of this medication does the nurse expect? Select all that apply.
A Heart palpitations
B Dry mouth
C Rhinorrhea
D Pinpoint pupils
E Sedation

Question Explanation
Correct Answer is A, B
Rationale: Promethazine is used as an antihistamine, sedative and antiemetic. It produces
anticholinergic effects, such as dry mouth and reduced nasal congestion, dilated pupils and
urinary retention. Although promethazine is a sedative, the nurse should understand that it can
cause some people to have heart palpitations and to feel restless and unable to sleep.
Concepts tested

Question 2088
A client has been prescribed alendronate for osteoporosis. Which statements indicate that the
client understands how to safely take this medication? Select all that apply.
A "I will notify my doctor if I experience worsening heartburn."
B "I will swallow the pill with a full glass of water."
C "I will take the pill with an antacid to prevent stomach upset."
D "I will always eat breakfast before taking the pill."
E "I will stand or sit quietly for 30 minutes after taking the pill."

Question Explanation
Correct Answer is A, B, E
Rationale: Alendronate is a bisphosphonate used to treat osteoporosis. It can cause esophagitis
or esophageal ulcers unless precautions are followed. The client must sit upright or stand for at

Page | 855
least 30 minutes after taking the medication. The client should take the medication with a full
glass of water, at least 30 minutes before eating or drinking anything or taking any other
medication. Antacids will interfere with absorption and should not be taken at the same time.
Concepts tested

Question 2089
A client with anemia has a new prescription for ferrous sulfate. When teaching the client about
diet and iron supplements, what should the nurse emphasize about taking an iron supplement?
A Take the iron tablet with a glass of orange juice
B Take an antacid with the iron supplement to reduce stomach upset
C Lie down for about 10 minutes after taking the pill
D Take the iron tablet with a glass of low-fat milk

Question Explanation
Correct Answer is A
Rationale: Iron is best taken on an empty stomach, one hour before or two hours after meals,
with a full glass of water or orange juice (ascorbic acid enhances the absorption of iron.) The
client should not take the medication with antacids, dairy products, coffee or tea because these
will decrease the effectiveness of the medicine. The client should not lie down for at least 10
minutes after taking the medicine.
Concepts tested

Question 2090
The nurse is caring for a client who is receiving procainamide intravenously. It is most
important that the nurse monitors which parameter?
A Hourly urinary output
B Continuous ECG readings
C Serum potassium levels
D Neurological signs

Question Explanation
Correct Answer is B
Rationale: Procainamide is used to suppress cardiac arrhythmias. When administered
intravenously, it must be accompanied by continuous cardiac monitoring.
Concepts tested

Question 2091
The nurse is preparing to start a blood transfusion for a client with severe anemia. To reduce the
risk of adverse transfusion reactions, which interventions are essential to include? Select all that
apply.
A Administration of supplemental oxygen
B Monitoring of vital signs before, during and after the transfusion
C Maintaining the client on complete bed rest during the transfusion
D Use and priming of the appropriate tubing for the prescribed blood component

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E Verification of client by name, blood band number, blood type compatibility
F Placement of an appropriate size venous access device

Question Explanation
Correct Answer is B, D, E, F
Rationale: Nursing actions during blood transfusions focus on prevention or early recognition of
adverse transfusion reactions. Preparation of the client for transfusion is critical, and blood
product administration procedures must be followed carefully. Human error is the most common
cause of ABO incompatibility reactions. A peripheral venous access device should preferably be
at least 20-gauge size. Client and blood product verification must be done by two [registered]
nurses at the client's bedside. Vital signs should be obtained immediately prior to starting the
transfusion, 15 and 30 minutes after start of the transfusion and hourly during the transfusion.
Supplemental oxygen and bed rest are generally not required during a blood transfusion and will
not prevent adverse transfusion reactions.
Concepts tested

Question 2092
The client is taking bupropion to treat depression and is worried about taking the medication.
The client tells the nurse a friend said the medication was removed from the market because it
caused seizures. What is an appropriate response by the nurse?
A Omit the next dose until you talk with your health care provider.
B Ask your friend about the source of this information.
C Your health care provider knows the best drug for your condition.
D The recommended dose of this medication was changed, which lowered the risk of seizures.

Question Explanation
Correct Answer is D
Rationale: Bupropion was introduced in the United States in 1985 and then withdrawn because
of the occurrence of seizures in some clients who took the drug. The drug was reintroduced in
1989 with specific recommendations about dose ranges to limit the occurrence of seizures. The
risk of seizure appears to be strongly associated with higher dosages.
Concepts tested

Question 2093
The nurse is caring for a client who is receiving a blood transfusion. The client develops urticaria
30 minutes after the transfusion began. What is the first action the the nurse should take?
A Take vital signs and observe for further deterioration
B Stop the infusion
C Administer Benadryl and continue the infusion
D Slow the rate of infusion

Question Explanation
Correct Answer is B

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Rationale: This is an indication of an allergy to the plasma protein. The priority action of the
nurse is to stop the transfusion by disconnecting at the IV insertion site. The nurse should then
start a saline line at the IV insertion site and notify the health care provider.
Concepts tested

Question 2094
A 4-month-old infant is receiving digoxin. The infant's blood pressure is 92/78 mm Hg; resting
pulse is 78 beats per minute; respirations are 28 breaths per minute; and serum potassium level is
4.8 mEq/L. The infant is irritable and has vomited twice since receiving the morning dose of
digoxin. Which finding is most indicative of digoxin toxicity?
A Vomiting
B Irritability
C Bradycardia
D Dyspnea

Question Explanation
Correct Answer is C
Rationale: The most common sign of digoxin toxicity in children is bradycardia which is a
heart rate below 100 beats per minute in an infant. Normal resting heart rate for infants 1-11
months-old is 100-160 beats per minute.
Concepts tested

Question 2095
A client is receiving total parenteral nutrition (TPN) via a tunneled catheter. The catheter
accidentally becomes dislodged from the site. Which action by the nurse should take priority?
A Check that the catheter tip is intact
B Apply a pressure dressing to the site
C Monitor respiratory status
D Assess for mental status changes

Question Explanation
Correct Answer is B
Rationale: The client is at risk of bleeding or developing an air embolus if the catheter exit site
is not covered with a pressure and occlusive dressing. An occlusive dressing is one that is totally
covered by adhesive tape around the edges, as well as over the entire dressing.
Concepts tested

Question 2096
The client is diagnosed with tuberculosis (TB). The nurse understands that the treatment plan for
this client will involve what type of drug therapy?
A High doses of B complex vitamins
B An anti-inflammatory agent
C Aminoglycoside antibiotics
D Administering two antituberculosis drugs

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Question Explanation
Correct Answer is D
Rationale: In order to prevent drug-resistant strains of TB, clients are always prescribed at least
two different anti-tubercular medications. Rifampin and isoniazid are the most effective drugs
used to treat TB and are always used together, for at least six months. Additional medications,
such as pyrazinamide and either streptomycin or ethambutol, may also be prescribed. Vitamin
B6 is usually prescribed to help prevent expected side effect of isoniazid.
Concepts tested

Question 2097
The visiting nurse is evaluating the plan of care for a client who reports that they have decided to
stop taking the recently prescribed sertraline due to frequent nightmares. Which action should the
nurse take first?
A Perform a suicide risk assessment
B Initiate transfer to the nearest psychiatric hospital
C Explore alternative medications
D Request for the medication to be changed to be given intramuscular

Question Explanation
Correct Answer is A
Rationale: Sertraline (Zoloft) is a selective serotonin reuptake inhibitor or SSRI, commonly used
to treat depression, general anxiety disorder and other psychiatric disorders. Like all other
antidepressants, SSRIs may increase the risk of suicide. To reduce the risk of suicide, clients
taking antidepressant drugs should be observed closely for suicidality, worsening mood, and
unusual changes in behavior. Close observation is especially important during the first few
months of therapy and whenever antidepressant dosage is changed (either increased or
decreased). SSRI are given orally, not IM.
Concepts tested

Question 2098
A client who had surgery is discharged on warfarin. Which statement by the client is incorrect
and indicates a need for further teaching?
A "I will keep all laboratory appointments."
B "I will report any bruises or unusual bleeding."
C "I know I must avoid crowds."
D "I plan on using an electric razor for shaving."

Question Explanation
Correct Answer is C
Rationale: There are no specific reasons for the client on warfarin to avoid crowds. Clients
should not use a straight edge razor, should report any unusual bleeding and must keep all
laboratory appointments when taking the blood thinner warfarin.
Concepts tested

Question 2099

Page | 859
A nurse is giving instructions to the parents of a newborn infant with oral candidiasis. Which
statement made by a parent is incorrect and indicates a need for more teaching?
A "Nystatin should be given four times a day after my baby eats."
B "I will use a dropper to place the medicine on each side of my baby's mouth."
C "I will boil the nipples and pacifiers for 20 minutes."
D "The therapy can be discontinued when the spots disappear."

Question Explanation
Correct Answer is D
Rationale: The therapy should be continued for a week, even if lesions have disappeared within
a few days. If the mother is breast-feeding, mother and baby should be treated at the same time to
prevent re-infection.
Concepts tested

Question 2100
The nurse is evaluating an older adult client with an upper gastrointestinal bleed who received
several packed red blood cell transfusions in the past 24 hours. Assessment findings include
crackles to auscultation, bounding pulses, orthopnea and an oxygen saturation of 90% on room
air. Vital signs include heart rate of 106 bpm, blood pressure 160/80 mm Hg, respirations 24 and
temperature 98.6o F (37o C). Which adverse transfusion reaction is the client most likely
experiencing?
A Hemolytic transfusion reaction
B Circulatory overload
C Transfusion-associated graft-versus-host disease
D Bacterial transfusion reaction

Question Explanation
Correct Answer is B
Rationale: The client's symptoms are most likely related to circulatory overload. Transfusion-
associated circulatory overload can occur when a blood product is infused too quickly, especially
in an older adult. This is most common with whole-blood transfusions or when the patient
received multiple packed red blood cell transfusions. Symptoms include: hypertension, bounding
pulse, distended jugular veins, dyspnea, restlessness and confusion.
Concepts tested

Question 2101
The nurse is caring for a client who was prescribed alprazolam. When educating the client about
the new medication, which intended effect should the nurse include?
A Reduce anxiety and provide a calming effect
B Reduce symptoms of depression
C Increase coordination and the ability to concentrate
D Alleviate signs and symptoms of spasticity

Question Explanation
Correct Answer is A

Page | 860
Rationale: Alprazolam is a benzodiazepine which is as an anxiolytic. The medication will not
increase coordination and the ability to concentrate or alleviate symptoms associated with nerve
damage, such as spasticity. Alprazolam will not reduce symptoms of depression.
Concepts tested

Question 2102
A nurse is teaching a client with asthma about the correct use of the fluticasone inhaler. Which
statement, if made by the client, would indicate that the teaching was effective?
A "I should not use a spacer with my inhaler."
B "I should rinse my mouth after using the inhaler."
C "If I forget a dose, I will double the next dose."
D "The inhaler can be used when I feel short of breath."

Question Explanation
Correct Answer is B
Rationale: Fluticasone is an inhaled corticosteroid used to prevent asthma attacks. After using
the inhaler, the client should rinse away any residue in the mouth to reduce the risk of an oral
fungal infection. Fluticasone is not a bronchodilator and should not be used as needed for
shortness of breath. The client should not double the dose of this medication and should use a
spacer with this inhaler.
Concepts tested

Question 2103
The nurse is providing education to a client that will be discharged with a prescription for
sublingual nitroglycerin as needed for acute angina. The nurse should include which of the
following in the teaching?
A If acute angina occurs, stop activity and take the medication as directed
B Keep the medications locked in a cabinet at their home
C If pain is not relieved after the sixth dose, call 911
D Drink a glass of water immediately after placing the tablet under the tongue

Question Explanation
Correct Answer is A
Rationale: The client should be taught the correct self-administration of nitroglycerin during
acute angina. On the onset of angina, the client should stop activity and place the nitroglycerin
under their tongue. Three sublingual nitroglycerin tablets should be taken in 5-minute
increments. If the pain is not relieved the client may be experiencing a myocardial infarction and
needs to call 911. Drinking a glass of water with the nitroglycerin could decrease sublingual
absorption. The nitroglycerin should not be kept at home, but carried with the client. The client
should be told to call 911 if the pain is not relieved after 3 doses, not 6.
Concepts tested

Question 2104
A client is being discharged with a prescription for warfarin. The client asks "May I take aspirin
with this medication? It helps my arthritis." Which response by the nurse is appropriate to
address the client's concern?
Page | 861
A "Avoid aspirin because it can increase the bleeding effects of warfarin.
B "Take the warfarin in the morning and the aspirin at night."
C "Use about half the recommended dose of aspirin."
D "When you take the aspirin, do not take the warfarin that day."

Question Explanation
Correct Answer is A
Rationale: Aspirin is a salicylate, which inhibits platelet aggregation. When used in conjunction
with warfarin, the risk of bleeding increases. Therefore, aspirin and warfarin should not be taken
together. It is inappropriate to tell the client to not take the prescribed medication, warfarin.
Concepts tested

Question 2105
The nurse is caring for a client with osteoporosis who has been prescribed alendronate. When
providing care, which intervention would be a priority?
A Notify the health care provider if the client reports jaw pain.
B Administer the alendronate 30 to 60 minutes before the client eats.
C Encourage the client to increase their intake of vitamin D.
D Monitor the client's serum calcium levels.

Question Explanation
Correct Answer is A
Rationale: Alendronate is a bisphosphonate that helps slow down bone resorption, decreasing
osteoporosis. Osteonecrosis of the jaw is a rare, adverse reaction to alendronate, and jaw pain can
be a symptom of this. Therefore, notifying the health care provider of the jaw pain is the priority.
The other interventions are also correct for a client with osteoporosis, but are not as important as
reporting the potential adverse drug effect.
Concepts tested

Question 2106
The nurse is assessing a client with hypertension who reports experiencing dizziness after taking
prescribed diltiazem. It is most important that the nurse assesses for which client characteristic?
A Activity and rest patterns
B Daily intake of potassium
C Appearance of feet and ankles
D Schedule for taking medication

Question Explanation
Correct Answer is D
Rationale: A critical focus is whether the client has complied with the prescribed medication
schedule and dose. Although diltiazem (Cardizem, Cartia, Dilacor, Diltia, Taztia, Tiazac) can be
taken either in the morning or evening, taking the medication in the evening might help with this
common side effect.

Page | 862
Concepts tested

Question 2107
A woman diagnosed with bipolar disorder is to take lithium as part of her treatment. What should
the nurse discuss with the client as part of the teaching plan?
A Alcohol abstinence
B Weight reduction
C Smoking cessation
D Risk of concomitant use of oral contraceptives

Question Explanation
Correct Answer is A
Rationale: Alcohol potentiates the effects of lithium, resulting in central nervous system
depression and impairment of judgment, thinking and psychomotor skills. The client should be
cautioned to avoid drinking alcoholic beverages.
Concepts tested

Question 2108
The nurse is caring for a 1-year-old child after heart surgery. The child weighs 22 pounds (10
kg). The health care provider has given an order for morphine sulfate 4 mg IV every 3 to 4 hours
as needed for pain. What should the nurse do next?
A Give half of the dose first, wait 30 minutes, then give the other half
B Check with the pharmacist to clarify the dose.
C Verify that the dose is appropriate for this child.
D Administer the prescribed dose as ordered.

Question Explanation
Correct Answer is C
Rationale: The nurse's responsibilities for safe medication administration include knowledge of
appropriate doses for pediatric clients and how to perform weight-based dosage calculations.
Morphine prescribed parenterally (SQ/IM/IV), the recommended pediatric dose is 0.1 to 0.2
mg/kg (1 to 2 mg in this case) every 2 to 4 hours. Therefore, the prescribed dose falls outside of
those guidelines (too high) and the nurse should clarify the prescription with the health care
provider.
Concepts tested

Question 2109
The nurse is caring for a client that is taking prednisone and aspirin for rheumatoid arthritis.
Which action by the nurse is appropriate for this client?
A Monitor the client's temperature every two hours
B Apply a hot pack to a warm, acutely inflamed joint
C Test the client's stool for occult blood
D Assess the client's pain level once a shift

Question Explanation

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Correct Answer is C
Rationale: Rheumatoid arthritis is a chronic, progressive immunologic disorder. This type of
arthritis is associated with progressive inflammation of joints and pain. The client's pain level
should be assessed more often than once a shift. However, the client's temperature does not need
to be measured every two hours. The client is at risk for gastrointestinal bleeding with the use of
these two medications. The nurse should anticipate checking the stool for occult blood and
monitor the client for signs and symptoms of anemia. When joints are acutely inflamed and
warm on palpitation, the nurse should apply an ice pack, not heat.
Concepts tested

Question 2110
The nurse is providing discharge education to a client who will be starting daily atenolol for the
treatment of hypertension. The nurse should emphasize to notify the health care provider if
which of the adverse effects occur?
A Decreased libido
B Decreased exercise tolerance
C Slow, irregular heart rate
D Dizziness in the morning

Question Explanation
Correct Answer is C
Rationale: Atenolol is a Beta-1 selective adrenergic blocking agent or a "beta blocker." These
medications are commonly used to treat hypertension or chronic angina. Due to their selectivity,
they are the preferred medications for clients who have the comorbidities of Chronic Obstructive
Pulmonary Disease (COPD). Common adverse effects often relate to the therapeutic action of the
drug and include impotence, decreased libido, dizziness, decreased exercise tolerance, slowed
heart rate, arrhythmias and heart failure. The client should be taught to assess their heart rate and
to notify the health care provider of any changes to the heart rate or rhythm.
Concepts tested

Question 2111
The nurse is caring for a client who is prescribed lithium for bipolar disorder. Which clinical
manifestations would indicate the client may be experiencing lithium toxicity?
A Electrolyte imbalance, tinnitus and cardiac dysrhythmias
B Vomiting, diarrhea and lethargy
C Ataxia, agnosia and coarse hand tremors
D Pruritus, rash and photosensitivity

Question Explanation
Correct Answer is B
Rationale: Serum lithium levels should be between 0.8 and 1.2 mEq/L (remember, the exact
numbers may vary slightly depending on the lab). Diarrhea, vomiting, drowsiness, muscular
weakness and lack of coordination may be early signs of lithium toxicity. Toxicity increases with

Page | 864
increasing serum lithium levels, but clients may exhibit toxic findings at lithium levels below 2.0
mEq/L. Dehydration, other medications and other conditions can interfere with lithium levels.
Concepts tested

Question 2112
The nurse notes that a client's prescription was changed from captopril to losartan, even though
the captopril provided effective blood pressure control. Which is the most likely reason for
discontinuing the captopril?
A Rash and itching
B Dry cough
C Blurred vision
D Sexual dysfunction

Question Explanation
Correct Answer is B
Rationale: Captopril is an ACE inhibitor that converts angiotensin I to the powerful
vasoconstrictor angiotensin II in the renin-angiotensin-aldosterone system (RAAS). It is used in
the management of hypertension and other cardiovascular diseases. A side effect of this
medication is a dry cough, which many clients find intolerable. This is a common reason for a
client's prescription to change from an ACEI to a similar medication such as an ARB (losartan).
The other side effects are not typically seen with an ACEI drug.
Concepts tested

Question 2113
The nurse is caring for a client diagnosed with heart failure who will begin treatment with
digoxin. Which therapeutic effect would the nurse expect to find after administering this
medication?
A Improved respiratory status with increased urinary output
B Increased heart rate with increased respirations
C Decreased chest pain with decreased blood pressure
D Diaphoresis with decreased urinary output

Question Explanation
Correct Answer is A
Rationale: Digoxin (Lanoxin), a cardiac glycoside, is used in clients with heart failure to slow
and strengthen the heartbeat. As cardiac output is improved, renal perfusion is improved and
urinary output increases. Clients can become toxic on this drug, indicated by findings of
bradycardia or tachycardias above 120, arrhythmia, visual or gastrointestinal disturbances.
Clients being treated with digoxin should have the apical pulse evaluated for one full minute
prior to the administration of the drug.
Concepts tested

Question 2114
The nurse is caring for a client who is prescribed warfarin. Which lab test would the nurse
monitor to determine a therapeutic response to the drug?

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A International Normalized Ratio (INR)
B Partial thromboplastin time (PTT)
C D-dimer
D Bleeding time

Question Explanation
Correct Answer is A
Rationale: The warfarin dosage is based on the result of a client's daily INR (or prothrombin
time [PT]). Warfarin affects the function of the coagulation cascade and inhibits the formation of
blood clots. The goal of warfarin therapy is to maintain a balance between preventing clots and
causing excessive bleeding, which is why careful monitoring is needed. A Partial thromboplastin
time (PTT) is associated with monitoring heparin. A bleeding time test is performed to monitor
basic platelet function. The d-dimer test is a test used to diagnose a blood clot.
Concepts tested

Question 2115
The nurse is assessing a client who takes a prescribed antipsychotic medication. Which findings
require immediate discontinuation of this medication?
A Hyperthermia and severe muscle rigidity
B Agitation and constant state of motion
C Cheek puffing and involuntary movements of extremities and trunk
D Involuntary rhythmic stereotypic movements and tongue protrusion

Question Explanation
Correct Answer is A
Rationale: Hyperthermia, severe muscle rigidity and malignant hypertension are findings
associated with neuroleptic malignant syndrome (NMS). NMS is a serious complication
associated with the use of antipsychotic drugs. Repetitive, involuntary movements of the face or
body may be a sign of tardive dyskinesia related to antipsychotic use. This is a serious concern,
but not an emergency. Tardive dyskinesia may be irreversible, even after the medication has
been discontinued. Agitation and being in a constant state of motion are most likely related to the
illness being treated, such as bipolar disorder or schizophrenia.
Concepts tested

Question 2116
The nurse is caring for an 83-year-old client who is experiencing a sudden onset of confusion.
Which medication most likely contributed to this change?
A Cardiac glycoside
B Antihistamine
C Liquid antacid
D Anticoagulant

Question Explanation
Correct Answer is B

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Rationale: Older adults are more susceptible to the side effects of anticholinergic medications,
such as antihistamines. Antihistamines often cause confusion in the older adult, especially at
high doses. Cardiac glycosides, anticoagulants and antacids are not associated with confusion or
mental status changes in the older adult.
Concepts tested

Question 2117
The oncology nurse is caring for a female client who is being treated for metastatic breast cancer.
The client is scheduled to receive their first dose of trastuzumab. Which assessment finding
is most important to notify the health care provider of?
A Blood glucose 130 mg/dL
B Absolute neutrophil count 2.5 (2,500 mm3)
C Intermittent nausea and vomiting
D Irregular apical pulse

Question Explanation
Correct Answer is D
Rationale: Trastuzumab is a monoclonal antibody used as anticancer therapy for women with
HER2-positive breast cancer. The main concern in administering trastuzumab is cardiotoxicity,
manifesting as ventricular dysfunction and congestive heart failure. Therefore, the irregular
apical pulse is the most important assessment findings. An ejection fraction is obtained as a
baseline before treatment and may be monitored every few months while the client is receiving
this medication. The other findings are to be expected, normal or near normal and not as
important as the irregular apical pulse.
Concepts tested

Question 2118
A nurse is educating a client about the use of warfarin at home. The nurse should reinforce the
need for the client to monitor which of the following?
A Avoidance of public transportation and large groups of people
B Extended exposure to outdoor sunlight
C Limit of strenuous physical exercise
D Consistent intake of foods high in vitamin K

Question Explanation
Correct Answer is D
Rationale: Warfarin, an oral anticoagulant, works by causing a decrease in the vitamin K-
dependent clotting factors produced by the liver. Due to this mechanism of action, vitamin K is
used as the antidote for warfarin overdose. A diet high in vitamin K could counteract the
therapeutic effect of warfarin. Foods high in vitamin K include dark green leafy vegetables,
tomatoes, bananas, cheese and fish. Best practice no longer recommends limiting the intake of
Vitamin K-containing foods, instead it is recommended to keep the intake of foods high in
Vitamin K 'consistent'. The other actions do not pertain to warfarin.
Concepts tested

Question 2119
Page | 867
The nurse is providing discharge education to a client who is prescribed alprazolam for a panic
disorder. What concept should the nurse emphasize concerning the drug action?
A The medication acts as a stimulant
B The medication works by suppressing dopamine
C If you miss a dose, double the next scheduled dose
D Short-term relief can be expected

Question Explanation
Correct Answer is D
Rationale: Alprazolam is a short-acting benzodiazepine, which works quickly to control panic
symptoms by enhancing the effects of the neurotransmitter Gamma-amino butyric acid (GABA).
This produces a calming effect. The drug does not suppress dopamine like dopamine antagonists
and some antipsychotic medications. Alprazolam will not be increased as tolerated, the lowest
dose that controls the symptoms will be maintained.
Concepts tested

Question 2120
The nurse is providing discharge education to a client diagnosed with coronary artery disease.
The client is prescribed to use a nitroglycerin transdermal patch at home. Which statement by the
client indicates a correct understanding of safe medication administration?
A "I will keep a record of chest pain occurrences now that I have this patch."
B "I will remove the old patch and cleanse the area before applying a new patch."
C "This drug can lead to hypertension. So, I will monitor my blood pressure at home."
D "I can place this patch on broken skin. It will absorb better."

Question Explanation
Correct Answer is B
Rationale: Numerous administration errors have been reported with nitroglycerin paste and
patches. The errors include improper storage and basic administration. The client should be
taught to remove the previous patch before applying the new patch and to properly label the tube
of nitroglycerin paste and keep it out of the reach of children. When selecting an area to place the
patch, the skin should be intact and show no signs of irritation. Nitroglycerin paste has been used
erroneously as lotion and caused toxic effects. Nitroglycerin causes vasodilation, which increases
the blood supply through the coronary arteries. This may cause hypotension in clients. Some
other common side effects include lightheadedness, nausea, dizziness, headache and redness or
irritation of the skin covered by the patch.
Concepts tested

Question 2121
The nurse is caring for a client who received tenecteplase to open an occluded coronary artery.
Which finding should be of the highest concern for the nurse?
A Bleeding gums
B Urinary retention
C Hematemesis
D Epistaxis

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Question Explanation
Correct Answer is C
Rationale: Tenecteplase, a thrombolytic agent, breaks down a thrombus by stimulating the
plasmin system. The plasmin system is a natural anticlotting system, which breaks down fibrin
and dissolves any clots. Since this medication is not specific to a certain type of clot, the client
should be expected to have an increased bleeding risk after administration. The most common
adverse effect of thrombolytic medications is bleeding and hemorrhage. The nurse should
monitor the client for signs and symptoms of abnormal bleeding. Hematemesis means vomiting
blood. This is usually related to a bleeding gastric ulcer and should be of the highest concern.
Epistaxis (nose bleed) and bleeding gums are usually minor bleeding and can be easily
monitored by the nurse.
Concepts tested

Question 2122
The nurse is caring for a client who is receiving isoniazid for tuberculosis (TB). Which
assessment finding would indicate the client is having a possible adverse response to this
medication?
A Tinnitus and decreased hearing
B Headache and nausea
C Tingling in extremities
D Yellowing of the sclera

Question Explanation
Correct Answer is D
Rationale: Isoniazid is a first-line anti-tuberculosis drug that is used as part of the combination
therapy for the treatment of tuberculosis. These first-line medications may be used for up to 2
years in clients who are being treated for tuberculosis. The use of long-term combination
treatment increases the effectiveness and decreases the occurrence of resistant strands. Clients
receiving this medication are at risk for drug-induced hepatitis. The appearance of jaundice may
indicate an elevation of the client's serum bilirubin levels and liver enzymes (AST and ALT). A
small number of clients taking isoniazid develop severe hepatitis that may progress to liver
failure and death unless the medication is stopped immediately. Other common side effects
include nausea and tingling in the extremities. This medication is not ototoxic and does not affect
hearing.
Concepts tested

Question 2123
The nurse is providing discharge education to a client newly diagnosed with chronic obstructive
pulmonary disease. The client is prescribed the Diskus inhaler Advair (fluticasone propionate
and salmeterol). The client asks, "How will I know when the inhaler is empty?" How should the
nurse respond?
A Shake the canister to detect any fluid movement
B The number of doses that remain will be on the inhaler
C Estimate how many doses are usually in the canister
D Drop the canister in water to observe floating

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Question Explanation
Correct Answer is B
Rationale: There are several methods to monitor the contents of an inhaler. New MDIs such as
Diskus inhalers often have counters on them. The counters record the number of doses left in the
canister. If the MDI does not have this feature, the client should write the date a refill is needed.
This can be done directly on the canister in a permanent marker. Manufacturers do not
recommend floating inhalers. The shaking or estimation method will not be accurate.
Concepts tested

Question 2124
The nurse is preparing to administer digoxin to a client admitted for acute decompensated heart
failure. Which action is the priority before giving this drug?
A Auscultate the lungs for crackles in the bases
B Monitor oxygen saturation on room air
C Assess the apical pulse for a full minute
D Assess the client's weight and compare to the baseline

Question Explanation
Correct Answer is C
Rationale: Digoxin, a cardiac glycoside, is used to slow the heart rate and increase the force of
contraction. The priority for the nurse is to count the client's apical pulse for one full minute even
if the heart rhythm is regular. Typically, when the pulse is less than 60, digoxin should not be
given. The other actions are also appropriate assessments for a client with heart failure.
However, they are not the priority when administering digoxin.
Concepts tested

Question 2125
The nurse is caring for an 81-year-old client with colorectal cancer. Previously, the client's pain
was managed with acetaminophen with codeine. However, the client is now experiencing
frequent, severe pain, and intravenous morphine has been prescribed. What should the nurse
recognize about this order?
A Appropriate despite the risk of diarrhea and abdominal upset
B Appropriate pain management and should be available around the clock
C Inappropriate and demonstrates lack of knowledge related to pain control
D Inappropriate due to the potential of respiratory depression

Question Explanation
Correct Answer is B
Rationale: Older adults with cancer pain are frequently undermedicated. Pain management with
IV morphine, while risky, is appropriate with proper assessment and monitoring of the client.
The client should be started on the lowest effective dose, and the pain should be re-evaluated
after administration. The nurse should assess the client for respiratory depression, constipation,
and altered mental status.
Concepts tested

Page | 870
Question 2126
The nurse is caring for a client who is prescribed erythromycin 500 mg orally every six hours for
the treatment of pneumonia. The nurse should monitor the client for which common side effect?
A Tendon rupture
B Nausea and vomiting
C Esophagitis
D Orange-red discoloration of urine

Question Explanation
Correct Answer is B
Rationale: Erythromycin is a macrolide anti-infective medication used that interferes with
protein synthesis in susceptible bacteria. Nausea, vomiting, and gastrointestinal (GI) upset are
common with erythromycin. The other side effects are not commonly seen with this drug.
Concepts tested

Question 2127
The nurse is providing care for a client diagnosed with a sickle cell crisis. Which prescribed
medication should the nurse clarify with the health care provider?
A Hydromorphone
B Meperidine
C Morphine
D Codeine

Question Explanation
Correct Answer is B
Rationale: Meperidine, an older opioid analgesic, is not recommended in clients with sickle cell
disease. Normeperidine, a metabolite in meperidine, is a central nervous system stimulant that
produces anxiety, tremors, myoclonus, and generalized seizures when it accumulates in the
client's system. Clients with sickle cell disease are at high risk for normeperidine-induced
seizures.
Concepts tested

Question 2128
The nurse is providing discharge education to a client with moderate persistent asthma. The
nurse should instruct the client to administer which medication first?
A Mast cell stabilizer
B Anticholinergic
C Bronchodilator
D Glucocorticoid

Question Explanation
Correct Answer is C
Rationale: Bronchodilators, such as albuterol, are beta-agonist drugs that relieve bronchospasm
by relaxing the smooth muscle of the airway. These medications should be inhaled first to open

Page | 871
the airways, which will allow the other medications to move more deeply into the lungs and
increase their effectiveness.
Concepts tested

Question 2129
The nurse is teaching a group of clients diagnosed with arthritis about the use of non-steroidal
anti-inflammatory agents (NSAIDs). In order to minimize the side effects of these drugs, which
action should the nurse emphasize?
A Eat a diet high in fiber
B Take the medication with food
C Take the drug with an antacid
D Limit foods high in vitamin K

Question Explanation
Correct Answer is B
Rationale: A common side effect of NSAIDs is gastrointestinal distress including heartburn,
nausea, and stomach pain. Taking the medication with food will decrease this side effect. The
other actions are not appropriate or indicated when taking NSAIDs.
Concepts tested

Question 2130
A client with schizophrenia is receiving haloperidol 2 mg orally three times a day. The client
approaches the nurse's station presenting with eyes rolled upward towards the head. The nurse
recognizes this finding as what type of side effect?
A Oculogyric crisis
B Nystagmus
C Tardive dyskinesia
D Dysphagia

Question Explanation
Correct Answer is A
Rationale: Oculogyric crisis is an acute dystonic reaction caused by some antipsychotic
medications, including haloperidol. Tardive dyskinesia is also caused by antipsychotic
medications but typically affects the muscles of the tongue, lips, jaw, and limbs. Nystagmus is an
involuntary eye movement, and dysphagia is when one has difficulty swallowing. Neither of
these conditions is directly caused by antipsychotic medications.
Concepts tested

Question 2131
A client is prescribed a new antipsychotic medication. The nurse is teaching the client about
possible side effects including tardive dyskinesia (TD). Which statement is accurate about
tardive dyskinesia?
A TD occurs within minutes of the first dose of any antipsychotic drug
B The high fever, sweating, and muscle stiffness will last about one week

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C The longer someone is treated with an antipsychotic medication, the higher the risk for
developing TD
D Almost every client treated with antipsychotic medications will eventually develop TD

Question Explanation
Correct Answer is C
Rationale: Long-term use of certain antipsychotic medications puts the client at a higher risk of
developing TD. The symptoms are characterized by spastic movements of certain muscles,
including the tongue, lips, jaw, and limbs. Early recognition by the health care provider,
including the use of the Abnormal Involuntary Movement Scale (AIMS) is key. Once
irreversible, there are now drug treatments, such as valbenazine, to treat the condition. It is
estimated that up to 30 percent of clients taking antipsychotic medication will develop TD. The
combination of high fever, sweating, and muscle stiffness indicates neuroleptic malignant
syndrome, not TD.
Concepts tested

Question 2132
The client is using nonsteroidal anti-inflammatory drugs (NSAIDs) to manage arthritis pain. The
nurse should caution the client about which potential side effect?
A Constipation
B Nystagmus
C Urinary incontinence
D Occult bleeding

Question Explanation
Correct Answer is D
Rationale: Nonsteroidal anti-inflammatory drugs (NSAIDs) taken for long periods of time may
cause serious side effects including bleeding in the gastrointestinal tract. Clients should be
instructed to take the medication with meals if stomach upset occurs. To avoid esophageal
irritation, the client should take the drug with a full glass of water and avoid lying down for 30 to
60 minutes after taking a dose.
Concepts tested

Question 2133
A client with an intravenous (IV) antibiotic infusing is scheduled to have blood drawn at 1:00 pm
for a peak antibiotic level measurement. The nurse notes that the IV infusion is running behind
schedule and won't be completely infused until 1:30 pm. What action should the nurse take?
A Increase the infusion rate to finish it by 1:00 pm
B Reschedule the laboratory test for 2:00 pm
C Notify the client's health care provider
D Stop the infusion at 1:00 pm and get the blood drawn

Question Explanation

Page | 873
Correct Answer is B
Rationale: If the antibiotic infusion will not be completed at the time the peak blood level is
scheduled to be drawn, a nurse should ask that the blood sampling time be adjusted. Typically
the peak level should be drawn about 30 to 60 minutes after completion of the infusion. The
infusion should not be increased because in this situation the volume of fluid to be infused is
unknown; rates for IV infusions should not be increased or decreased by more than 10% of the
ordered rate. Trough and/or peak levels are commonly drawn for aminoglycosides (such as
vancomycin, gentamicin, and tobramycin.)
Concepts tested

Question 2134
A client is admitted with a tentative diagnosis of left-sided heart failure. Which assessment
finding is consistent with this diagnosis?
A Cyanosis
B Heart murmur
C Chest pain
D Inspiratory crackles

Question Explanation
Correct Answer is D
Rationale: Signs and symptoms of HF are related to the ventricle most affected. Left-sided heart
failure affects the left ventricular function. Crackles that do not clear with coughing are an early
sign of left-sided heart failure. As pulmonary congestion increases, crackles become more
pronounced. Oxygen saturation may decrease at this time.
Concepts tested

Question 2135
A hospitalized infant is receiving gentamicin. While monitoring for drug toxicity, the nurse
should focus on which laboratory result?
A Serum creatinine
B Growth hormone levels
C Thyroxin levels
D Platelet counts

Question Explanation
Correct Answer is A
Rationale: Toxicity to the aminoglycoside antibiotic gentamicin is seen in increased BUN and
serum creatinine levels. Kidney damage may be reversible if the drug is stopped at the first sign
of toxicity. In addition to nephrotoxicity, this medication has a Black Box warning for
neurotoxicity and ototoxicity.
Concepts tested

Question 2136
A client is being discharged with a prescription for an iron supplement. Which client statement
indicates the need for further teaching by the nurse?
Page | 874
A "I will take vitamin C along with the iron supplement."
B "I will take the iron supplement with a full glass of milk."
C "I will not take antacids with my iron supplement."
D "I will have greenish-black stools from the medication."

Question Explanation
Correct Answer is B
Rationale: Iron supplements should be taken along with vitamin C, such as orange juice because
this increases absorption. Conversely, antacids, milk, caffeinated beverages, and calcium
supplements can decrease the absorption of iron. Iron should be taken one hour before or two
hours after meals to enhance absorption, although clients who report gastrointestinal intolerance
may take it with food. Iron will cause stool to turn greenish-black and tarry.
Concepts tested

Question 2137
A client stung by a bee presents to the emergency department with difficulty breathing and
swelling of the tongue. Which medication should the nurse anticipate to administer?
A Diphenhydramine subcutaneous route
B Methylprednisolone oral route
C Epinephrine intravenous route
D Albuterol via nebulizer

Question Explanation
Correct Answer is C
Rationale: Difficulty breathing and swelling of the face, eyes, or tongue are severe and life-
threatening allergic reactions to the bee sting. Epinephrine, 0.3-0.5 mL of a 1:1000 solution,
should be administered immediately. The other medications are typically given as secondary
interventions to help with bronchoconstriction and histamine release.
Concepts tested

Question 2138
The nurse is teaching a client about an oral hypoglycemic medication. The nurse should
place priority emphasis on which of the following points?
A Distinguishing signs and symptoms of hypoglycemia and hyperglycemia
B Taking the medication at specified times
C Adherence with recommended diet plan
D Consulting with the health care provider about dose changes based on blood glucose

Question Explanation
Correct Answer is B
Rationale: A regular interval between doses should be maintained because oral hypoglycemics
simulate the islets of Langerhans to produce insulin. If doses are not spaced correctly, insulin
levels may increase, causing hypoglycemia, or decrease, causing hyperglycemia. The other
actions are important and would be discussed after this initial point.
Concepts tested

Page | 875
Question 2139
A client begins treatment with rifampin for suspected pulmonary tuberculosis. Which
information should the nurse include when teaching the client about this drug?
A "Avoid prolonged exposure to the sun while taking this drug."
B "You may notice an orange-red color to your urine."
C "Check your radial pulse before taking the drug."
D "It is important to stay upright for 30 minutes after taking this drug."

Question Explanation
Correct Answer is B
Rationale: Rifampin can cause a harmless reddish-orange discoloration of urine, feces, saliva,
sweat, tears, skin, and even contact lenses. This effect can be very alarming for the client who
may interpret it as some sort of bleeding. Understanding that this is a normal effect will promote
adherence. The other instructions are not indicated when taking rifampin.
Concepts tested

Question 2140
A nurse is caring for a child who will be started on heparin therapy. Which assessment is
a priority for the nurse to make before initiating this therapy?
A Weight
B Lung sounds
C Vital signs
D Skin turgor

Question Explanation
Correct Answer is A
Rationale: The dosage of anticoagulant therapy in children is calculated on the basis of weight
(weight-based calculation).
Concepts tested

Question 2141
The health care provider writes a new order for a fentanyl patch to manage chronic pain
experienced by a client in hospice care. The nurse is teaching the client and family members
about the fentanyl patch and knows that teaching was effective when the client makes which of
the following statements? Select all that apply.
A "I can soak in a hot tub to help decrease my pain."
B "If my pain is too great while I am on the patch, I can take a supplemental pain medication."
C "I should cut up the patch before I throw it away so no one else can use it."
D "It may take up to a half day or longer for the patch to start working the first time I use it."
E "I will take the old patch off before I apply the new patch on."

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Question Explanation
Correct Answer is B, D, E
Rationale: Fentanyl patches are slowly absorbed via the subcutaneous tissue at a predetermined
rate for up to 72 hours. Due to the slow absorption rate, the first patch may take 12 to 24 hours
before effective analgesia is felt; a short-acting opioid may be given for breakthrough pain. The
client can shower or bathe with the patch, but it should not be exposed to heat (hot tubs, heating
pads) because it speeds up the absorption of the medication. Old patches are removed and the
new patch is applied to a different skin area. Old patches are disposed of by folding the old patch
in half, not by cutting them up and throwing them in the trash (which may be dangerous for
people and pets).
Concepts tested

Question 2142
A toddler ingested half a bottle of aspirin tablets. Which finding should the nurse expect to see in
this child?
A Epistaxis
B Dyspnea
C Edema
D Hypothermia

Question Explanation
Correct Answer is A
Rationale: A large dose of aspirin inhibits prothrombin formation and lowers platelet levels.
With an overdose, clotting time is prolonged. Spontaneous bleeding often occurs from the nose
or mucous membranes in the mouth. The other choices are not symptomatic of prolonged
clotting time.
Concepts tested

Question 2143
A nurse has asked a second nurse to sign for a wasted narcotic. The waste was not witnessed by
the second nurse. What is the appropriate initial action?
A Report the situation immediately to the nurse manager or nursing supervisor
B Counsel the colleague about this risky behavior
C Confront the nurse about suspected drug use
D Sign the narcotic sheet then document the event in an incident report

Question Explanation
Correct Answer is A
Rationale: The incident must be reported to either the unit nurse manager or, if not available, the
nursing supervisor on duty. It is not the responsibility of the nurse to determine how or why the
event occurred nor to conduct any sort of confrontation or counseling. Not having witnessed the
waste then signing the narcotic sheet is a breach of protocol and policy. While an incident report
should be completed, it does not directly address the issue at hand.
Concepts tested

Question 2144
Page | 877
To which nursing home resident could a nurse safely administer tricyclic antidepressants (TCAs)
without questioning the health care provider's order?
A A client with coronary artery disease (CAD)
B A client with benign prostatic hypertrophy (BPH)
C A client with narrow-angle glaucoma
D A client with mild hypertension

Question Explanation
Correct Answer is D
Rationale: Tricyclics can be safely administered to the hypertensive client. The expected
anticholinergic effects of tricyclic antidepressants include difficulty in urination, which is why
TCAs are contraindicated with BPH. TCAs are also contraindicated in narrow-angle glaucoma
(they can cause elevated pressure in the eyes) and for certain heart abnormalities.
Concepts tested

Question 2145
The health care provider orders trazodone ER 150 mg at bedtime. Which common side effect of
this drug should the client understand?
A Relieves nasal stuffiness
B Reduces arthritic pain
C Decreases acne breakouts
D Causes drowsiness

Question Explanation
Correct Answer is D
Rationale: Trazodone is an antidepressant medication that produces drowsiness, so it is ordered
at bedtime. In addition to treating depression, it targets the symptom of insomnia often
experienced by clients who are depressed. Other common side effects of trazodone include dry
mouth, stuffy nose, constipation or change in sexual interest/ability. The other choices are not
side effects of this medication.
Concepts tested

Question 2146
A nurse is caring for a client with a new order for bupropion hydrochloride for treatment of
depression. The order reads "Wellbutrin 175 mg PO twice a day for four days." What is the
appropriate action?
A Monitor neurologic signs frequently
B Observe the client for mood swings
C Question this medication dose
D Give the medication as ordered

Question Explanation
Correct Answer is C

Page | 878
Rationale: Bupropion should be started at 100 mg twice a day for three days then increased to
150 mg twice a day. When used for depression, it may take up to four weeks for effective results.
Common side effects are dry mouth, headache, and agitation. Doses should be administered in
equally spaced time increments throughout the day to minimize the risk of seizures.
Concepts tested

Question 2147
A client is being treated with long-term, low-dose glucocorticoids for an autoimmune disorder.
Which physical change should the nurse expect to see with this client?
A Jaundice
B Hirsutism
C Ascites
D Buffalo hump

Question Explanation
Correct Answer is D
Rationale: Long-term use of glucocorticoids can lead to Cushing's syndrome. Physical changes
with Cushing's include weight gain, increased blood glucose, acne, thinning of the skin, easy
bruising, and changes in body shape, such as a hump behind the shoulders due to the
accumulation of fat on the back of the neck. This is commonly referred to as a "'buffalo hump".
Jaundice, hirsutism, and ascites are not typically seen with long-term
corticosteroid/glucocorticoid therapy.
Concepts tested

Question 2148
A client with cirrhosis of the liver asks the nurse about the purpose of taking lactulose. How
should the nurse respond?
A "It is used to control portal hypertension."
B "It helps to reduce ammonia levels in your blood."
C "It helps to regenerate your liver."
D "It adds dietary fiber to your diet."

Question Explanation
Correct Answer is B
Rationale: Lactulose is a synthetic disaccharide that can be given orally or rectally. It blocks the
absorption and production of ammonia from the gastrointestinal tract, reducing serum ammonia
levels, and is used to treat hepatic encephalopathy. The other answers are incorrect.
Concepts tested

Question 2149
A client with chronic obstructive pulmonary disease (COPD) is receiving aminophylline 25
mg/hour intravenously (IV). Which finding would be associated with the side effects of this
medication?
A Pruritus
B Restlessness and palpitations

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C Flushing and headache
D Decreased urine volume

Question Explanation
Correct Answer is B
Rationale: Aminophylline is a bronchodilator often used to treat symptoms of asthma, bronchitis,
and emphysema. Side effects include restlessness, palpitations, chest pain or discomfort,
increased urine volume, vertigo, and vomiting. The other choices are not side effects of this drug.
Concepts tested

Question 2150
A client diagnosed with bipolar disorder is reluctant to take lithium as prescribed. Which
response should the nurse make in this situation?
A "If you refuse your medicine, we'll just have to give you a shot."
B "What is it about the medicine that you don't like or are concerned about?"
C "I can see that you are uncomfortable right now. I'll wait until tomorrow to discuss this with
you."
D "You need to take your medicine. This is how you will get well."

Question Explanation
Correct Answer is B
Rationale: This response validates the client’s feelings and is exploring concerns. It should
generate therapeutic dialogue between the client and nurse. It provides an opportunity for the
nurse to teach the client about lithium. Telling the client an injection will be given is coercive
and incorrect since lithium does not come in an injectable form, and the client’s behavior does
not indicate aggression or need for another as-needed medication. Waiting until tomorrow is not
a viable option as the client does need to take this medication, which needs to reach a therapeutic
serum level. Advising the client to take the medication in order to get well is vague and does not
validate feelings or explore concerns.
Concepts tested

Question 2151
A nurse is teaching parents of a child recently prescribed the medication phenytoin for seizure
control. Which side effect will the nurse include?
A Gingival hyperplasia
B Insomnia
C Hypertension
D Increased appetite

Question Explanation
Correct Answer is A
Rationale: Gingival hyperplasia (overgrowth of the gums) is a common side effect of phenytoin.
Other common side effects include ataxia, central nervous system depression, drowsiness,
headache, hypotension, mental confusion, nausea, vomiting, rash, and nystagmus.
Concepts tested

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Question 2152
A nurse is administering lidocaine to a client with a myocardial infarction. Which assessment
finding requires the nurse's immediate action?
A Central venous pressure reading of 9 mmHg
B Respiratory rate of 22
C Pulse rate of 48 beats per minute
D Blood pressure of 144/92

Question Explanation
Correct Answer is C
Rationale: Lidocaine can cause significant bradycardia and hypotension. A pulse of 48 beats per
minute needs immediate attention and is often treated with atropine. At this time, the respiratory
rate of 22 and blood pressure of 144/92 should be monitored. A normal central venous pressure
ranges from 4 to 12 mm Hg. A central venous pressure above 12 may indicate hypervolemia or
cardiac failure.
Concepts tested

Question 2153
A client is being discharged with a prescription for warfarin. Which information
is most important to be included in the nurse's discharge teaching?
A Use a soft toothbrush
B Take acetaminophen for minor pain
C Report nose or gum bleeding
D Avoid eating leafy green vegetables

Question Explanation
Correct Answer is C
Rationale: The most important teaching is to make sure that the client understands to report any
sign of bleeding, including nose or gum bleeding, blood noted in stools or urine, coughing up
blood, or easy bruising. Dark green leafy vegetables are high in vitamin K which can lower the
effectiveness of warfarin (Coumadin). Acetaminophen does not contain aspirin, which can cause
internal bleeding so is safe to use when taking warfarin. A soft toothbrush will be less irritating
to the gums and therefore decrease the risk of bleeding gums. Although green leafy vegetables
contain vitamin K, it is no longer recommended to avoid them but to keep their intake consistent.
Concepts tested

Question 2154
A nurse is caring for a client several days after a cerebral vascular accident (CVA). Coumadin
has been prescribed. Today's prothrombin level is 40 seconds. Which finding requires priority
follow-up?
A Pharyngitis
B Gum bleeding
C Anorexia
D Generalized weakness

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Question Explanation
Correct Answer is B
Rationale: Coumadin is an anticoagulant. The normal range of the prothrombin level is 10 to 14
seconds. This prothrombin level is elevated indicating the blood is taking longer to clot and
presents a risk of internal bleeding. Generalized weakness post CVA is a normal finding. A sore
throat (pharyngitis) and loss of appetite (anorexia) do not pose a serious risk at this time.
Concepts tested

Question 2155
A client with advanced liver disease has been taking rifaximin. Which assessment finding would
indicate that the medication is being effective?
A Less jaundice
B Increased appetite
C Less edema
D Less confusion

Question Explanation
Correct Answer is D
Rationale: Clients with advanced liver disease experience elevated serum ammonia levels, which
typically lead to hepatic encephalopathy. Signs and symptoms of hepatic encephalopathy include
personality changes, confusion, restlessness, and forgetfulness. Rifaximin is an antibiotic that
helps reduce ammonia levels and hepatic encephalopathy by stopping the growth of bacteria and
the production of ammonia in the GI tract. Lessening confusion would indicate that the
medication is being effective.
Concepts tested

Question 2156
A nurse is teaching a parent how to administer oral iron supplements to a 2-year-old child.
Which intervention should be included in the teaching?
A Administer the iron with your child's meals
B Add the medicine to a bottle of formula
C Give the medicine with orange juice and through a straw
D Stop the medication if the stools become tarry green

Question Explanation
Correct Answer is C
Rationale: Absorption of iron is facilitated in an environment rich in vitamin C. Because liquid
iron preparation will stain teeth, a straw should be used. Parents should be informed that dark,
tarry stools are expected outcomes of taking iron supplements. Iron is best absorbed on an empty
stomach, but it may be given after meals if the child experiences an upset stomach.
Concepts tested

Question 2157
Which prescribed medication for a client with chronic diarrhea should the nurse clarify with the
health care provider?
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A Psyllium (Metamucil) 2.1 grams daily
B Ferrous sulfate (Feosol) 325 mg daily
C Senna (Senokot) 1 tablet every day
D Diphenoxylate with atropine (Lomotil) as needed

Question Explanation
Correct Answer is C
Rationale: Patients with diarrhea would not need a stimulant laxative such as senna. Senna
[Senokot, Ex-Lax] is a plant-derived laxative that contains anthraquinones as active ingredients.
Stimulant laxatives stimulate intestinal motility and increase the amount of water within the
intestinal lumen producing a semifluid stool typically within 6 to 12 hours after administration.
The other medications are not contraindicated with diarrhea. Paradoxically, methylcellulose,
polycarbophil, and other bulk-forming laxatives can help manage diarrhea. Benefits derive from
making stools firmer and less watery.
Concepts tested

Question 2158
A nurse is caring for a client who is scheduled to receive a unit of packed red blood cells. Which
is an appropriate action by the nurse during the administration of the infusion?
A Limit the infusion time to a maximum of four hours
B Slow the rate of infusion if the client develops a fever or chills
C Store the packed red cells in the unit refrigerator while starting an intravenous (IV) line
D Assess vital signs every 15 minutes for the duration of the infusion

Question Explanation
Correct Answer is A
Rationale: Blood should never be infused for longer than four hours due to the risk of bacterial
growth in the bag. Similarly, once the blood has left the blood bank, it should never be stored in
an unapproved refrigerator. If the client develops fever or chills, the blood should be
immediately stopped, not slowed. Vital signs are typically checked every 15 minutes in the first
30 to 60 minutes of an infusion since most reactions occur within that time. After the first 30 to
60 minutes, vital signs should be checked at least hourly or per agency protocol until the
transfusion is complete.
Concepts tested

Question 2159
A client is prescribed trimethoprim/sulfamethoxazole for recurrent urinary tract infections.
Which information should the nurse include during client teaching?
A "Drink at least eight large glasses of water a day."
B "Stop the medication when your symptoms disappear."
C "A harmless skin rash may appear."
D Be sure to take the medication with food."

Question Explanation
Correct Answer is A

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Rationale: Trimethoprim/sulfamethoxazole (Bactrim) is a highly insoluble drug that can cause
crystalluria, and clients should drink plenty of fluids while taking this medication to lower the
risk of developing kidney stones. Increased fluid intake is also recommended with a UTI to
promote the "flushing out" of bacteria. The drug may be taken with or without food. Clients
should take the medication for the prescribed length of time. Sulfonamide-containing products
should be discontinued at the first appearance of skin rash. In rare instances, a skin rash may be
followed by a more severe reaction, such as Stevens-Johnson syndrome or toxic epidermal
necrolysis.
Concepts tested

Question 2160
The nurse is caring for a client with inflammatory bowel disease who admits to using
complementary therapies including herbal remedies and peppermint tea. Which of the following
statements should the nurse make?
A "I would suggest that you discontinue the use of these therapies as they may be dangerous."
B "These therapies are known to interfere with prescribed medications, so it is important to stop
using them."
C "It is important to inform your health care provider of the use of these therapies."
D "These therapies are probably not harmful but may be costing you unnecessary money."

Question Explanation
Correct Answer is C
Rationale: Some herbal remedies including peppermint tea and peppermint oil have been shown
to relieve symptoms of irritable bowel syndrome. However, they may interact with prescribed
medications. The health care provider needs to be aware of the use of all complementary and
integrative health therapies, so an informed decision can be made if it is safe to continue them or
not.
Concepts tested

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RISK OF REDUCTION
POTENTIAL
Question 2161
The nurse is caring for a client who received intravenous morphine for severe pain 15 minutes
ago. Which change in vital signs would be the priority for the nurse to follow up?
A Blood pressure decreased from 150/82 to 115/68 mmHg.
B Heart rate decreased from 112 to 82 beats per minute.
C Respiration decreased from 16 to 6 breaths per minute.
D Oxygen saturation has decreased from 98% to 95%.

Question Explanation
Correct Answer is C
Rationale: Clients who receive opioid analgesics should be closely monitored for adverse effects,
such as respiratory depression. The client’s respiratory rate indicates possible respiratory
compromise from intravenous morphine, and it is a priority for the nurse to closely monitor the
client’s respiratory status. The client's elevated blood pressure and heart rate prior to morphine
administration indicate the presence of pain and the change indicates therapeutic response. The
heart rate and blood pressure are within range to indicate adequate circulatory status in the client.
The client’s oxygen saturation should be maintained at 95% or higher, and the decrease is not a
priority finding at this time.
Concepts tested

Question 2162
The nurse is caring for a client who had a myocardial infarction 1 day ago and has a cardiac
output of 2 l/min. The nurse should monitor the client for which complication?
A Acute kidney injury
B Pulmonary embolism
C Deep vein thrombosis
D Bradycardia

Question Explanation
Correct Answer is A
Rationale: A cardiac output of 2 l/min indicates possible heart failure or cardiogenic shock
secondary to myocardial damage. The client is at high risk for end-organ damage, such as kidney
injury, and it is a priority for the client to be closely monitored for signs of acute kidney injury
such as oliguria and anuria.
Concepts tested

Question 2163

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A nurse is preparing to begin a 24-hour urine collection for a client. Which action will the nurse
perform to ensure accurate urine collection?
A Ask the client to void and include the urine in the collection
B Place a sign outside the client’s room indicating not to discard urine specimens
C Inform the client to empty their bladder and document the time in the medical record
D Instruct the client to discard the last urine before the collection time ends

Question Explanation
Correct Answer is C
Rationale: Recording the time the urine collection begins is a crucial step to obtaining an
accurate sample. The time should be easily accessible to other healthcare providers for continuity
of care. The first urine should be discarded. The urine collection begins after the first urine is
discarded. Placing a sign outside of the client’s room does not provide the client privacy. The
sign should be placed on the client’s bathroom door to remind the client not to discard their
urine. The last urine before the collection time ends should be included with the specimen for
analysis.
Concepts tested

Question 2164
The nurse is caring for a client with uncontrolled diabetes. Which of the following laboratory
values is consistent with this diagnosis?
A Serum blood glucose level of 108 mg/dl
B Glycosylated hemoglobin (Hgb A1C) of 5%
C Serum blood glucose level of 134 mg/dl
D Glycosylated hemoglobin (Hgb A1C) of 9%

Question Explanation
Correct Answer is D
Rationale: The best indicator of long-term glycemic control is a glycosylated hemoglobin (Hgb
A1C) level. A level greater than 6% is indicative of poor glycemic control; therefore, an Hgb
A1C value of 9% is consistent with uncontrolled diabetes.
Concepts tested

Question 2165
The nurse is teaching a client about the purpose of complete blood count (CBC) testing. Which
statement by the client indicates the need for further teaching?
A “This test will determine the microorganism that is causing my bacteremia.”
B “This test will determine if I have anemia.”
C “This test will measure if I have issues with blood clotting.”
D “This test will measure if I have an acute infection.”

Question Explanation
Correct Answer is A
Rationale: Complete blood counts measure white blood cell counts, hemoglobin and hematocrit
levels, red blood cell counts, and platelets. This can aid in determining if there is a presence of an

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active infection, clotting issues, or anemias. The test cannot determine specific organisms within
the blood; a blood culture is required to determine this.
Concepts tested

Question 2166
A nurse is reviewing the laboratory results of a client admitted with orthopnea, fatigue, and
frothy sputum. Which finding indicates a diagnosis of heart failure?
A PaO2 level of 75 mmHg
B INR level of 1.2
C BNP of 300 pg/ml
D WBC count of 12,000/mm³

Question Explanation
Correct Answer is C
Rationale: A brain natriuretic factor (BNP) of 300 pg/ml indicates heart failure. The normal
value is less than 100 pg/ml. BNP is a hormone produced by the ventricles of the heart and is
increased in response to ventricular pressure overload. A partial pressure of oxygen level (PaO2)
of 75 mmHg is not specific to heart failure. Low PaO2 levels may indicate a respiratory disorder.
An international normalized ratio (INR) level of 1.2 is not associated with a heart failure
diagnosis. INR levels are used to evaluate anticoagulation therapy. A white blood cell (WBC)
count of 12,000/mm³ is not indicative of heart failure. Elevated WBCs indicate an infectious
process.
Concepts tested

Question 2167
The nurse is caring for a client who has just been admitted to the acute care facility. Which of the
following findings indicate that the client is at risk for skin breakdown?
A Hematuria
B Abdominal pain
C Hypertension
D Diaphoresis

Question Explanation
Correct Answer is D
Rationale: Diaphoresis causes a client to be at risk for breakdown due to the excessive moisture
that the skin is exposed to. Hematuria does not indicate that the client is incontinent, just that
there is blood in the urine. Abdominal pain and hypertension are not directly related to skin
breakdown.
Concepts tested

Question 2168
The nurse is assessing a client at a follow-up appointment for diabetes management. Which of
the following assessments should be performed and compared to baseline data to evaluate the
progression of the condition?
A Otoscope examination

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B Sensory assessment of the feet
C Percussion of the abdomen
D Oxygen saturation

Question Explanation
Correct Answer is B
Rationale: Clients who have diabetes mellitus often develop peripheral neuropathy. The nurse
should assess the sensory perception of the feet and compare the findings to previous visit
assessment data. Otoscope examination and percussion of the abdomen are not assessments that
are directly related to diabetes. Oxygen saturation will most likely be assessed but does not
provide insight into the progression of diabetes mellitus.
Concepts tested
Question 2169
The nurse is caring for a client receiving total parenteral nutrition (TPN) who has a new
prescription to discontinue the infusion. The infusion is tapered off slowly to prevent which of
the following complications?
A Fluid volume deficit
B Electrolyte imbalance
C Hypoglycemia
D Protein calorie malnutrition

Question Explanation
Correct Answer is C
Rationale: TPN is a hypertonic solution containing protein, carbohydrates, and fats. Immediate
discontinuation may result in hypoglycemia, as the client’s insulin supply may become higher
than the glucose demand. Therefore, the infusion is tapered off slowly. Tapering off the infusion
will not prevent a fluid deficit, malnutrition, or electrolyte imbalance.
Concepts tested

Question 2170
The nurse has inserted an orogastric tube (OGT) into the client being mechanically ventilated via
an oral endotracheal tube. Which of the following interventions should be used to confirm the
initial placement of the OGT?
A Instill 30-ml of air into the tube while listening for the air over the epigastric region
B Aspirate 30-ml of gastric contents and use litmus paper to determine the pH
C Attach a colorimetric capnometer and assess for end-tidal CO2
D Obtain a chest radiograph to identify the end of the tube below the level of the diaphragm

Question Explanation
Correct Answer is D
Rationale: The old technique of auscultation of air injected into a gastric tube has proven
unreliable. With the exception of the chest x-ray, other methods should not be used for the initial
placement of gastric tubes but can be used thereafter. A radiograph is the gold standard for
identifying correct tube placement.
Concepts tested

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Question 2171
The nurse is developing the plan of care for a client with a peripheral venous access who is
receiving an infusion of prescribed IV fluids. Which intervention should the nurse implement to
prevent infiltration?
A Change the site dressing daily
B Rotate IV sites every 3 days
C Assess the site every 24 hours
D Secure the site with a stabilization device

Question Explanation
Correct Answer is D
Rationale: Infiltration occurs when the IV fluids leave the vascular space into the subcutaneous
tissues, often from a dislodged catheter. To prevent infiltration, the nurse should use a site-
stabilization device, assess the site every 4 hours, and keep tubing visible to prevent
dislodgement. Changing dressing daily could increase the risk for dislodging the catheter and
should only be done when visibly soiled.
Concepts tested

Question 2172
The charge nurse is observing a newly hired nurse apply bilateral sequential compression devices
(SCD) to assigned clients. It indicates correct understanding if the newly hired nurse is observed
applying SCDs to which of the following clients?
A The client who was admitted with sickle cell crisis
B The client who had a lumbar fusion and is on prescribed bedrest
C The client with diabetes who was admitted with gangrenous lower extremity ulcers
D The client who has been admitted with bilateral lower extremity venous thromboembolisms

Question Explanation
Correct Answer is B
Rationale: It indicates a correct understanding of SCD application if the nurse is observed
applying SCDs to the client with prescribed bedrest. SCDs should be used consistently for clients
with immobility to improve complications of immobility, such as reduced circulation and
possible thromboembolism. SCDs should not be placed on clients with known or suspected
venous thromboembolism as this could cause dislodgement of the clots. SCDs should not be
placed over open wounds or infections, and clients with sickle cell crisis should have all
restrictive clothing and devices removed in order to improve perfusion to all body areas,
including anti-embolism stockings, SCDs, and automatic blood pressure cuffs.
Concepts tested

Question 2173
The nurse has attended a staff education conference about
electroconvulsive therapy (ECT). Which of the following statements indicates a need for further
teaching?

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A “Clients will have 4 electrodes placed on their scalp, which deliver an electrical current and
monitor brain activity.”
B “General anesthesia is given during the procedure; therefore, cardiac and airway monitoring
is required.”
C “The procedure is performed in order to resolve seizure activity in clients with epilepsy.”
D “Clients may experience memory loss following the procedure, which may resolve over time.”

Question Explanation
Correct Answer is C
Rationale: It requires further teaching if the nurse states that the purpose of the procedure is to
resolve seizure activity in clients with epilepsy. The goal of ECT is to induce seizure activity in
the brain that may improve depression and bipolar disorder by affecting chemicals and neurons
in the brain. Clients will have 4 electrodes placed on their scalp: 2 for monitoring brain activity
and 2 for delivering an electrical current. General anesthesia is provided during the procedure,
and clients should be monitored closely for airway or cardiovascular compromise. Memory loss
is a common and temporary side effect of ECT.
Concepts tested

Question 2174
A nurse is assessing a client with a hemoglobin A1C level of 9.0%. The client reports feeling
“pins and needles” in their feet throughout the day. The nurse counsels the client on which
intervention to prevent neurological complications?
A Applying warm compresses to the feet
B Keeping glucose levels within normal range
C Inspecting the feet daily for any injuries
D Taking pain medication as prescribed

Question Explanation
Correct Answer is B
Rationale: The client’s symptoms and laboratory value are indicative of peripheral neuropathy
caused by diabetes mellitus. Controlling blood sugar levels can prevent peripheral neuropathy
from worsening. Applying warm compresses to the feet is not indicated for a client with
peripheral neuropathy. The client may sustain burns if unable to detect temperature changes.
Inspecting the feet daily for any injuries helps prevent delay in treatment; however, this alone
does not prevent peripheral neuropathy from worsening. Taking pain medication as prescribed
will help decrease the pain associated with peripheral neuropathy; however, it will not prevent
the condition from worsening.
Concepts tested

Question 2175
The nurse is caring for a client who is using pneumatic compression devices to promote venous
stasis after a surgical procedure. Which of the following statements by the client indicates an
effective response to this therapy?
A “These sleeves make my legs warm.”
B “I will take the device off when it becomes uncomfortable.”

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C “I don’t have any pain in my legs.”
D “My toes get numb when I wear these for a long time.”

Question Explanation
Correct Answer is C
Rationale: Pneumatic compression devices are designed to promote venous return and prevent
deep vein thrombosis. The client should not have pain with the use of this device. The devices
should be kept on for the majority of the day and only removed for assessments and ambulation.
Numbness of the toes and temperature changes of the extremities indicate that the devices may
not be working effectively.
Concepts tested

Question 2176
The nurse is caring for a client who is immobile. Which of the following locations is most
appropriate for the nurse to assess for peripheral edema?
A On the sternum
B Over the tibia
C Above the elbow
D Behind the knee

Question Explanation
Correct Answer is B
Rationale: Peripheral edema should be assessed over a bony area of an extremity, such as the
pretibial area. The sternum is not considered a peripheral site, and the areas above the elbow and
behind the knee often have adipose tissue that may make the assessment less accurate.
Concepts tested

Question 2177
The night shift nurse is caring for a client diagnosed with a hemorrhagic cerebrovascular
accident. The client has new onset confusion and is agitated. Which action would be a priority
for the nurse?
A Call the healthcare provider and suggest a CT scan
B Stay with the client and reorient them to the situation
C Administer the prescribed PRN anxiolytic
D Lower the lighting to promote relaxation.

Question Explanation
Correct Answer is A
Rationale: The priority intervention here is to obtain a CT scan to assess for further bleeding.
The client with new onset confusion may have increased ICP from blood in the brain.
Administering an anxiolytic may mask the signs of neurologic changes. Encouraging the client to
sleep may also delay identification and treatment of a medical emergency.
Concepts tested

Question 2178

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The nurse is caring for a client who is in a second-degree heart block and reports dizziness and
shortness of breath. The nurse notes the client's blood pressure is 90/40 mmHg. Which action
should the nurse take?
A Administer prescribed atropine
B Prepare for transcutaneous pacing
C Perform synchronized cardioversion
D Administer prescribed vasopressin

Question Explanation
Correct Answer is B
Rationale: A second-degree block occurs when the electrical conduction is interrupted, usually at
the AV node, and does conduct through the Purkinje fibers. This results in the failure of the
ventricles to contract, which decreases cardiac output. To treat a second-degree block, the nurse
should prepare the client for transcutaneous pacing, which will increase cardiac output.
Synchronized cardioversion is used to treat tachycardia dysrhythmias, such as SVT or atrial
fibrillation. Atropine contraindicating in treating a second-degree block. Vasopressin causes
vasoconstriction which increases blood pressure but will not treat second-degree block.
Concepts tested

Question 2179
A nurse is teaching a client how to do fecal occult blood testing. Which statement by the client
indicates a need for further teaching?
A "I will continue taking aspirin 81 mg daily."
B "I will refrain from eating raw fruits and vegetables."
C "I will avoid steak and other red meats."
D “I will avoid taking ferrous sulfate 24 hours before the test.”

Question Explanation
Correct Answer is D

Question 2180
The nurse has provided preoperative teaching to a client who is scheduled for surgery in 1 week.
Which of the following statements by the client indicates a correct understanding of the
teaching?
A “I will need to refrain from drinking any clear liquids for 1 hour before my surgery.”
B “I should arrive on the day of surgery with the site of surgery marked with a pen to avoid
surgical errors.”
C “I will be able to drive myself home following the procedure and can resume normal activities
that evening.”
D “I will need to cleanse my skin using an antiseptic solution 1 day before my procedure.”

Question Explanation
Correct Answer is D
Rationale: It indicates a correct understanding of the teaching if the client states that they will
need to cleanse the skin the day prior to the procedure to reduce risk of surgical site infection.

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Clear liquids must be held at least 2 hours prior to surgery and often much longer to reduce the
risk of aspiration while under anesthesia. The surgeon must mark the site of the surgical
procedure to reduce the risk of wrong-site surgical errors. Clients who receive sedation or
anesthesia must have a ride home and should not undergo regular activities for at least 24 hours,
and sometimes longer, depending on the procedure performed.
Concepts tested

Question 2181
The nurse is assessing vital signs on a group of assigned clients. Which client should the nurse
see first?
A The client with dehydration who has a blood pressure that has increased from 90/48 mmHg to
98/52 mmHg
B The client with chronic obstructive pulmonary disease (COPD) who has an oxygen saturation
of 93% on 2 l oxygen via nasal cannula
C The client who had a permanent pacemaker placed 1 day ago and has a pulse that has
decreased from 60 to 48 beats per minute
D The client who has bacterial pneumonia and has a temperature of 101.1&deg;F
The client who has bacterial pneumonia and has a temperature of 101.1°F

Question Explanation
Correct Answer is C
Rationale: It is a priority for the nurse to follow up with a client who had a permanent pacemaker
placed and has developed bradycardia as this may indicate the pacemaker is failing to capture.
The client with dehydration is showing improvement in their condition with increased blood
pressure. The client with COPD has an oxygen saturation within the normal range for their
condition. The client with a fever from pneumonia is exhibiting expected findings from their
condition.
Concepts tested

Question 2182
The nurse is caring for a client who had a coronary artery bypass graft (CABG) 1 day ago and
has a pulmonary capillary wedge pressure (PCWP) of 20 mmHg. The nurse should monitor the
client for which complication?
A Pulmonary edema
B Hemorrhage
C Hypovolemia
D Tachycardia

Question Explanation
Correct Answer is A
Rationale: A PCWP value of 20 mmHg is elevated and indicates left ventricular failure. Clients
with acute left ventricular failure are at risk for developing acute pulmonary edema and
subsequent respiratory compromise; therefore, it is a priority to monitor this complication based
on the PCWP values.
Concepts tested

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Question 2183
A nurse is preparing to implement continuous external fetal monitoring on a client in labor.
Which action will the nurse perform to ensure accurate fetal monitoring?
A Apply the ultrasound transducer above the level of the xyphoid process
B Instruct the client not to change positions while in bed
C Inform the client that a vaginal examination will be performed
D Secure the tocotransducer at the level of the uterine fundus

Question Explanation
Correct Answer is D
Rationale: The tocotransducer should be secured at the level of the uterine fundus. The
tocotransducer measures the frequency and duration of uterine contractions. The ultrasound
transducer should be placed at the level of maximal fetal heart rate intensity, usually below the
level of the umbilicus on a client in labor. The client should be encouraged to change positions
frequently. The nurse should adjust the transducers accordingly. External fetal monitoring is not
invasive. A vaginal examination is not indicated.
Concepts tested

Question 2184
The nurse is caring for a client with respiratory acidosis. Which of the following arterial blood
gas values is consistent with this diagnosis?
A pH of 7.37
B PCO2 of 50 mm Hg
C PaO2 of 90 mmHg
D HCO3 of 25 mEq/l

Question Explanation
Correct Answer is B
Rationale: Clients with respiratory acidosis often have elevated partial pressure carbon dioxide
levels. Levels of PCO2 greater than 45 mm Hg indicate possible respiratory acidosis. Normal pH
is 7.35 to 7.45, normal PaO2 is above 75 mmHg, and normal HCO3 is 22-26 mEq/l.
Concepts tested

Question 2185
The nurse is accessing an implanted port for blood specimen collection. Which action should the
nurse take?
A Place the non-coring (Huber) needle at a 90-degree angle to access the port Correct Answer
B Clean the port with sterile water before accessing the port
C Instill 20 mL of heparin into the port after accessing the port
D Don a gown, gloves, and a mask prior to starting the procedure

Question Explanation
Rationale: The nurse should access the implanted port using a non-coring (Huber) needle
inserted at a 90-degree angle. Ports should have 10 ml of heparin instilled or flushed with normal
saline after accessing the port for blood specimens. Masks should be worn prior to accessing the

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port, but a gown is not required. Ports should be cleansed with chlorhexidine solution prior to
accessing the port.
Concepts tested

Question 2186
A nurse is reviewing laboratory results of a client with chronic kidney disease. Which finding
does the nurse expect to see on the report?
A BUN level of 19 mg/dl
B Potassium level of 3.1 mEq/l
C Hematocrit level of 39%
D Creatinine level of 4.5 mg/dl

Question Explanation
Correct Answer is D
Rationale: A creatinine level of 4.5 mg/dl is indicative of chronic kidney disease (CKD). The
normal creatinine level ranges from 0.5 to 1.3 mg/dl. Creatinine levels evaluate renal function. A
blood, urea, nitrogen (BUN) level of 19 mg/dl is a normal finding. BUN levels are expected to be
elevated in clients with CKD. A potassium level of 3.1 mEq/l is not consistent with chronic
kidney disease. Potassium levels are expected to be elevated with CKD. The normal potassium
level is 3.5 to 5.0 mEq/l. A hematocrit level of 39% is a normal finding. Hematocrit levels are
expected to be decreased in clients with CKD.
Concepts tested

Question 2187
The nurse is completing an initial assessment on a client in the acute care facility. Which of the
following findings should the nurse recognize as a risk factor for skin breakdown?
A Immobility
B Tattoos
C Facial asymmetry
D Memory loss

Question Explanation
Correct Answer is A
Rationale: The client who is immobile is at an increased risk for skin breakdown because they
often put pressure on bony prominences. Tattoos, facial asymmetry, and memory loss do not
directly affect the likelihood of skin breakdown.
Concepts tested

Question 2188
The nurse is caring for a client who has an indwelling urinary catheter. Which of the following
findings requires additional assessment?
A Straw colored urine is in the drain tube.
B One hundred ml of urine are in the drainage bag.
C Urine in the drain tube is cloudy.

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D Urinary output does not have an odor.

Question Explanation
Correct Answer is C
Rationale: Cloudy urine may indicate the presence of infection and requires additional
assessment. Odorless, straw-colored urine and an output of 100 ml are normal assessment
findings.
Concepts tested

Question 2189
The nurse is preparing to remove a peripheral intravenous catheter from a client who is taking
prescribed clopidogrel due to a cerebrovascular accident. Which of the following actions is
appropriate?
A Apply pressure to the site for a longer period
B Leave the catheter in until the clopidogrel is discontinued
C Elevate the extremity after removal
D Use a warm compress on the insertion site

Question Explanation
Correct Answer is A
Rationale: When peripheral venous access is no longer required or when the insertion site shows
signs of local complications, the nurse assumes responsibility for discontinuing the access
device. Apply pressure immediately to the area just above the insertion site until hemostasis is
achieved. The time will be prolonged in clients receiving a platelet aggregate inhibitor, such as
clopidogrel but will occur. Leaving the catheter in increases the risk of other complications, such
as infection or thrombosis. Elevation and warm heat are used for infiltration.
Concepts tested

Question 2190
The nurse is preparing to insert a nasogastric tube in an adult client. The nurse should take what
action to determine the length of tube to be inserted?
A Place the tube at the tip of the nose and measure by extending the tube to the earlobe and
down to the xiphoid process
B Place the tube at the tip of the nose and measure by extending the tube to the earlobe and
down to the top of the sternum
C Place the tube at the earlobe and measure by extending to the nose and then down to the top of
the sternum
D Place the tube at the earlobe and measure by extending to the nose and down to the xiphoid
process

Question Explanation
Correct Answer is A
Rationale: When a nurse is preparing to insert a nasogastric tube, the nurse will need to measure
the client for the length of the tube. This length is an estimate of how far the nurse should insert
the tube into the nasal passage, passing through into the stomach. Adequate measuring ensures

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that the tube is placed in the stomach and not in the airway or left in the esophagus. To measure
the tube length, the nurse will place the tube at the tip of the client's nose and extend the tube to
the earlobe, and then down to the xiphoid process. The remaining options identify incorrect
procedures for measuring the length of the tube.
Concepts tested

Question 2191
The nurse is assessing the peripheral IV site for a client who is receiving an infusion of
prescribed antibiotics and is reporting pain at the site. The nurse notes the IV site has a red streak
and a palpable venous cord. Which action should the nurse take first?
A Complete a client occurrence form
B Document findings and actions in the electronic health record
C Change the IV insertion site to a new location
D Stop the infusion of the medication immediately

Question Explanation
Correct Answer is D
Rationale: When the site is red and painful, it indicates phlebitis. The medication needs to be
immediately stopped and the site needs to be discontinued. If the client still needs the
medication, a new IV site needs to be started after the previous one has been discontinued. All
actions related to the IV site need to be documented, but it is not first. A client occurrence form
is not needed - just documentation in the electronic health record.
Concepts tested

Question 2192
The nurse is preparing to apply newly prescribed knee-length anti-embolism stockings for a
client. Which of the following nursing actions requires follow-up?
A Measuring the length of both legs from the heel to the popliteal space
B Assessing the client for presence of pain in the calf with dorsiflexion of the foot
C Measuring the circumference of the calf at the narrowest point
D Assessing the client’s skin temperature, color, and skin condition prior to application of the
stockings

Question Explanation
Correct Answer is C
Rationale: It requires follow-up if the nurse is observed measuring the client’s calf at the
narrowest point. The correct technique for selecting the appropriate size anti-embolism stocking
is to measure from the heel to the popliteal space and the circumference of the calf at the widest
point. Clients should be assessed for skin color, temperature, and skin condition as well as the
presence of pain upon dorsiflexion of the foot (Homans sign), which could indicate venous
thromboembolism.
Concepts tested

Question 2193
The nurse is caring for a client with suspected septic shock. Which of the following interventions
should the nurse implement first?
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A Initiate intravenous norepinephrine as prescribed
B Administer intravenous normal saline bolus as prescribed
C Obtain prescribed blood, sputum, and urine specimens for culture and sensitivity (C&S)
D Initiate prescribed intravenous broad-spectrum antibiotic therapy

Question Explanation
Correct Answer is B
Rationale: The initial intervention for septic shock should be to restore adequate fluid volume
status by volume resuscitation with intravenous crystalloids. If this is unsuccessful, vasopressor
therapy may be considered. After initiation of fluid resuscitation, the nurse should obtain cultures
followed by antimicrobial therapy.
Concepts tested

Question 2194
A nurse is caring for a client with peripheral arterial disease. The client verbalizes numbness to
the lower extremities when lying in bed. Which intervention should the nurse implement to
prevent neurological complications?
A Apply a heating pad to the extremities
B Elevate the lower extremities above the level of the heart
C Instruct the client to perform leg raises while in bed
D Advise the client to switch positions often

Question Explanation
Correct Answer is C
Rationale: Collateral circulation increases the availability of blood flow to the extremities and
prevents numbness associated with narrowing of blood vessels. A gradual increase in exercise
builds up collateral circulation. Direct heat should never be applied to extremities that have
decreased sensation. The inability to detect temperature changes may cause burns. The legs
should be elevated but not above the level of the heart. Extreme elevation can slow arterial blood
flow to the feet. Switching positions often while in bed will prevent skin breakdown; however,
this will not prevent neurological complications.
Concepts tested

Question 2196
The nurse is assisting a client with ambulation one day after a total knee preplacement. Which of
the following findings indicates an appropriate response to the activity?
A The client has pain that is a 7 on the numeric pain scale.
B The client requires a walker for ambulation.
C The client reports feeling weak after taking several steps.
D The client states that they have a fear of falling.

Question Explanation
Correct Answer is B
Rationale: Use of a walker, cane, or other assistive devices is normal after orthopedic surgeries.
Some pain is expected, but significant pain can make ambulation unsafe. If the client feels weak

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at any point, the ambulation should be discontinued and reattempted at a later time. Concerns
about falling should be addressed, but this does not indicate an appropriate response to
ambulation.
Concepts tested

Question 2197
The nurse is interviewing a client in the outpatient clinic who is seeking care for a sudden weight
increase. Which of the following questions by the nurse is appropriate to assess for fluid
retention?
A “Have you noticed any swelling in your legs?”
B “How many calories do you eat a day?”
C "When was your last bowel movement?”
D “Do you have a history of any eating disorders?”

Question Explanation
Correct Answer is A
Rationale: Fluid retention is often manifested by peripheral edema, so asking the client if they
have experienced swelling of the lower extremities will allow the nurse to gather information
about the history of the condition. While the other questions might be appropriate to assess for
gastrointestinal concerns, they do not assess peripheral circulation.
Concepts tested

Question 2198
The nurse is assessing the skin of a postoperative client. Which finding would indicate to the
nurse a risk for skin breakdown?
A Perspiration that requires frequent linen changes
B Occasional ambulation with minimal assistance
C Frequent repositioning because the bed is uncomfortable
D Client requests snacks as well as scheduled meals

Question Explanation
Correct Answer is A
Rationale: Most pressure injury risk assessment tools include an assessment of mobility,
nutrition, and moisture. Skin that is constantly exposed to moisture is at high risk of skin
breakdown. Whether the moisture is from perspiration, wound drainage, urine, or stool, the skin
is compromised. Moisture can create an environment in which microorganisms can multiply and
the skin is more likely to blister, suffer abrasions, and become macerated (softening or
disintegration of the skin in response to moisture).
Concepts tested

Question 2199
The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who is
receiving prescribed low-flow oxygen 2 l/min via nasal cannula. Which finding would indicate to
the nurse that intervention is required?
A SpO2 level of 88%

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B PaO2 level of 55%
C Breath sounds bilateral wheezing
D Decreased effort with incentive spirometer

Question Explanation
Correct Answer is B
Rationale: The client with COPD, which is inflammation and loss of elasticity of the lung
tissues, will have chronic hypoxia with SpO2 stats of 88% or greater, wheezing with inspiration,
and decreased effort with an incentive spirometer. A PaO2 level of 55% is below normal,
indicating the client might be experiencing respiratory distress.
Concepts tested

Question 2200
The nurse is teaching a client who has chronic venous insufficiency about self-care. Which
information should the nurse include in the teaching?
A “Routinely check the tips of your toes for ulcers that can occur in people with this condition.”
B “Frequently flex and extend your ankles if you must remain standing for a long time at
work.”
C “Avoid eating green, leafy vegetables to minimize the risk for blood clots in your calves.”
D “Apply a topical antibiotic to any areas on your lower legs that have brown discoloration.”

Question Explanation
Correct Answer is B
Rationale: Chronic venous insufficiency is characterized by the incompetence of the valves in
the leg veins, which results in elevated venous pressure in the legs. Sequelae may include pain,
edema, venous hemorrhage, venous thrombosis, and stasis ulcer development. Prolonged
stationary standing may be detrimental for a client with chronic venous insufficiency because
blood is allowed to remain stagnant in the legs, increasing venous pressure. Clients with chronic
venous insufficiency may develop brown discoloration in the skin of the lower legs, as the
elevated venous pressure causes capillary leakage of red blood cells, which eventually break
down and release hemosiderin. This discoloration does not have an infectious etiology and thus
is not improved by topical antibiotic application.
Concepts tested

Question 2201
The nurse in the ambulatory surgical center is assessing a client scheduled for surgery requiring
general anesthesia. The client states, “I ate a light breakfast about 2 hours ago.” Which of the
following statements by the nurse would be appropriate?
A “We will have to wait another 2 hours to do your surgery.”
B “You will receive medication to prevent you from vomiting during the surgery.”
C “There is a possibility that your surgery will be rescheduled.” Correct Answer
D “You may experience nausea after the surgery.”

Question Explanation
Correct Answer is C

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Rationale: The minimum fasting period after eating a light meal is 6 hours, so the nurse should
notify the anesthesiologist, and the surgery will likely be rescheduled. Obtaining urine and blood
samples prior to surgery is often done a few days prior to surgery. Clients may experience nausea
and may be given anti-emetics postoperatively, but it is independent of the minimum fasting
period.
Concepts tested

Question 2202
The nurse is caring for an older adult client who has a urinary tract infection (UTI). Which trend
in vital signs should be a priority for the nurse?
A Temperature has increased from 99.9 to 100.2°F
B Heart rate has increased from 97 to 105 beats per minute
C Respiratory rate has decreased from 20 to 16 breaths per minute
D Blood pressure has decreased from 112/76 mmHg to 90/52 mmHg

Question Explanation
Correct Answer is D
Rationale: The client with a UTI is at risk for developing complications such as sepsis. The
greatest concern is the 20-point reduction in systolic blood pressure, which may indicate sepsis
and require prompt intervention to reduce potential damage to body organs from hypoperfusion.
The client’s respiratory rate is within normal limits. While the heart rate and temperature are
slightly elevated, these findings do not warrant immediate intervention over the reduced blood
pressure.
Concepts tested

Question 2203
The nurse is planning a staff education conference about lumbar punctures. Which statement
should the nurse include in the teaching?
A “Clients should be positioned laterally with the head bent toward the chest and the knees
flexed into the abdomen.”
B “A needle will be inserted into the spinal cord and cerebral spinal fluid with be withdrawn.”
C “The client will need to remain in the prone position following the procedure.”
D “Clients will require restraints in order to limit movement during the procedure.”

Question Explanation
Correct Answer is A
Rationale: The nurse should include that the client should be positioned laterally with the head
bent toward the chest and the knees flexed into the abdomen, as this position allows for the
physician to access the space between the 3rd and 4th lumbar vertebrae. A needle will be inserted
into the subarachnoid space in the spinal canal, avoiding the spinal cord to prevent damage. The
client will need to lie flat in a supine position following the procedure to place pressure on the
insertion site. The client may require sedation to reduce movement during the procedure, not
restraints.
Concepts tested

Question 2204
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A nurse is applying an external fetal monitor on a client in labor. Which area should the nurse
secure the tocotransducer to?
A Over the uterine fundus
B At the area of maximal fetal heart rate intensity
C Above the symphysis pubis
D Below the area of the last fetal movement

Question Explanation
Correct Answer is A
Rationale: The tocotransducer should be placed over the uterine fundus. A tocotransducer is used
to record uterine contractions. The area of maximal fetal heart rate intensity is the landmark for
the ultrasound transducer, which records the fetal heart rate. The uterine fundus is located higher
in the client’s abdomen during labor. The position of the fundus lowers after delivery. The area
of the last fetal movement does not provide accuracy of uterine contractions.
Concepts tested

Question 2205
The nurse is caring for a client with thrombocytopenia. Which of the following platelet
laboratory values is consistent with this diagnosis?
A 157,000 cells/mm3
B 90,000 cells/mm3
C 350,000 cells/mm3
D 450,000 cells/mm3

Question Explanation
Correct Answer is B
Rationale: Thrombocytopenia is a state of low serum platelet levels, which can be caused by
various anemias, chemotherapy, and HIV infection. A normal value for platelets is 150,000 –
400,000 cells/mm3. A platelet count of 90,000 cells/mm3 indicates thrombocytopenia.
Concepts tested

Question 2206
The nurse observing a graduate nurse access a peripherally inserted central catheter (PICC) for
blood specimen collection. Which action by the graduate nurse requires follow-up?
A Flushing the catheter with a 5 ml syringe of normal saline prior to accessing the port
B Donning a mask and gloves prior to accessing the venous access device
C Wasting 10 ml of blood prior to collecting the specimen
D Cleansing the hub of the venous access port with alcohol prior to accessing the device

Question Explanation
Correct Answer is A
Rationale: It requires follow-up if the nurse is observed flushing the line with a 5 ml syringe
prior to obtaining blood specimens. PICC lines should always be flushed with a 10 ml syringe or
greater. Smaller syringes exert a higher pressure and increase the risk for rupturing the catheter.
Aseptic technique using a mask and gloves is required when accessing the device, and the site

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should be cleansed with alcohol before and after. The nurse should waste 5-10 ml of blood prior
to collecting the blood specimen to prevent contamination from fluids and hemolysis of the
specimen.
Concepts tested

Question 2307
A nurse is providing care to a client with liver cirrhosis. Which finding should the nurse expect
to see on a laboratory report?
A Ammonia level of 100 mcg/dl
B Prothrombin time of 12 seconds
C Albumin level of 5.5 g/dl
D Total bilirubin level of 0.9 mg/dl

Question Explanation
Correct Answer is A
Rationale: An ammonia level of 100 mcg/dl is expected in a client with liver cirrhosis. The liver
is unable to convert ammonia to urea causing increased levels in the blood. The normal ammonia
level is 10 to 80 mcg/dl. A prothrombin time (PT) of 12 seconds is a normal finding. PT is
expected to be prolonged in clients with liver cirrhosis. An albumin level of 5.5 g/dl is above the
normal range. Albumin levels are expected to be decreased in clients with liver cirrhosis due to a
lack of hepatic synthesis. The normal albumin level is 3.5 to 5.0 g/dl. A total bilirubin level of
0.9 mg/dl is a normal finding. Total bilirubin levels are expected to be elevated in a client with
liver cirrhosis due to the inability of the liver to excrete it.
Concepts tested

Question 2308
The nurse is screening clients for factors that impact skin integrity. The nurse should identify
which client has an increased risk of skin breakdown?
A A client who is malnourished
B A client who has anemia
C A client with visual impairments
D A client who is pregnant

Question Explanation
Correct Answer is A
Rationale: Clients who are malnourished have an increased risk of skin breakdown because of
the lack of subcutaneous tissue surrounding bony prominences. Anemia, visual impairments, and
pregnancy do not increase the likelihood of skin breakdown.
Concepts tested

Question 2309
The nurse is assessing the drainage in a suction canister from a client’s newly placed nasogastric
tube (NG). Which of the following would be an expected finding?
A Coffee ground appearance
B Drainage pH of 7.0

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C No drainage in 2 hours
D Green colored output

Question Explanation
Correct Answer is D
Rationale: Output from the stomach is typically green in color. A coffee ground appearance
indicates the presence of blood. There should be output after the initial insertion of an NG tube,
so lack of output may indicate that the tube is not in the stomach. Output pH should be less than
5.5.
Concepts tested

Question 2310
The recovery room nurse is assessing a client who is one-hour post-operative from a total knee
arthroplasty with spinal anesthesia. Which of the following findings would indicate that the
client is experiencing a complication?
A Pulse oximetry reading fluctuates between 96% and 98%
B Client reports knee pain increased from 3/10 to 5/10
C Systolic blood pressure decreased from 140 mmHg to 110 mmHg
D Temperature has increased from 99.0°F to 99.3°F

Question Explanation
Correct Answer is C
Rationale: As the client’s anesthesia wears off and their pain increases, an expected finding
would be that the blood pressure would rise. A decrease in systolic BP would indicate that the
client may be bleeding and needs to be reported to the healthcare provider. Fluctuating
O2 saturations are expected, as well as a small increase in temperature, due to the inflammatory
process.
Concepts tested

Question 2311
A nurse is caring for a client with a bowel obstruction who has a nasogastric (NG) tube placed
and connected to wall suction. Which of the following actions would be appropriate for the nurse
to take?
A Hold the client’s medications until the NG tube is discontinued
B Maintain the position of the bed in Semi-Fowler’s
C Apply an oil-based lubricant to the client's affected nares to prevent irritation
D Encourage the client to lie on the right side when abdominal distention is noted

Question Explanation
Correct Answer is B
Rationale: When caring for a client with a NG tube connected to wall suction, the nurse should
maintain the position of the bed in Semi-Fowler’s to prevent aspiration. Water-based lubricant is
preferred when inserting and maintaining an NG tube. Water-based lubricant is considered less
toxic if aspirated. Abdominal distention can indicate retention of secretions. Having the client lie
on the left side can dislodge a gastric tube that is suctioning against the stomach wall. Holding

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the client’s medications is not necessary. Per the provider's order, the nurse will administer
prescribed medications via the mouth and/or NG tube and hold the suction for an hour after to
allow the medications to absorb.
Concepts tested

Question 2312
The nurse is assessing a client who had a thoracotomy and has a pleural chest tube connected to a
dry suction drainage system. Which finding would require the nurse to take immediate action?
A Drainage system is secured to the end of the bed.
B Tubing is looped next to the client.
C The client reports feeling the chest tube move.
D Bubbling is noted in the water seal chamber.

Question Explanation
Correct Answer is D
Rationale: A pleural chest tube is placed after a thoracotomy to promote drainage from the
pleural space and promote re-expansion of the lung. A dry suction drainage system uses an
internal vacuum that, when connected to wall suction, will create the suction pressure. Bubbling
in the water seal chamber can indicate that there is an air leak in the system requiring immediate
action by the nurse. An air leak could indicate the client has a pneumothorax. To prevent tipping
over, the drainage system can be secured to the end of the bed. Looping the tubing next to the
client will prevent drainage from settling in the tube. It is normal for clients to report that the
tube feels like it is moving.
Concepts tested

Question 2313
The nurse is observing a newly hired nurse apply anti-embolism stockings for a client. Which of
the following nursing actions requires follow-up?
A Assisting the client to dangle the legs for several minutes before applying the stockings
B Applying the stockings in the morning before the client gets out of bed
C Assessing the client’s skin temperature, color, and skin condition prior to application of the
stockings
D Drying the client’s legs thoroughly prior to applying the antiembolism stockings

Question Explanation
Correct Answer is A
Rationale: It requires follow-up if the nurse is observed having the client dangle the legs for
several minutes prior to applying the stockings. Stockings should be applied, if possible, first
thing in the morning prior to getting out of bed before veins become engorged from walking. If
the client has been walking, the client should lie down and elevate the legs for 15–30 minutes
before applying the stockings. Skin color, temperature, and integrity should be assessed before
and after applying stockings. Legs should be dry prior to the application of stockings to reduce
the risk of skin breakdown.
Concepts tested

Question 2314
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A nurse is providing care to a client with esophageal varices and a history of cirrhosis. The client
suddenly vomits 750 milliliters of frank, red blood. Which action should the nurse perform first?
A Call a rapid response
B Insert an additional intravenous line
C Prepare to infuse packed red blood cells
D Request a prescription for a type and crossmatch

Question Explanation
Correct Answer is A
Rationale: A volume of 750 milliliters of hematemesis is indicative of rapid blood loss. The
nurse should first call a rapid response to prevent hypotensive shock. Inserting an additional
intravenous line is necessary for pharmacological treatment; however, the nurse should first call
a rapid response, so the client can be evaluated. Packed red blood cells will help replace the
blood loss; however, the nurse should first call a rapid response before preparing blood
transfusion equipment. A prescription for a type and crossmatch is necessary for a blood
transfusion; however, this action is not the priority.
Concepts tested

Question 2315
A nurse is assessing a client with a spinal cord injury. Upon assessment, the nurse notes a soft,
distended abdomen. Which action will the nurse expect to perform to prevent complications of
neurogenic bowel?
A Administer a laxative suppository
B Place the client on NPO status
C Gather supplies to insert a nasogastric tube
D Prepare the client for surgery

Question Explanation
Correct Answer is A
Rationale: Spinal cord injuries can cause neurogenic bowel. Neuron injuries prevent adequate
peristalsis and can lead to constipation. The nurse should expect to administer laxative
suppositories to stimulate bowel movements. Placing the client on a nothing by mouth (NPO)
status is not indicated. Neurogenic bowel is a common result of spinal cord injuries and is treated
with other methods. A nasogastric (NG) tube is not indicated for the client at this time. The
client’s abdomen is distended but soft. This does not indicate an obstruction. Surgical
intervention is not indicated for the client at this time. The client’s symptoms are not indicative
of bowel perforation.
Concepts tested

Question 2316
The nurse is evaluating a client’s response to oral intake after a surgical procedure. The client
has a prescription to advance diet as tolerated. Which of the following findings indicates that the
client’s diet can be advanced?
A The client states they are nauseous.
B The client reports a feeling of fullness after a small cup of water.

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C The client’s abdomen is distended.
D The client has normoactive bowel sounds.

Question Explanation
Correct Answer is D
Rationale: The return of bowel sounds after general anesthesia indicates that peristalsis is
occurring; therefore, the diet can be advanced. If the client becomes nauseous or overwhelmingly
full after small amounts of intake, the diet should not be advanced. Distention of the abdomen
does not indicate readiness to advance the diet.
Concepts tested

Question 2317
The nurse is caring for a client who has been diagnosed with type 2 diabetes mellitus. Which of
the following findings indicates that the client may be experiencing hypoglycemia?
A Orthopnea
B Increased urination
C Tremors
D Abdominal pain

Question Explanation
Correct Answer is C
Rationale: Tremors, confusion, diaphoresis, and impaired coordination are signs of
hypoglycemia and should indicate to the nurse that further assessment is needed. Increased
urination often occurs in hyperglycemia. Orthopnea and abdominal pain are not directly affected
by blood glucose levels.
Concepts tested

Question 2318
The home health nurse is assessing an older adult client for safety risks. Which of the following
findings increases the client’s risk of injury from falling?
A The client attends a silver sneakers program.
B The client is taking prescribed temazepam for sleep.
C The client has hardwood floors throughout the home.
D The client wears glasses for reading.

Question Explanation
Correct Answer is B
Rationale: Falls can be prevented if they can be predicted. Fall risk factors can be person-based
and environmental-based. Risk factors may include advanced age, previous falls, muscle
weakness, poor vision, obstacles and tripping hazards, and psychoactive medications. The client
in this case is taking a benzodiazepine, which is known to contribute to falls. Wearing glasses for
reading does not increase the risk of falls.
Concepts tested

Question 2319

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The nurse is planning care for a client with cystic fibrosis who has a prescription for chest
physiotherapy (CPT). Which action should the nurse plan to take?
A Administer prescribed bronchodilator before therapy
B Percuss each lung segment for 15 minutes
C Perform therapy 30 minutes after eating
D Apply vibration during inspiration

Question Explanation
Correct Answer is A
Rationale: CPT is prescribed. Apply vibration during inspiration is for clients who have thick
bronchial secretions with difficulty clearing their airways. CPT involves the use of percussion
and vibration to mobilize secretions. The nurse should administer the prescribed bronchodilator
before therapy, which will open airways and make the removal of secretions easier. The nurse
should only percuss lung segments for 2-5 minutes. Vibration should be applied when the client
takes a deep breath in.
Concepts tested

Question 2320
The nurse is educating a client who has heart failure about disease management. Which
statement by the client indicates to the nurse that the teaching was effective?
A "I will take my diuretic before sleep and drink fluids during the day."
B "I will weigh myself on the same scale three times a week."
C "I know that my exercise routine is working when I am breathing hard."
D "I will read food labels and limit my sodium to 2 grams per day."

Question Explanation
Correct Answer is D
Rationale: A client with heart failure should be taught how to manage their disease, which should
include how to prevent fluid volume overload and decrease impaired activity tolerance. The
client should be taught to weigh themselves daily using the same scale and limit sodium intake to
2 grams daily. The client should be advised to avoid taking diuretics right before bed and limit
fluid intake during the day. The client should be instructed to stop activity before they become
short of breath.
Concepts tested

Question 2321
The nurse is collecting the health history of a client who is scheduled for surgery. Which
statement by the client would be a priority for the nurse to follow up?
A “I got very nauseous the last time I had surgery.”
B “My father had an infection after surgery.”
C “My mother had a reaction during a surgery.”
D “I am concerned about the pain after the surgery.”

Question Explanation
Correct Answer is C

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Rationale: When collecting the health history from a client who is scheduled for surgery, the
nurse will assess the client’s previous experiences and family history related to surgical
procedures. Nausea and pain are expected effects of surgery that the nurse will educate the client
about but are not the priority. A parent that had an infection after surgery is important to
document but not the priority. Malignant hyperthermia, which is an adverse reaction to
anesthesia, can be genetic and would be the priority for the nurse to follow up.
Concepts tested

Question 2322
The charge nurse is observing a newly hired nurse care for a client whose temperature has
increased from 99.9 to 102°F during the shift. Which of the following actions by the newly hired
nurse requires intervention?
A Administering prescribed antipyretics
B Requesting to discontinue intravenous fluids
C Removing excess blankets and clothing
D Providing a tepid sponge bath to the client

Question Explanation
Correct Answer is B
Rationale: It requires intervention if the nurse is observed requesting to discontinue intravenous
fluids in a febrile client. Clients should have adequate fluid and nutrition replacement to meet
increased metabolic demands while in febrile states. It is correct to administer prescribed
antipyretics, remove excess blankets and clothing, and provide tepid sponge baths during febrile
states.
Concepts tested

Question 2323
The nurse is planning a staff education conference about performing a thoracentesis. Which of
the following should the nurse include in the teaching?
A “Instruct clients to take a deep breath while the needle is being inserted to reduce risk of
puncturing the pleura.”
B “Position clients sitting forward and leaning over a tray table or pillow.”
C “Encourage clients to take shallow breaths following the procedure to reduce postprocedural
pain.”
D “Inform the client to expect to have several liters of fluid removed during the procedure.”

Question Explanation
Correct Answer is B
Rationale: The nurse should include that the client should be positioned sitting forward and
leaning over a tray table or pillow, as this position widens the space between the ribs and permits
easier access to the pleural fluid. Clients should be instructed not to move, cough, or take deep
breaths during insertion of the needle to avoid puncture of the pleura or lung. Clients should be
instructed to take deep breaths following the procedure to promote lung expansion. No more than
1 l is removed at a time during a thoracentesis to prevent re-expansion pulmonary edema.
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Concepts tested

Question 2324
A nurse is performing intermittent auscultation of the fetal heart rate on a client in labor. Which
action by the nurse indicates the correct method of auscultation?
A Placing the listening device over the area of fetal movement
B Counting the fetal heart rate for 15 seconds between contractions
C Performing Leopold maneuvers prior to placing the listening device over the fetal heart rate
D Palpating the uterine fundus to assess for maximum fetal heart rate intensity

Question Explanation
Correct Answer is C
Rationale: Leopold maneuvers help to identify fetal presentation and placement of the
auscultation device near the area of maximal fetal heart rate intensity. The listening device
should be placed over the area of maximal fetal heart rate intensity, not movement. The fetal
heart rate should be counted for 30 to 60 seconds between uterine contractions to obtain the
baseline. Palpating the uterine fundus determines uterine contractions, not the fetal heart rate.
Concepts tested

Question 2325
The nurse is caring for a client with anemia. Which of the following laboratory values is
consistent with this diagnosis?
A Hemoglobin (Hgb) level of 10 g/dl
B Hematocrit (HCT) of 45%
C Hemoglobin (Hgb) of 20 g/dl
D Hematocrit (HCT) of 55%

Question Explanation
Correct Answer is A
Rationale: Anemia is indicated by low hemoglobin and hematocrit levels. Normal hemoglobin
levels are 14-18 g/dl for males and 12-16 g/dl for females. A hemoglobin level of 10 g/dl
indicates anemia. Normal hematocrit levels are 42-54% for males and 37-47% for females. A
hematocrit level of 45% is within normal limits and 55% is elevated, which can be seen in
conditions such as dehydration.
Concepts tested

Question 2326
The nurse is observing a graduate nurse obtain a capillary blood glucose specimen for a client.
Which of the following actions by the graduate nurse requires follow-up?
A Wiping the finger with an alcohol wipe and allowing the site to dry completely
B Placing the lancet perpendicular to the skin prior to piercing the finger
C Holding the reagent strip under the puncture site and removing when half of the indicator
square is covered with blood
D Applying pressure to the puncture site with gauze after obtaining the blood specimen

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Question Explanation
Correct Answer is C
Rationale: It requires follow-up if the nurse is observed covering only half of the indicator square
on the reagent strip with blood. The entire square needs to be covered with blood to obtain an
accurate reading. It is the correct technique to allow the site to dry completely before piercing the
finger, to hold the lancet perpendicular to the skin to ensure accurate depth of the needle, and to
apply pressure after obtaining the blood sample to ensure hemostasis.
Concepts tested

Question 2327
A nurse is reviewing laboratory results for their assigned clients. Which finding should the
nurse immediately report to the healthcare provider?
A Potassium level of 6.7 mEq/l in a client with chronic kidney disease
B Serum glucose level of 225 mg/dl in a client with diabetes type 2
C Hemoglobin level of 10.5 g/dl in a client with chronic anemia
D White blood cell count of 12,000/mm³ in a client with meningitis

Question Explanation
Correct Answer is A
Rationale: The nurse should immediately report a potassium level of 6.7 mEq/l regardless of the
client’s medical history. A potassium level of 6.7 mEq/l is a critical value and can lead to cardiac
dysrhythmias. A glucose level of 225 mg/dl is not a critical finding in a client with a history of
diabetes type 2. Glucose levels above 250 mg/dl should be reported promptly. A hemoglobin
level of 10.5 g/dl is not uncommon in a client with chronic anemia. The normal hemoglobin level
ranges from 12 to 18 g/dl. A white blood cell (WBC) count of 12,000/mm³ is an expected finding
in a client with meningitis. Leukocytosis is common with an infectious process. The normal
WBC count is 5,000 to 10,000/mm³.
Concepts tested

Question 2328
The nurse is caring for a client who has just been admitted to the acute care facility. Which of the
following conditions indicates that the client is at risk for decreased peripheral vascular
perfusion?
A Cystic fibrosis
B Osteoarthritis
C Urinary incontinence
D Diabetes mellitus

Question Explanation
Correct Answer is D
Rationale: The client who has been diagnosed with diabetes mellitus is at an increased risk for
peripheral vascular deficits. Osteoarthritis, incontinence, and cystic fibrosis are not conditions
that directly affect peripheral circulation.
Concepts tested

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Question 2329
The nurse is assessing a client who is seeking care for abdominal pain and diarrhea. Which of the
following questions by the nurse is appropriate to establish a baseline of the client’s bowel
movements?
A “Where exactly is the pain in your abdomen?”
B “Can you describe what your stool normally looks like?”
C “Has anyone around you been sick in the last week?”
D “Do certain foods make your diarrhea better or worse?”

Question Explanation
Correct Answer is B
Rationale: Asking the client to describe their normal bowel movements will allow the nurse to
establish the baseline for any further stool changes. The nurse could ask about the location of
pain, exposure to someone sick, and triggering foods, but these do not gather data about the
client’s normal bowel movements.
Concepts tested

Question 2330
The nurse is reviewing the morning laboratory results for clients on the orthopedic unit. Which
client needs to be assessed first?
A aPTT is 75 seconds for the client receiving a heparin infusion for pulmonary embolism.
B Hemoglobin is 14 g/dl on a client postoperative day 1 after a hip replacement.
C Red blood cell count is 4.8 x 106/mm3 for a client preoperative knee surgery.
D Platelet count is 75,000 in a client with a pelvic fracture.

Question Explanation
Correct Answer is D
Rationale: The normal platelet count is 150,000 to 400,000 µl. Clients with pelvic injuries are at
high risk for hemorrhage, and the low platelet count is a sign that bleeding has or may take place.
Heparin protocols use the aPTT to determine the therapeutic window. The goal of treatment is to
achieve a value between 60 and 80. A hemoglobin value of 14 is considered acceptable, as is the
RBC of 4.8.
Concepts tested

Question 2331
The nurse is assessing a nasogastric tube for a client with a bowel obstruction. The nurse
aspirates the stomach content and notes a gastric pH of 3.0. Which action would be appropriate
for the nurse to take?
A Document the placement and gastric pH
B Discard the gastric contents and flush the tube with water
C Notify the healthcare provider and request a prescription for CXR
D Inject air into the tube and auscultate epigastric sounds

Question Explanation
Correct Answer is A

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Rationale: If the nasogastric tube is in the stomach, the pH of the contents will be acidic. Correct
placement is confirmed when gastric contents have a pH that is 3.5 or lower. A CXR would be
indicated if the pH is higher than 3.5 or an indication that the tube is no longer in the stomach.
Any stomach contents that are aspirated should be injected back into the stomach to prevent
electrolyte imbalance. Injecting air into the tube and auscultating epigastric sounds is no longer
evidenced-based practice to assess NG tube placement.
Concepts tested

Question 2332
The nurse is assisting a client who has a pneumothorax and has a left pleural chest tube
connected to dry suction drainage system up to the chair. The nurse notes that during the transfer,
the chest tube disconnects from the drainage system. Which action should the nurse take?
A Clamp the chest tube close to the insertion site
B Insert the chest tube into a bottle of sterile water
C Apply an occlusive dressing to the end of the chest tube
D Reconnect the chest tube to the drainage system

Question Explanation
Correct Answer is B
Rationale: The pleural chest connected to a dry drainage system is a closed system that provides
negative pressure to promote the expansion of the pleural space. If the chest tube becomes
disconnected from the drainage system, the nurse should insert the end of the chest tube into a
bottle of sterile water, which creates a seal. The nurse should not clamp or apply a dressing to the
chest tube as this will increase intrapleural pressure. The nurse should not reconnect to the used
drainage system. The nurse will create a water seal first, then obtain a new drainage system to
connect to the chest tube.
Concepts tested

Question 2333
The nurse is observing a newly hired nurse apply anti-embolism stockings for a client. Which of
the following actions requires follow-up?
A Turning the upper portion of the stocking inside out so the foot portion is inside the leg
B Asking the client to point the toes to place the foot portion over the toes and heels
C Grasping the loose portion of the stocking at the ankle and pulling it right side out and over
the leg
D Bunching the stocking at the top and ankle once applied to reduce client discomfort

Question Explanation
Correct Answer is D
Rationale: It requires follow-up if the nurse is observed bunching the stocking at the top and
ankle to reduce discomfort. Stockings should have all folds and creases removed and should not
be bunched or folded, which can cause skin irritation or impair venous return. The other actions
are correct steps for applying anti-embolism stockings on a client.
Concepts tested
Page | 913
Question 2334
A nurse is providing care to a client with a deep vein thrombosis on the right lower extremity.
Which action will the nurse perform to prevent circulatory complications?
A Massage the affected extremity to decrease discomfort
B Place a pillow under the right knee to elevate the extremity
C Apply ice packs to the extremity to decrease edema
D Encourage range of motion exercises to increase mobility

Question Explanation
Correct Answer is D
Rationale: Range of motion exercises should be encouraged to promote circulation and maintain
mobility while in bed. Massaging the affected extremity is contraindicated. Massaging the limb
may cause the blood clot to dislodge and enter the systemic circulation. Placing a pillow below
the knee will cause pressure and decrease circulation to the extremity. The pillow should be
placed along the calf area. Ice packs will cause vasoconstriction and decrease circulation. The
nurse should use warm, moist compresses as prescribed.
Concepts tested

Question 2335
A nurse is evaluating the results of a stress test performed on a client. Which finding indicates an
expected response to the procedure?
A Blood pressure drops from 125/82 mmHg to 91/50 mmHg during the stress test
B A prolonged episode of dyspnea with accessory muscle use occurs after the stress test
C P waves have no relationship to QRS complexes on an ECG after the stress test
D Heart rate increases from 80 beats/min to 120 beats/min during the stress test

Question Explanation
Correct Answer is D
Rationale: A stress test evaluates the heart’s ability to adapt to physical activity. An elevation in
heart rate is an expected finding when exercising. Hypotension is not expected when exercising.
A significant decrease in blood pressure may indicate heart disease. A prolonged episode of
dyspnea with accessory muscle use after the stress test is not an expected finding. Shortness of
breath should improve gradually after the physical activity has stopped. P waves that have no
relationship to QRS complexes on an electrocardiogram are indicative of cardiac arrhythmia.
The client may require further treatment.
Concepts tested

Question 2336
The nurse is caring for a client who has just undergone a cardiac catheterization. Which of the
following actions by the nurse is appropriate to assess peripheral circulation after the procedure?
A Auscultating heart sounds
B Comparing the pulses in all extremities
C Assessing for bruits in the carotid arteries
D Obtaining an echocardiogram

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Question Explanation
Correct Answer is B
Rationale: A cardiac catheterization involves the use of major vessels in an extremity. Palpating
pulses in all extremities to ensure that they are symmetrical is important to determine if there is
any circulatory impairment to the affected extremity. All other responses do not assess peripheral
circulation.
Concepts tested

Question 2337
The nurse is assessing a client who has been taking prednisone for an exacerbation of
inflammatory bowel disease. Which of the following statements by the client requires immediate
follow-up?
A “I’m having difficulty sleeping at night.”
B “I feel like I am urinating more frequently.”
C “I’ve been more irritable than usual.”
D “I think I have gained some weight over the past month.”

Question Explanation
Correct Answer is B
Rationale: Corticosteroids are administered to control the symptoms of many different disorders
but have many side effects including difficulty sleeping, irritability, and weight gain. However, a
more concerning side effect of prednisone use is hyperglycemia. Hyperglycemia symptoms
include polyuria (frequent urination), polyphagia (hunger), and polydipsia (thirst). This needs to
be managed immediately to avoid adverse client outcomes.
Concepts tested

Question 2338
The nurse is planning care for a group of assigned clients on a medical unit. Which client should
the nurse identify as requiring immediate risk reduction interventions?
A The client with a history of a fall in the last three months
B The client who uses a cane at home
C The client who frequently calls for assistance to the bathroom
D The client who reports mild dizziness when sitting up in the morning

Question Explanation
Correct Answer is A
Rationale: A recent fall is the biggest indicator that a client will fall again. Falling once doubles
the chance that an older adult will fall again. While all the other clients are at risk and require
some form of intervention, the client with a history of falls is the priority for the nurse. One out
of five falls causes a serious injury, such as a traumatic brain injury (TBI), or fractures, such as
hip fractures.
Concepts tested

Question 2339
Page | 915
The nurse is preparing a client with atrial fibrillation for synchronized cardioversion. Which
action is the priority for the nurse to take?
A Remove the client's oxygen
B Disconnect the client's IV fluids
C Place a bite guard in the client's mouth
D Disconnect the client blood pressure monitor

Question Explanation
Correct Answer is A
Rationale: Synchronized cardioversion is the external administration of an electrical impulse to
reset the cardiac conduction. Pads are placed on the client’s chest, which is used to conduct the
electrical current. The priority of the nurse is to remove the client’s oxygen source, which could
spark a fire if contact with the electrical current occurs. The client can still be connected to the
IV fluids and blood pressure monitor. A bite guard can be used, but it is not the priority.
Concepts tested

Question 2340
The nurse is preparing to reposition a client who is postoperative day one from right hip
arthroplasty. Which actions should the nurse take?
A Keep the client’s hip in abduction at all times
B Flex the client’s hip at a 90-degree angle
C Move the client towards the unaffected side
D Place the client’s legs together

Question Explanation
Correct Answer is A
Rationale: A client who is postoperative hip arthroplasty should be positioned with the hips
abducted at all times, which prevents dislocation of the hip. The client should be moved towards
the affected side to prevent dislocation. Placing the client’s legs together and flexing the hip
could cause hip dislocation.
Concepts tested

Question 2341
A nurse is reviewing the laboratory results of a client who is preoperative knee surgery. The
nurse should notify which results to the healthcare provider?
A Hematocrit of 40%
B WBC count of 20,000/mm3
C Creatinine level of 0.9 mg/dl
D Potassium level of 3.9 mEq/l

Question Explanation
Correct Answer is B

Page | 916
Rationale: Clients having surgery will have laboratory tests done to identify any issues, such as
infections, electrolyte imbalances, renal impairment, or bleeding complications. The nurse
should report any abnormal labs to the healthcare provider. A WBC of 20,000/mm3 is elevated,
indicating the client may have an infection or inflammatory response. A normal hematocrit is 40-
50% for men and 36.1-44% for women. Creatinine levels should be between 0.5-1.1 mg/dl, and
potassium levels should be between 3.6-5.0 mEq/l.
Concepts tested

Question 2342
The nurse is planning a staff education conference about proper techniques for obtaining blood
pressure measurements. Which of the following should the nurse include?
A If the blood pressure is measured soon after exercising, it is possible to obtain a falsely low
blood pressure.
B If the blood pressure cuff is too narrow, it is possible to obtain a falsely high blood pressure.
C If the blood pressure cuff is deflated too slowly, it is possible to obtain a falsely low blood
pressure.
D If the client’s arm is above the level of the heart, it is possible to obtain a falsely high blood
pressure.

Question Explanation
Correct Answer is B
Rationale: The nurse should include in the teaching that a blood pressure cuff that is too narrow
may cause a falsely elevated blood pressure reading. Similarly, a cuff that is too wide may cause
a falsely low reading. Obtaining a blood pressure soon after exercise or smoking may cause a
falsely high reading. Deflating the cuff too quickly may result in a falsely low blood pressure.
Positioning the client's arm above the level of the heart during measurement may cause a falsely
low blood pressure reading.
Concepts tested

Question 2343
The nurse is planning a staff education conference about performing a liver biopsy. Which of the
following should the nurse include in the teaching?
A “Vitamin K should be withheld for several days prior to a liver biopsy.”
B “Clients should be positioned in the prone position during the procedure.”
C “Clients should be instructed to hold their breath as the needle is inserted.”
D “Clients must lie on their left side for several hours following the procedure.”

Question Explanation
Correct Answer is C
Rationale: The nurse should include that client will be instructed to hold their breath for up to 10
seconds while the needle is being inserted and prepare them to do so for the procedure. Vitamin
K may be administered several days before the procedure to reduce the risk of hemorrhage,
particularly in clients with liver disease and coagulopathies. Clients should be positioned supine
with the upper right quadrant of the abdomen exposed. Clients will need to lie on their right side
for several hours after the procedure to place pressure on the insertion site, which reduces risk of
bleeding.
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Concepts tested

Question 2344
A nurse is providing care to a client in labor with continuous internal fetal monitoring. Which
action by the nurse ensures safe fetal monitoring?
A Obtaining the client’s temperature every hour
B Securing the electrode wire with a band around the client’s abdomen
C Adjusting the electrode on the fetal presenting part after every contraction
D Instructing the client to remain supine in bed

Question Explanation
Correct Answer is A
Rationale: Obtaining the client’s temperature every hour ensures that there is no fever present.
Internal fetal monitoring is an invasive procedure with a risk for infection. The electrode wire
should be secured to the client’s thigh closer to the fetal presenting part. The nurse should not
touch the electrode after it has been placed by the provider as it can cause injury to the fetus. The
nurse’s role is to monitor the client and the fetal heart rate. The client is able to reposition
frequently with an internal fetal monitor. Tracing is not affected by movement.
Concepts tested

Question 2345
The nurse is comparing arterial blood gas results obtained at 1000 for a client with chronic
obstructive pulmonary disease (COPD) with results obtained at 0800. Which of the following
findings is of greatest concern to the nurse?
A PaO2 has decreased from a baseline of 82 mmHg to 78 mmHg
B Oxygen saturation has decreased from a baseline of 94% to 90%
C PCO2 has increased from a a baseline of 55 mmHg to 65 mm Hg
D HCO3 has increased from a baseline of 28 mEq/l to 32 mEq/l

Question Explanation
Correct Answer is C
Rationale: Acute hypercapnia with rapid rises above the client’s baseline represents a serious
decline in the client’s condition and can lead to respiratory failure. Normal PCO2 values are 35-
45 mm Hg. Clients with COPD often have chronic elevation in PCO2 levels; however, an
increase of 10 mmHg indicates a rapid decline in respiratory status. Clients with COPD often
have chronic hypoxemia and the values for the PaO2 and oxygen saturation have decreased
slightly but are still within the expected range for a client with COPD. The HCO3 indicates
metabolic compensation for acidosis related to COPD.
Concepts tested

Question 2346
The nurse is observing a newly hired nurse access an implanted port for blood specimen
collection. Which of the following actions by the newly hired nurse requires follow-up?
A Cleansing the site with chlorhexidine solution 2 inches around the port
B Piercing the port with the non-coring (Huber) needle at a 45-degree angle

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C Priming the tubing connected to the non-coring (Huber) needle with saline prior to accessing
the port
D Discarding the first syringe of aspirated blood sample

Question Explanation
Correct Answer is B
Rationale: It requires follow-up if the nurse is observed piercing the port with the Huber needle
at 45 degrees. The needle should be inserted perpendicularly at a 90-degree angle. It is correct to
cleanse the site with chlorhexidine 2 inches around the port, to prime the tubing connected to the
port prior to accessing it, and to discard the first syringe of blood as this sample will be diluted
with saline from the tubing and yield inaccurate test results.
Concepts tested

Question 2347
A nurse is reviewing laboratory results of a client taking warfarin for atrial fibrillation. Which
finding should immediately be reported to the healthcare provider?
A PTT of 45 seconds
B INR of 3.9
C Platelet count of 145,000/mm³
D D-dimer of 1.25 nmol/l

Question Explanation
Correct Answer is B
Rationale: An international normalized ratio (INR) of 3.9 should be reported to the healthcare
provider immediately. The target INR for a client taking warfarin for atrial fibrillation is between
2.0 to 3.0. An increased INR can lead to bleeding. A partial thromboplastin time (PTT) of 45
seconds is a normal finding. PTT is not a value used to assess the effectiveness of warfarin
therapy. A platelet count of 145,000/mm³ is not consistent with warfarin therapy.
Thrombocytopenia is a possible complication of heparin. A D-dimer of 1.25 nmol/l is a normal
finding. D-dimer is an indicator of fibrinolysis and is not used to evaluate warfarin therapy.
Concepts tested

Question 2348
The nurse is completing an initial assessment on a client. Which of the following findings should
the nurse identify as a risk factor for insufficient vascular perfusion?
A A fiberglass cast on the lower extremity
B Use of a supplemental oxygen device
C History of skin cancer
D Generalized weakness

Question Explanation
Correct Answer is A
Rationale: A limb that is immobilized (especially those that are casted, splinted, or braced) is at
an increased risk of circulation impairment. Supplemental oxygen devices do not affect

Page | 919
peripheral vascular circulation. A history of skin cancer and generalized weakness do not directly
affect vascular perfusion.
Concepts tested

Question 2349
The nurse is caring for a client who has been diagnosed with acute kidney injury. Which of the
following changes in urinary output would indicate that the client condition is improving?
A Increase in urine output
B Urinary hesitancy
C Elevated urine concentration
D Occasional hematuria

Question Explanation
Correct Answer is A
Rationale: An increase in urinary output indicates that the client’s glomerular filtration rate is
recovering from the initial injury. In the oliguria stage of acute kidney injury, the urine is very
concentrated; once diuresis begins, the urine will be less concentrated. Hesitancy and hematuria
do not indicate improvement of acute kidney injury.
Concepts tested

Question 2350
The emergency department nurse is caring for a client who was brought to the emergency
department for syncope, hypotension, and frequent episodes of diarrhea. Which of the following
laboratory results supports the diagnosis of gastrointestinal (GI) bleeding?
A Hemoglobin level of 6.7 g/dl
B Red blood cell (RBC) count of 5.2 x 106 mm3
C Hematocrit of 45%
D Platelet count of 160,000 µl

Question Explanation
Correct Answer is A
Rationale: The normal hemoglobin range is 12 to 18. This client’s hemoglobin indicates severe
anemia, likely from blood loss since the client is experiencing hypotension. Low hemoglobin
leads to poor cerebral and peripheral tissue perfusion leading to syncope. The other values are all
in the normal ranges.
Concepts tested

Question 2351
The nurse is inserting a nasogastric (NG) tube into a client who has a bowel obstruction. As the
tube passes through the pharynx, which instruction should the nurse provide the client?
A “Take little sips of water.”
B “Tilt your head back.”
C “Hold your breath.”
D “Resist the urge to cough.”

Page | 920
Question Explanation
Correct Answer is A
Rationale: When inserting a NG tube, the tube will pass through the pharynx which can cause a
client to gag. To prevent the tube from inadvertently being inserted into the trachea, the nurse
should instruct the client to take little sips of water, which encourages the swallowing of the
tube. The client should be instructed that coughing is normal and protects the airway. The client
should avoid tilting their head back, which can make the insertion difficult. The client should be
instructed to take small, shallow breaths during the insertion.
Concepts tested

Question 2352
The nurse is preparing to administer a prescribed nasogastric (NG) tube feeding bolus to a client.
Which action should the nurse take first?
A Remove the plunger and attach the syringe to the tube
B Flush the NG tube with 30 ml of water and remove the syringe
C Aspirate the gastric contents and note the residual amount
D Unclamp the NG tube and allow the premeasured tube feed to enter by gravity

Question Explanation
Correct Answer is C
Rationale: When administering scheduled bolus tube feeding, after checking the placement of the
tube, the nurse would then check residual by aspirating the stomach contents. The nurse would
then flush the tube with 30 ml of sterile water, remove the plunger from the syringe, attach the
syringe to the tube, pour premeasured feed into the syringe, unclamp, and allow the tube feed to
enter the tube via gravity.
Concepts tested

Question 2353
The nurse is caring for a client who was admitted 1 hour ago with an acute ischemic stroke and
has a left-sided facial droop. Which action by unlicensed assistive personnel (UAP) requires
immediate follow-up by the nurse?
A Providing the client with a pitcher of water
B Elevating the head of the bed to a semi-Fowler’s position
C Applying sequential compression devices (SCDs) to bilateral lower extremities
D Suctioning secretions from the client’s oral cavity using an oropharyngeal suction catheter

Question Explanation
Correct Answer is A
Rationale: It requires immediate follow-up if the UAP is observed providing the client with a
pitcher of water. Clients who are experiencing an acute stroke are at high risk for aspiration and
require a thorough swallowing evaluation. It is appropriate for the UAP to elevate the head of the
bed, to apply SCDs, and to suction excess secretions from the client's mouth to prevent
aspiration.
Concepts tested

Question 2354
Page | 921
A nurse is providing care to a client who sustained a spinal cord injury 1 day ago. The client
suddenly develops a fever, hypotension, and bradycardia. Which action does the nurse expect to
perform?
A Prime intravenous tubing for prescribed antibiotics
B Prepare to administer prescribed vasopressors
C Assess the client for the presence of a distended bladder
D Remove tight clothing around the client’s torso area

Question Explanation
Correct Answer is B
Rationale: The client’s manifestations are indicative of neurogenic shock. Neurogenic shock
occurs as a result of miscommunication within the sympathetic nervous system, resulting in loss
of temperature regulation and vasodilation. The nurse should be prepared to administer
vasopressors to promote vasoconstriction and increase blood pressure. Antibiotics are not
indicated for neurogenic shock. The fever is due to a loss of temperature regulation. Assessing
the client for a distended bladder will not correct neurogenic shock. Pressure in the lower part of
the body leads to autonomic dysreflexia. Removing tight clothing is indicated for autonomic
dysreflexia, not neurogenic shock.
Concepts tested

Question 2355
A nurse is providing care to a client post pacemaker placement for a third-degree heart block.
Which characteristic on the electrocardiogram indicates the pacemaker is functioning properly?
A The R-R interval is regular, and the PRI is absent.
B The ventricular rate is 45 bpm.
C The P waves are uniform and present in front of every QRS complex.
D The QRS complexes measure greater than 0.12 seconds.

Question Explanation
Correct Answer is C
Rationale: Uniform P waves that are present in front of every QRS complex are characteristic of
a normal sinus rhythm. This is an expected finding after a pacemaker placement. A QRS
complex measuring more than 0.12 seconds is not a normal finding. Prolonged QRS complexes
signal ventricular abnormalities. A ventricular rate of 45 beats/min is not a normal finding. The
normal ventricular rate is 60 to 100 beats/min. An absent PR interval is not a normal finding. The
absence of a PRI indicates a heart block is still present.
Concepts tested

Question 2356
The nurse is assessing a client who has just had a cast placed for an upper extremity fracture.
Which of the following findings indicates that the client is experiencing a decrease of peripheral
circulation to the casted extremity?
A Unequal pulses are present in the upper extremities.
B Fingers are warm to the touch.
C Capillary refill is less than two seconds.

Page | 922
D Turgor is brisk.

Question Explanation
Correct Answer is A
Rationale: A decrease in the pulse strength of the affected extremity indicates that there is
circulatory impairment to the affected extremity. Warm fingers and quick capillary refill indicate
appropriate circulation. Turgor assesses hydration status rather than circulation.
Concepts tested

Question 2357
The nurse is caring for a client who is being tapered off an infusion of total parenteral nutrition.
Which of the following findings would alert the nurse that the infusion rate was reduced too
rapidly?
A Urine output increases.
B The client reports feeling thirsty.
C The EKG shows increasing heart rate.
D The client reports dry mouth.

Question Explanation
Correct Answer is C
Rationale: Parenteral nutrition infusion rate changes are made incrementally to avoid severe
hyperglycemia or hypoglycemia. Infusions are tapered off slowly to try to avoid hypoglycemia.
In mild hypoglycemia, as the blood glucose level falls, the sympathetic nervous system is
stimulated causing symptoms such as sweating, tremor, tachycardia, palpitation, and
nervousness. Hyperglycemia results in increased urination (polyuria), increased thirst
(polydipsia), and increased appetite (polyphagia), along with many other symptoms.
Concepts tested

Question 2358
The nurse is assessing a client with peripheral vascular disease. The nurse is unable to palpate
the posterior tibial pulse. Which pulse site should the nurse assess next?
A Dorsalis pedis
B Femoral
C Popliteal
D Radial

Question Explanation
Correct Answer is C
Rationale: When assessing pulse sites, the nurse should begin at the distal pulse site. In the lower
extremity, it would be the dorsalis pedis. The nurse moves up the extremity assessing the next
proximal site. If the nurse is unable to assess the posterior tibial pulse, the nurse should then
assess the popliteal site.
Concepts tested

Question 2359

Page | 923
A nurse is preparing to administer the first of two large-volume, cleansing enemas prescribed for
a client in preparation for a diagnostic procedure. Which of the following is an appropriate step
in the procedure?
A Warm the enema solution prior to instillation
B Prepare 1,500 ml of enema fluid
C Hang the enema container 24 inches above the anus
D Use tap water as the enema fluid

Question Explanation
Correct Answer is A
Rationale: When administering a large-volume enema, there are specific actions the nurse is to
take to perform the intervention. It is important to warm the enema solution because cold fluid
can cause abdominal cramping. The solution should not be too hot, though, because hot fluid can
injure the intestinal mucosa. For a large-volume cleansing enema, the recommended amount of
fluid to instill for an adult client is 750 to 1,000 ml. Tap water is a hypotonic solution that moves
fluid from the colon into the interstitial spaces and can cause circulatory overload and electrolyte
imbalances. For this reason, tap water enemas cannot be given more than once, and two enemas
have been prescribed for this client. The height of the fluid container affects the speed of
instillation. The maximum recommended height is 18 inches. Hanging the container higher than
that can cause rapid instillation and possibly painful distention of the colon.
Concepts tested

Question 2360
The nurse is educating a client who is newly diagnosed with chronic obstructive pulmonary
disease (COPD) about symptom management. Which statement should the nurse include in the
teaching?
A “Keep your fluid intake to less than a liter a day.”
B “Choose foods that are low in protein.”
C “You can exercise until you feel short of breath.”
D “Perform pursed-lip breathing to prolong exhalation.”

Question Explanation
Correct Answer is D
Rationale: Clients with COPD are at risk for malnutrition due to dyspnea and should be taught to
eat a high protein diet. Clients with COPD can participate in exercise but should be instructed to
rest before they experience shortness of breath, which could be a sign of overworking. Increasing
fluid intake will decrease and thin secretions in the airway. Pursed-lip breathing provides
positive pressure to allow for the client to prolong exhalation, which will decrease trapped air
and reduce airway resistance.
Concepts tested

Question 2361
The perioperative nurse is planning care for a client. Which interventions would be a priority for
the nurse in the operating room?
A Provide updates to the client’s family members

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B Verify that the client received teaching
C Ensure safe client position
D Identify discharge needs

Question Explanation
Correct Answer is B
Rationale: The role of the perioperative nurse is to maintain the client’s safety, dignity, and
confidentiality. Clients are at risk for neuromuscular damage from positioning in the OR, which
the nurse will ensure the client is in a safe position. The preoperative nurse is responsible for
teaching and identifying discharge needs. The healthcare provider will update the client’s family
members.
Concepts tested

Question 2362
The nurse is preparing to assess the blood pressure (BP) of an assigned client. Which action
should the nurse take when measuring the BP in the upper extremity?
A Placement of the deflated BP cuff approximately 2 inches below the antecubital space
B Palpation of the brachial pulse prior to placement of the cuff around the arm
C Placement of the stethoscope directly over the radial artery
D Inflation of the BP cuff to 10 mmHg above the client’s stated normal

Question Explanation
Correct Answer is B
Rationale: It is the correct technique to palpate the brachial pulse before placement of the cuff to
ensure the bladder of the cuff is directly above the artery for an accurate reading. The cuff should
be placed approximately 2 inches above the antecubital space. The stethoscope should be placed
over the brachial artery. The cuff should be inflated to 30 mmHg above where the brachial pulse
disappears when the cuff is inflated.
Concepts tested

Question 2363
The nurse is planning a staff education conference about performing a paracentesis. Which
statement should the nurse include in the teaching?
A “Clients should be instructed to void immediately before the procedure.”
B “Clients should be placed in the prone position for the procedure.”
C “Clients should be instructed to expect dizziness while fluid is being removed.”
D “Clients will typically have several liters of fluid removed during the procedure.”

Question Explanation
Correct Answer is A
Rationale: The nurse should have the client void immediately prior to the procedure as an empty
bladder reduces the possibility of puncturing the bladder during the procedure. Clients should be
placed in the supine position. Clients should report any dizziness and be monitored closely for

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hypotension or shock induced by fluid loss. The maximum amount of fluid that should be
removed at one time during a paracentesis is 1,500 ml.
Concepts tested

Question 2364
A nurse is reviewing the transvaginal ultrasound results for a client with a suspected ectopic
pregnancy. Which finding does the nurse expect to observe on the ultrasound?
A Fetal biparietal diameter of 8.5 cm
B Grade II placenta
C Tubal gestational sac
D Fetal weight of 2,500 g

Question Explanation
Correct Answer is C
Rationale: A tubal gestational sac indicates an ectopic pregnancy. Gestational sacs should be
located inside the uterus in a normal pregnancy. A fetal biparietal diameter of 8.5 cm indicates an
advanced gestational age. This finding is not consistent with an ectopic pregnancy. A fetal
weight of 2,500 grams is consistent with advanced gestational age, not an ectopic pregnancy. An
ultrasound provides only an estimate of the fetal weight based on other anatomical
measurements. Grade II placenta indicates a mature placenta consistent with advanced
gestational age. This finding is not observed in an ectopic pregnancy.
Concepts tested

Question 2365
The nurse is reviewing laboratory results for a client with end-stage renal disease (ESRD).
Which of the following findings is of greatest concern to the nurse?
A Serum creatinine level of 3.5 mg/dl
B Serum potassium level of 6.2 mEq/l
C Blood urea nitrogen (BUN) level of 25 mg/dl
D Hemoglobin (Hgb) level of 11 g/dl

Question Explanation
Correct Answer is B
Rationale: A serum creatinine level of 6.2 mEq/l indicates severe hyperkalemia due to renal
failure and requires follow-up as the client with ESRD will need hemodialysis to prevent cardiac
arrhythmias related to hyperkalemia. A serum creatinine level of 3.5 mg/dl and a BUN level of
23 mg/dl are elevated and are expected findings in ESRD. A Hgb level of 11 g/dl is slightly
decreased and indicates anemia due to ESRD, which is also an expected finding.
Concepts tested

Question 2366
The nurse is observing a newly hired nurse obtain a capillary blood glucose specimen for a
client. Which of the following actions by the newly hired nurse requires intervention?
A Calibrating the glucose meter before testing
B Wiping off the first drop of blood before measurement

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C Puncturing the tip of the client’s thumb
D Placing the finger in the dependent position

Question Explanation
Correct Answer is C
Rationale: It requires intervention if the nurse is observed selecting the tip of the thumb as the
puncture site for specimen collection. The preferred site is the middle or ring finger and along
the side of the finger, not the tip. This promotes client comfort, provides accurate test results, and
prevents nerve, skin, or bone injury. It is the correct technique to calibrate the meter, wipe off the
first drop of blood, and place the finger in the dependent position to facilitate blood flow for the
sample.
Concepts tested

Question 2367
A nurse is reviewing laboratory results for a client with pyelonephritis. Which finding should the
nurse immediately report to the healthcare provider?
A White blood cell count of 11,000/mm³
B BUN level of 22 mg/dl
C Lactate level of 2.5 mmol/l
D Creatinine level of 1.4 mg/dl

Question Explanation
Correct Answer is C
Rationale: The nurse should immediately report a lactate level of 2.5 mmol/l. Increased lactate
levels are indicative of acidosis and urosepsis. A white blood cell (WBC) count of 11,000/mm³ is
an expected finding for a client with a kidney infection. The normal WBC count is 5,000 to
10,000/mm³. A blood urea nitrogen (BUN) level of 22 mg/dl and a creatinine level of 1.4 mg/dl
are expected findings in an acute episode of pyelonephritis. The normal BUN level is 10 to 20
mg/dl, and the normal creatinine level ranges from 0.5 to 1.3 mg/dl.
Concepts tested

Question 2368
The nurse is screening clients for factors that affect the peripheral vascular system. Which of the
following clients is at risk for insufficient vascular perfusion?
A A client who has gastroesophageal reflux
B A client who has just had a cardiac catheterization
C A client who uses a walker for ambulation
D A client who has dementia

Question Explanation
Correct Answer is B
Rationale: Cardiac catheterization requires the insertion of a catheter into a large blood vessel,
such as the femoral artery. Circulation may be impaired to the extremity that was used for the

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insertion site. Gastroesophageal reflux and dementia do not affect peripheral circulation. The use
of an assistive device for ambulation does not increase the risk of peripheral vascular
impairment.
Concepts tested

Question 2369
The nurse is assessing a client after cardiac catheterization. Which of the following findings
would indicate that the client is experiencing a complication of the procedure?
A Pulses 2+
B Blood pressure 134/91 mmHg
C Bradycardia
D Bruising of the access site

Question Explanation
Correct Answer is C
Rationale: Bradycardia, hypotension, and nausea indicate that the client is experiencing a
vasovagal reaction after cardiac catheterization. Pulses 2+ and bruising of the insertion site are
normal findings after the procedure. Blood pressure of 134/91 is slightly elevated but is not a
complication of cardiac catheterization.
Concepts tested

Question 2370
The nurse is caring for a client who underwent cardiac catheterization using the femoral artery.
The client’s BP is 85/40 and they report severe back and lower abdominal pain. Which of the
following complications would be suspected?
A Arterial obstruction
B Pseudoaneurysm
C Acute kidney injury
D Retroperitoneal hematoma

Question Explanation
Correct Answer is D
Rationale: Hypotension, along with back, flank, and abdominal pain, may indicate a
retroperitoneal hematoma caused by blood leaking outside of the artery after percutaneous
coronary interventions. Weak/absent distal pulses are an indication of occlusion.
Pseudoaneurysm is caused by vessel trauma and causes a swelling at the insertion site. Acute
kidney injury would lead to decreased urine output and elevated BUN and serum creatinine
levels.
Concepts tested

Question 2371
The nurse is providing care to a client with an indwelling urinary catheter. The nurse notes the
presence of sediment in the tubing leading to the catheter bag. What action should the nurse
take?
A Irrigate the tubing with sterile normal saline

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B Place the drainage bag at the foot of the bed
C Strip the tubing
D Replace the drainage bag

Question Explanation
Correct Answer is A
Rationale: When caring for a client with an indwelling urinary catheter, the nurse will assess the
patency of the catheter. The presence of sediment is common, however, a buildup of sediment
could cause a blockage in the tubing. A blockage in the tubing will prevent the drainage of the
tubing. The nurse can irrigate the tubing to remove the sediment. Stripping the tubing is done to
remove any clots from the tubing. Placing the drainage bag at the foot of the bed will promote
drainage from the tube but will not remove sediment. The drainage bag is replaced when it is
damaged.
Concepts tested

Question 2372
The nurse is administering medication to a client through a percutaneous endoscopic gastrostomy
(PEG) tube. Which action by the nurse will maintain the patency of the tube?
A Crush medication to a fine powder before pouring into the tube
B Flush the tube with water between each medication
C Push medication through the tube with water
D Keep the tube unclamped for an hour

Question Explanation
Correct Answer is B
Rationale: A PEG tube, which is a feeding tube that is surgically placed through the client’s
abdomen into the stomach, is used to administer prescribed medication. To maintain tube
patency, the nurse should dilute all medication with water, administer one medication at a time,
and flush the tube with 15 to 30 ml of water between each medication. The medication should
instill through the tube by gravity, and pushing it through the tube with the syringe and water
would cause the tube to clog. After a medication is administered, the nurse should clamp the tube
for at least 20-30 minutes before resuming tube feeding.
Concepts tested

Question 2373
The nurse is implementing measures to reduce complications for a client with increased
intracranial pressure (ICP). Which of the following actions requires intervention?
A Flexing the client’s neck forward to reduce risk of aspiration
B Raising the head of the bed to maintain a semi-Fowler’s position
C Repositioning the client with slow, gentle movements
D Dimming the lights and reducing environmental noise

Question Explanation
Correct Answer is A

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Rationale: It requires follow-up if the nurse is observed flexing the client’s neck, which can
further increase intracranial pressure. The head should be maintained upright and in the midline
position. It is the correct management of increased ICP to reduce environmental stimuli, elevate
the head of the client’s bed, and move the client slowly and gently.
Concepts tested

Question 2374
A nurse is assessing a client with a suspected abdominal aortic aneurysm. Which action does the
nurse perform when providing care to this client?
A Palpate the abdomen for any pulsations
B Monitor the client’s blood pressure
C Administer prescribed fluid boluses
D Prepare the client for immediate surgery

Question Explanation
Correct Answer is B
Rationale: Monitoring the client’s blood pressure is essential in preventing an aneurysm rupture.
The nurse should immediately report an increase in blood pressure. Pulsations in the abdomen
should not be palpated as this can cause a rupture of the aneurysm. Administering fluid boluses
is not indicated at this time. Fluid resuscitation is necessary during an aneurysm rupture.
Preparing the client for surgery is not indicated. Immediate surgery is indicated for ruptured
aneurysms.
Concepts tested

Question 2375
A nurse is assessing a client post-peripheral bypass graft to the left lower extremity. Which
finding indicates the procedure was effective?
A Capillary refill time to left foot is 2 seconds
B Strength of left dorsalis pedis pulse is +1
C Left foot is cold to the touch
D Skin to the left lower extremity appears taut

Question Explanation
Correct Answer is A
Rationale: A capillary refill time of 2 seconds indicates adequate blood flow and perfusion. The
normal capillary refill time is less than 3 seconds. A +1 dorsalis pedis pulse strength is not a
normal finding. A +1 strength is indicative of weak circulation. The normal strength is +2. A
cold extremity is not a normal finding. Cold extremities are indicative of poor circulation. The
nurse should inform the healthcare provider of the finding. Taut or tense skin is not a normal
finding. Taut skin is indicative of compartment syndrome and should be reported immediately.
Concepts tested

Question 2376
The nurse is caring for a client who has just undergone a lower extremity arterial bypass graft.
Which of the following assessments should the nurse complete to ensure adequate peripheral
circulation?
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A Assess the apical pulse
B Palpate pulses in the extremities
C Auscultate vascular sounds in the abdomen
D Obtain the client’s blood pressure

Question Explanation
Correct Answer is B
Rationale: Palpating pulses in all extremities allows the nurse to evaluate the circulation to each
extremity. Pulses should be symmetrical. Assessing the apical pulse indicates cardiac output but
does not adequately assess peripheral circulation. Auscultating abdominal vascular sounds
assesses for aneurysms but does not assess for peripheral circulation. The client’s blood pressure
measures stroke volume and cardiac output.
Concepts tested

Question 2377
The nurse is reviewing the lab results of a client with diabetes type I. Which of the following
results indicates poor glucose control?
A Glycosylated hemoglobin level of 9.0%
B Fasting serum glucose of 100 mg/dl
C Oral glucose tolerance test result of 135 mg/dl
D Urinalysis glucose level of 0

Question Explanation
Correct Answer is A
Rationale: Glycosylated hemoglobin, or HgbA1C, is a measure of glucose control resulting from
glucose molecules attaching to hemoglobin for the life of the red blood cell (120 days). The
longer the glucose in the blood remains above normal, the more glucose binds to hemoglobin and
the higher the A1C level becomes. Normal values range from 4% to 6%. The target range for
people with diabetes is less than 7%. The other values indicate good glucose control.
Concepts tested

Question 2378
The nurse is performing a cardiac assessment on a client with a history of aortic valve
regurgitation. At which landmark should the nurse place the diaphragm of the stethoscope to
auscultate the aortic valve?
A Second intercostal space right of the sternal border
B Fifth intercostal space mid-clavicular line
C Second intercostal space left of the sternal border
D Fourth intercostal space left of the sternal border

Question Explanation
Correct Answer is A

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Rationale: When auscultating heart sounds, the nurse will use landmarks to identify where to
place the stethoscope. The aortic valve is located at the second intercostal space right of the
sternal border. The mitral valve is located at the fifth intercostal space mid-clavicular line. The
pulmonic valve is located at the second intercostal space left of the sternal border. The tricuspid
valve is located at the fourth intercostal space left of the sternal border.
Concepts tested

Question 2379
The nurse is educating a client about a newly placed implanted port. Which of the following
should the nurse include in the teaching?
A “You will have the sutures removed in one week.”
B “Clean the site once a day.”
C “Keep the external catheter secured to the chest wall.”
D “An x-ray will be needed before each use.”

Question Explanation
Correct Answer is D
Rationale: An implanted port is a type of long-term central venous access device, which is a
subcutaneous injection port attached to a catheter that sits in the superior vena cava. An
implanted port requires minimal care with the insertion site and equipment not visible. There are
no sutures or site care required by the client to maintain. The client should be instructed that an
x-ray will be needed before the use of the port.
Concepts tested

Question 2380
The charge nurse is observing a newly hired nurse caring for a client with a cast applied to the
left lower extremity for a femur fracture. Which of the following actions by the nurse requires
intervention?
A Performing frequent neurovascular checks on the left lower extremity
B Positioning the casted extremity below the level of the heart
C Applying ice to the casted extremity
D Encouraging the client to increase their fluid intake

Question Explanation
Correct Answer is B
Rationale: The casted extremity should be positioned above the level of the heart to reduce
edema. The charge nurse should intervene if the nurse positions the casted extremity below the
level of the heart as this can increase edema. Increased edema can cause neurovascular
complications. The nurse should perform frequent neurovascular checks, apply ice as needed,
and encourage increased fluid intake to prevent complications of immobility due to fractures,
such as constipation and renal stones.
Concepts tested

Question 2381
The nurse is caring for a client who had an epidural anesthesia during surgery. The nurse should
monitor the client for which complication of the epidural?
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A Hypoglycemia
B Hypotension
C Hypoxia
D Tachycardia

Question Explanation
Correct Answer is B
Rationale: Epidural anesthesia is a regional block where the anesthetic agent is injected into the
epidural space of the lumbar or thoracic spine. The client will have a loss of sensation below the
level of injection. Epidural anesthesia has the effect of vasodilation, which can lead to
hypotension. The client is awake with epidural anesthesia so will not have respiratory
depression. Tachycardia can occur with benzodiazepines, and hypoglycemia can occur with
nonbarbiturate hypnotics, which are used in moderate sedation.
Concepts tested

Question 2382
The charge nurse is observing unlicensed assistive personnel (UAP) obtain oxygen saturation
measurements of a client. Which of the following actions by the UAP requires intervention?
A Applying a clip oxygen sensor for a client with an adhesive tape allergy
B Placing the sensor on the fingertip of a client with severe peripheral vascular disease
C Removing the nail polish from a client’s nail prior to applying the sensor
D Positioning the sensor on the side of the finger for a client with thickened nails

Question Explanation
Correct Answer is B
Rationale: It requires intervention if the UAP is observed applying the sensor to the fingertip of a
client with peripheral vascular disease. Clients who take vasoconstrictive medications or have
circulatory compromise in their extremities should have their oxygen saturation measured from a
central location, such as the nose or forehead, to ensure accurate measurements. It is the correct
technique to use a clip sensor instead of an adhesive sensor for a client with an adhesive tape
allergy. It is the correct technique to remove nail polish to ensure accurate measurement and to
position the sensor on the side of the finger on clients with very thick nails that may otherwise
cause inaccurate measurements.
Concepts tested

Question 2383
A nurse is reviewing the urinalysis (UA) of a client admitted with prolonged vomiting and
diarrhea. Which finding on the UA is consistent with dehydration?
A Specific gravity of 1.035
B Positive ketones
C Protein level of 30 mg/dl
D Positive nitrites

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Question Explanation
Correct Answer is A
Rationale: The specific gravity on a urinalysis (UA) measures the kidney’s ability to concentrate
urine. In clients with fluid volume loss due to vomiting and diarrhea, the specific gravity is
expected to increase indicating dehydration. Positive ketones are not an expected finding for a
client with dehydration due to water loss. Positive ketones are consistent with conditions causing
ketosis. Positive protein in the urine is not an expected finding with volume loss. Proteinuria may
indicate glomerular damage or decreased tubular absorption. Positive nitrites are not an expected
finding with dehydration. Nitrites may indicate a urinary tract infection.
Concepts tested

Question 2384
A nurse is reviewing the findings of a nonstress test performed on a client who is 34-weeks
pregnant. Which finding indicates further assessments are required?
A There was 1 fetal heart acceleration for a period of 10 seconds throughout the test.
B Fetal heart rate decelerations were present with 50% of uterine contractions.
C There is an absence of fetal heart decelerations with 3 uterine contractions.
D The fetal heart rate accelerated 15 beats/min for 15 seconds multiple times.

Question Explanation
Correct Answer is A
Rationale: One fetal heart rate (FHR) acceleration for a period of 10 seconds is not an expected
finding on a nonstress test. A normal nonstress test on a client who is at least 32-weeks pregnant
is characterized by two or more fetal heart rate accelerations lasting 15 seconds or more. Fetal
heart rate decelerations in response to uterine contractions are abnormal findings with a
contraction stress test, not a nonstress test. The absence of FHR decelerations in relation to
uterine contractions is a normal finding of a contraction stress test. Multiple FHR accelerations
lasting 15 seconds with an acceleration of 15 beats/min is an expected finding.
Concepts tested

Question 2385
The nurse is reviewing laboratory results for a client who had a left-heart cardiac catheterization
1 hour ago. Which of the following findings is of greatest concern to the nurse?
A Creatinine level of 2.2 mg/dl
B Hemoglobin level of 14 g/dl
C Glucose level of 120 mg/dl
D Potassium level of 4.9 mEq/l

Question Explanation
Correct Answer is A
Rationale: A creatinine level of 2.2 mg/dl indicates possible contrast-induced acute kidney injury
following cardiac catheterization and requires follow-up and immediate treatment to prevent
further kidney damage. The other laboratory values are not of concern over the elevated
creatinine.
Concepts tested

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Question 2386
A nurse is preparing to obtain a urine culture from a client with an indwelling catheter. Which
action will the nurse take to collect the sample?
A Empty urine from the collection bag into a clean specimen container
B Detach the collection bag from the catheter and allow the urine to drain into the specimen
container
C Discontinue the indwelling catheter and obtain the sample when the client urinates
D Attach a syringe to the catheter access port and aspirate urine

Question Explanation
Correct Answer is D
Rationale: A urine sample from an indwelling catheter should be obtained from the access port to
ensure fresh urine. A syringe is required to aspirate the urine from the access port. A urine
sample should not be collected from the collection bag. The drainage bag is not considered
sterile and may alter the results of the urine culture. Detaching the collection bag from the
catheter is not required to obtain a urine sample. Detaching the bag may introduce bacteria into
the urethra. The indwelling catheter does not need to be discontinued to obtain a urine sample.
Concepts tested

Question 2387
A nurse is providing care to a client admitted for gastrointestinal bleeding. Which laboratory
finding will the nurse immediately report to the healthcare provider?
A PT of 12 seconds
B Albumin level of 3.8 g/dl
C INR of 1.6
D Hemoglobin level of 6.1 g/dl

Question Explanation
Correct Answer is D
Rationale: A hemoglobin level of 6.1 mg/dl should immediately be reported. Gastrointestinal
bleeding can lead to hemorrhage and shock. The normal hemoglobin level ranges from 12 to 18
g/dl A prothrombin time (PT) of 12 seconds and an international normalized ratio (INR) of 1.6
are slightly above normal and are expected findings in a client with gastrointestinal bleeding.
The normal PT time is 9.5 to 11.8 seconds, and the normal INR level is between 0.8 and 1.2. An
albumin level of 3.8 g/dl is slightly below normal and expected in a client with gastrointestinal
bleeding. The normal albumin level is between 4 and 6 g/dl.
Concepts tested

Question 2388
The nurse is obtaining a client’s health history. Which of the following statements by the client
indicates that they are at risk for insufficient vascular perfusion?
A “My father died of pneumonia when he was sixty years old.”
B “I am allergic to lots of different antibiotics.”
C “I have noticed that I am getting weaker as I get older
D “I get pain in my calves when I walk for more than a few minutes.”

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Question Explanation
Correct Answer is D
Rationale: Calf pain with activity is often caused by peripheral arterial disease. This would
indicate that the client is at risk for impaired perfusion. Allergies and age-related weakness are
not risk factors for peripheral vascular insufficiency. Certain aspects within family history may
be risk factors, but in this case, pneumonia does not affect the likelihood of peripheral vascular
conditions.
Concepts tested

Question 2389
The nurse is caring for a client who had a femoral cardiac catheterization with coronary artery
stent placement. Which of the following nursing actions is appropriate?
A Check the gag reflex prior to feeding the client
B Complete a neurovascular check of the lower extremities
C Perform passive range of motion to all extremities
D Keep the client in high Fowler’s position

Question Explanation
Correct Answer is B
Rationale: Rare, but serious, complications associated with cardiac catheterization include
bleeding, infection, and arterial obstruction. Nursing responsibilities after cardiac catheterization
include observing the site for bleeding or hematoma formation, assessing peripheral pulses, and
evaluating temperature, color, and capillary refill. Additional components of the neurovascular
check include assessing for pain, numbness, and tingling sensations that may indicate arterial
insufficiency. Clients will also be monitored for dysrhythmia. Bedrest will be maintained for a
duration determined by hospital policy and type of catheterization. The leg will remain straight,
and the head of the bed will be elevated less than 30 degrees.
Concepts tested

Question 2390
The nurse is caring for a client who was admitted for melena. The client has had severe
abdominal pain 2-3 hours after eating that has been occurring for several months. Which of the
following problems would be suspected?
A Duodenal ulcer
B Acute gastritis
C Esophageal varices
D Reflux disease

Question Explanation
Correct Answer is A
Rationale: Bleeding from duodenal ulcers is four times more common than from gastric ulcers.
Posterior duodenal ulcers are the most likely to bleed based on proximity to branches of the
gastroduodenal artery. Duodenal ulcers tend to differ from gastric ulcers in that abdominal pain
occurs 2-3 hours after eating vs immediately after eating. Because the duodenum is below the
pyloric sphincter, it is more likely to cause melena than upper GI bleeding. Esophageal varices
Page | 936
may cause hematemesis but do not cause pain associated with meals or melena. Gastritis and
reflux disease rarely lead to bleeding and would not cause melena.
Concepts tested

Question 2391
The nurse is inserting an indwelling urinary catheter into a male client. After cleaning the area,
which action should the nurse take?
A Inject the lubricant into the urinary meatus
B Instruct the client to take shallow breaths
C Insert the catheter until urine is observed in the tubing
D Hold the penis upright

Question Explanation
Correct Answer is A
Rationale: When inserting an indwelling urinary catheter into a male client, the priority of the
nurse is to prevent pain and trauma to the urinary meatus. The nurse should inject the lubricant
directly into the urinary meatus, which will provide adequate lubrication to prevent trauma. The
nurse should hold the penis perpendicular to the body, which allows the catheter to be inserted at
the natural angle of the urinary meatus. The catheter should be inserted all the way to the
bifurcation to ensure that the tip of the catheter is in the bladder before inflating the balloon. The
client should be instructed to bear down during catheter insertion, which relaxes the bladder
sphincter.
Concepts tested

Question 2392
A nurse is caring for a client who is receiving mechanical ventilation via an endotracheal tube.
When should the nurse suction a client's ET tube to maintain patency?
A When peripheral wheezes are heard in all lobes
B After the client completes deep breathing exercises
C When adventitious sounds are auscultated over the central airways
D After the ventilator alarms go off

Question Explanation
Correct Answer is C
Rationale: Adventitious sounds over the central airways indicate accumulation of secretions,
which need to be removed to maintain the airway. Wheezing in the lobes will not cause airway
obstruction. Ventilators alarm for many reasons, and the cause needs to be determined before
suctioning. Deep breathing exercises should help open and clear the airway, so suctioning is not
needed.
Concepts tested

Question 2393
The nurse is observing a newly hired nurse implement precautions during a client’s seizure.
Which of the following actions requires intervention?
A Applying padding to the client’s bed rails

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B Tucking the client’s chin to prevent aspiration
C Recording the time of onset of the seizure
D Removing sharp or hard objects to prevent injury

Question Explanation
Correct Answer is B
Rationale: It requires intervention if the nurse is observed tucking the client’s chin during a
seizure. The nurse should turn the head to the side to prevent aspiration as well as maintain a
patent airway and adequate oxygenation. It is the correct technique for the nurse to record the
time of onset of the seizure, apply padding to the side rails, and remove all hard or sharp objects.
Concepts tested

Question 2394
A nurse is preparing to administer bolus feedings to a client with a nasogastric tube. Which
action will the nurse perform to prevent aspiration?
A Turn off the suction after administering the feedings
B Hold the feeding syringe above the level of the abdomen
C Test the pH level of collected gastric contents
D Ensure the formula is administered at room temperature

Question Explanation
Correct Answer is C
Rationale: Testing the pH level of gastric contents is one method of checking for tube placement.
A gastric pH level below 4 is expected. The nurse should follow up with an alternate placement
check if the pH level is out of range. Turning off the suction allows for nutrient absorption;
however, it does not prevent aspiration. Holding the syringe above the level of the abdomen will
help the feedings flow by gravity; however, this does not prevent aspiration. Ensuring the
feedings are administered at room temperature will decrease gastric discomfort; however, it will
not prevent aspiration.
Concepts tested

Question 2395
A nurse is assessing a client post-bronchoscopy for tracheobronchial foreign body removal.
Which finding indicates the treatment was successful?
A Hyperresonance upon percussion
B Intercostal retractions upon inspiration
C Wheezing noted upon expiration
D Vesicular breath sounds upon auscultation

Question Explanation
Correct Answer is D
Rationale: A bronchoscopy is a procedure performed to remove foreign bodies from the airways
with the use of a scope. Vesicular breath sounds are a normal finding after a bronchoscopy.
Vesicular sounds indicate the airways are open and air is flowing adequately into the lungs.
Hyperresonance upon percussion is not a normal finding. Hyperresonance indicates air trapped

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in the lower airways. Intercostal retractions are not a normal finding. Retractions are indicative
of a blocked airway. Wheezing upon expiration is not a normal finding. Wheezing indicates a
narrowing of the airways.
Concepts tested

Question 2396
The nurse is caring for a client who has just undergone an abdominal aortic aneurysm repair.
Which of the following assessments should the nurse perform to ensure adequate peripheral
circulation?
A Palpate the lower extremity pulses
B Auscultate the carotid arteries
C Obtain manual blood pressure readings
D Inspect the surgical site

Question Explanation
Correct Answer is A
Rationale: Palpating pulses in the extremities allows the nurse to evaluate the circulation to each
extremity. Pulses should be symmetrical. The nurse would inspect the surgical site for signs of
bleeding or infection. Blood pressure measures cardiac output and stroke volume but does not
adequately assess peripheral circulation. The nurse would auscultate the carotid arteries to assess
for occlusions, which impair blood flow to the brain, not peripheral circulation.
Concepts tested

Question 2397
The nurse is caring for a client who is postoperative below the knee amputation. Which
assessment finding would indicate to the nurse that the client is at risk for delayed wound
healing?
A The client reports a strict vegetarian diet.
B Posterior popliteal pulses are 2+ with palpation.
C Post prandial blood glucose is 118 mg/dl.
D The client has a history of kidney transplant.

Question Explanation
Correct Answer is D
Rationale: Immunosuppressive therapy is increasingly being used in clinical practice and has
been shown to affect wound healing to varying degrees. It is shown that some agents affect
wound healing to such an extent that reduction or avoidance of these drugs until complete wound
healing is achieved is advocated. Clients who have had organ transplants are often on immune-
suppressing medications; therefore, this finding requires follow-up. While a vegan may be at risk
of protein deficit, the vegetarian is at less risk.
Concepts tested

Question 2398
The nurse is assessing a client with a wound on the left great toe. Which finding would indicate
to the nurse thatthe client is experiencing arterial insufficiency?
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A Copious serous drainage from the wound
B Opaque toenails that are thick
C Peripheral pulses palpated 2+ bilaterally
D Bilateral pedal +4 pitted edema

Question Explanation
Correct Answer is B
Rationale: The legs are most frequently affected by arterial insufficiency. Symptoms include
coldness, numbness, intermittent claudication, ulcerations, and muscle atrophy. Nails will
become thickened and opaque. Ulcerations are typically on the tips of the toes or between the
toes. Chronic venous insufficiency is characterized by pain described as aching or heavy. The
foot and ankle may be edematous. Ulcerations are in the area of the medial or lateral malleolus
(gaiter area) and are typically large, superficial, and highly exudative. Venous hypertension
causes extravasation of blood, which discolors the area.
Concepts tested

Question 2399
The nurse is teaching a client with varicose veins about sclerotherapy. Which information should
the nurse include in the teaching?
A “You must avoid wearing compression stockings before the procedure.”
B “You will be under general anesthesia for the procedure.”
C “You will receive intravenous injections during the procedure.”
D “You must remain on bed rest for 24 hours after the procedure.”

Question Explanation
Correct Answer is C
Rationale: Sclerotherapy involves the injection of a liquid or foam sclerosing substance directly
into varicose veins. The sclerosing agent causes endothelial inflammation ultimately resulting in
the destruction of varicose veins, which are subsequently disintegrated. Wearing compression
stockings generally improves varicose vein symptoms in clients awaiting sclerotherapy; there is
no reason to avoid wearing them even immediately prior to the procedure. Sclerotherapy is
performed in an outpatient setting without anesthesia. Bed rest is not necessary after
sclerotherapy.
Concepts tested

Question 2400
The nurse is caring for a client with a femur fracture who has a cast placed on the left lower
extremity. Which of the following client findings is a priority to follow up?
A Client reports mild pain
B Affected extremity is pink in color and warm to touch
C Moderate amounts of serous drainage are on the cast
D Petechiae is on the client’s chest

Question Explanation
Correct Answer is D

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Rationale: It is a priority for the nurse to follow up if the client has petechiae on the chest and
hypoxemia, which are signs of the life-threatening complication of fat embolism syndrome. After
addressing the possible complication, the nurse can then address the drainage and pain. A warm
and pink affected extremity indicates adequate circulation and does not require follow-up.
Concepts tested

Question 2401
The nurse is monitoring a client who received prescribed fentanyl during a bronchoscopy. The
nurse notes that the client’s respiratory rate is 10 breaths per minute. Which is the priority action
for the nurse to take?
A Administer IV naloxone
B Begin rescue breathing with bag-mask-valve
C Alert the rapid response team
D Raise the head of the bed

Question Explanation
Correct Answer is B
Rationale: Fentanyl is an opioid and is used to decrease pain during a procedure, like a
bronchoscopy. Opioids can decrease the respiratory drive leading to hypoventilation. The
priority action for a client with a low respiratory rate is to increase ventilation through rescue
breathing. Raising the head of the bed can assist with opening the airway but does not increase
ventilation. Naloxone is the medication that reverses the effect of opioids but breathing is the
priority. Once the nurse has provided ventilatory support to the client, the nurse would then alert
the rapid response team.
Concepts tested

Question 2402
The nurse is obtaining a thigh blood pressure on a client. Which of the following actions
indicates the correct technique?
A Assisting the client to a standing position prior to securing the cuff
B Placing the cuff with the compression bladder over the popliteal artery
C Inflating the cuff until the client’s toes are no longer pink
D Placing the stethoscope over the client’s dorsalis pedis artery

Question Explanation
Correct Answer is B
Rationale: It indicates the correct technique for obtaining thigh blood pressure if the compression
bladder is placed over the popliteal artery to ensure accurate measurement. Clients should be
assisted to a prone or supine position. The cuff should be inflated to 20 to 30 mmHg higher than
the brachial artery systolic pressure. The stethoscope should be placed over the popliteal artery.
Concepts tested

Question 2403
A nurse is providing care to a client with suspected community-acquired pneumonia. In addition
to a white blood cell count of 12,000/mm³, which diagnostic result does the nurse expect to find?

Page | 941
A Air volume of 1,500 mm on the incentive spirometer
B Increased areas of density on a chest x-ray
C HCO3 level of 20 mEq/l in an arterial blood gas
D Negative sputum culture

Question Explanation
Correct Answer is B
Rationale: Increased areas of density on a chest x-ray indicate consolidation of the lungs.
Community-acquired pneumonia (CAP) is a respiratory infection characterized by an increased
white blood cell count and inflammation of the airways. An incentive spirometer is a device used
to assess the volume of air inhaled with each breath. The incentive spirometer is not used to
diagnose pneumonia. Bicarbonate (HCO3) levels below normal do not indicate pneumonia. A
low level of HCO3 is indicative of metabolic acidosis. A negative finding on a sputum culture is
not consistent with an infectious respiratory disease process.
Concepts tested

Question 2404
A nurse is reviewing the results of an amniocentesis performed on a client who is pregnant. The
nurse knows that low levels of alpha-fetoprotein may indicate which fetal condition?
A Anencephaly
B Down syndrome
C Spina bifida
D Omphalocele

Question Explanation
Correct Answer is B
Rationale: Down syndrome is a chromosomal disorder associated with low levels of alpha-
fetoprotein (AFP). AFP is a fetal serum protein used to assess for neural tube defects or
chromosomal disorders. Anencephaly is the incomplete fetal skull and brain development. Spina
bifida is the incomplete development of the fetal spinal cord. Omphalocele is an abdominal wall
defect that results in the abdominal organs protruding into the umbilical cord. Anencephaly,
spina bifida, and omphalocele are neural tube defects associated with high levels of AFP.
Concepts tested

Question 2405
The nurse is reviewing laboratory results for a group of clients with diabetes. Which of the
following findings is of greatest concern to the nurse?
A Serum blood glucose level of 260 mg/dl
B Serum pH of 7.35
C Serum HC03 level of 18 mEq/l
D Hemoglobin A1C of 13%

Question Explanation
Correct Answer is D

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Rationale: The nurse should follow up for a hemoglobin A1C of 13%, which indicates long-term
uncontrolled blood glucose levels in a diabetic client. This places the client at greater risk of
complications of diabetes, such as diabetic ketoacidosis. The serum blood glucose is elevated;
however, this can be attributed to several factors, and the hemoglobin A1C is a better indicator of
diabetic glucose control. The serum pH and bicarbonate are within normal limits and indicate the
absence of complications, such as acidosis.
Concepts tested

Question 2406
A nurse is obtaining a wound culture from a client with an open perirectal abscess. Which action
will the nurse perform when collecting the sample?
A Don a sterile glove on the dominant hand before collecting the sample
B Apply an antimicrobial cleanser to the wound prior to obtaining the sample
C Swab the outside perimeter of the wound while obtaining the sample
D Irrigate the wound with sterile solution before collecting the sample

Question Explanation
Correct Answer is D
Rationale: The wound should be irrigated prior to collecting the sample to ensure wound debris
and previous drainage is removed. Sterile gloves are not required for a perirectal wound. A
perirectal abscess is not considered sterile. The wound should not be cleansed with an
antimicrobial cleanser. An antimicrobial cleanser may eliminate organisms necessary for the
identification of an infectious organism. The sample should be obtained from within the wound
borders to ensure an accurate culture.
Concepts tested

Question 2407
A nurse is reviewing the laboratory results of a client admitted with heat exhaustion. Which
laboratory finding will the nurse immediately report to the healthcare provider?
A Glucose level of 70 mg/dl
B Sodium level of 125 mEq/l
C BUN level of 26 mg/dl
D Potassium level of 3.2 mEq/l

Question Explanation
Correct Answer is B
Rationale: The nurse should immediately report a sodium level of 125 mEq/l. If not promptly
treated, hyponatremia can lead to seizures, coma, and death. The normal sodium level is 135 to
145 mEq/l. A glucose level of 70 mg/dl is a low-normal finding. Hypoglycemia is expected in a
client with heat exhaustion. The normal glucose level is 65 to 99 mg/dl. A blood urea nitrogen
(BUN) level of 26 mg/dl is slightly above normal and expected in dehydration due to
hemoconcentration. The normal BUN level is 6 to 20 mg/dl. A potassium level of 3.2 mEq/l is
slightly below normal. Dehydration due to skin water loss leads to hypokalemia. The normal
potassium level is between 3.5 and 5.0 mEq/l.
Concepts tested
Page | 943
Question 2408
The nurse is educating a client with diabetes mellitus on prevention of associated complications.
Which of the following statements by the nurse is appropriate?
A “You should inspect your feet frequently.”
B “Stop taking the medication if your glucose is controlled.”
C “You should limit your physical activity to prevent injury.”
D “Visit the ophthalmologist every few years.”

Question Explanation
Correct Answer is A
Rationale: Foot care for diabetic clients is important to prevent diabetic ulcers. Medications
should not be changed or discontinued without consulting with the treating provider. Physical
activity should not be limited, and proactive ophthalmologist visits should happen at least once
per year.
Concepts tested

Question 2409
The nurse is monitoring a client with a history of heart failure who is receiving a transfusion of
packed red blood cells (PRBCS). The client reports the sudden onset of shortness of breath, and
crackles are auscultated in the bases of the lungs. What is the priority assessment?
A Mental status assessment and metabolic panel
B Skin turgor and intake and output (I&O)
C Heart sounds and beta natriuretic peptide (BNP)
D Capillary refill and presence of edema

Question Explanation
Correct Answer is A
Rationale: Any fluid that increases intravascular volume can place the patient at risk of acute
circulatory overload. Increases in the extracellular fluid (ECF) can lead to swelling of cells in the
central nervous system initially causing confusion, which may progress to coma or seizures.
These findings can be best identified through laboratory tests and an assessment of mental status.
Although skin turgor, capillary refill, and heart sounds may also be affected by increases in ECF,
these are signs that do not have as immediate of an impact on patient outcomes as cerebral
edema.
Concepts tested

Question 2410
The nurse is caring for a client after a cerebrovascular accident who has altered mental status and
weakness. When performing oral care, which of the following positions will the patient be placed
in to reduce the risk of aspiration?
A Side-lying
B Semi Fowler's
C High Fowler's
D Reverse Trendelenburg

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Question Explanation
Correct Answer is A
Rationale: A side-lying position will allow liquids to drain out of the mouth, preferably onto a
towel or into a basin. A semi Fowler's or high Fowler's position will not protect the airway nor
would reverse Trendelenburg.
Concepts tested

Question 2411
The nurse has inserted an indwelling urinary catheter into a male client who is uncircumcised.
Which action should the nurse do next?
A Gently pull the catheter back into place
B Attach catheter to securing device
C Replace foreskin over the catheter
D Inflate the catheter tip balloon

Question Explanation
Correct Answer is D
Rationale: After inserting an indwelling urinary catheter into a male client who is uncircumcised,
the priority action by the nurse is to inflate the catheter tip balloon. Inflating the catheter tip
balloon ensures that the catheter will not dislodge from the bladder. Once the catheter tip is
inflated, then the nurse will gently pull the catheter back into place, replace the foreskin over the
catheter, and attach the catheter to a securing device.
Concepts tested

Question 2412
The nurse is preparing to administer a 250 ml bolus tube feed to a client with a percutaneous
endoscopic gastrostomy (PEG) tube. The nurse aspirates the gastric contents and measures 95 ml
of residual. Which action should the nurse take?
A Hold scheduled feeding
B Wait one hour before administering feeding
C Continue with the scheduled feeding as prescribed
D Administer half of the prescribed feeding

Question Explanation
Correct Answer is C
Rationale: Before administering a bolus tube feed, the nurse will aspirate the stomach contents
and measure residual. Residual is the amount of fluid left in the stomach from the previous
feeding. A residual amount of 200 ml or more could indicate that the client has not digested the
previous feeding. If the residual is 200 ml or more, the nurse should hold the scheduled feeding.
Any residual less than 200 ml means the nurse would administer the feeding as scheduled. A
nurse may need to reduce the amount of feeding or adjust the tube feeding time if the residual
amount continues to be above 200 ml.
Concepts tested

Page | 945
Question 2413
The nurse is observing a newly hired nurse implement measures to reduce the risk of falls in a
client with altered mental status. Which of the following actions requires intervention?
A Placing padding on the floor
B Raising all side rails
C Maintaining the bed in the lowest position
D Moving the client closer to the nurse’s station

Question Explanation
Correct Answer is B
Rationale: It requires intervention if the nurse is observed raising all side rails on the client’s bed.
This can be seen as entrapment and can often increase the risk of falls when the client attempts to
climb over the side rails. It is correct for the nurse to place padding on the floor along the sides
of the beds to reduce impact or injury in the event of a fall, to maintain the bed in the lowest
position to decrease the risk of injury from fall, and to move the client closer to the nurse’s
station to improve observation.
Concepts tested

Question 2414
A nurse is assessing the home of a client with a toddler. Which action will the nurse perform to
prevent the risk of aspiration?
A Place plastic bags out of reach
B Inspect the home for any paint chips
C Check the toys for loose parts
D Ensure medications are in child-proof containers

Question Explanation
Correct Answer is C
Rationale: Loose parts on toys or objects around the home increases the risk of aspiration. The
toddler may place the loose part in their mouth and cause an obstruction. Plastic bags increase
the risk of suffocation, not aspiration. Paint chips are a source of lead and can lead to poisoning
if ingested, not aspiration. Ensuring medications are in child-proof containers decreases the risk
of poisoning, not aspiration.
Concepts tested

Question 2415
A nurse is assessing a newborn after receiving phototherapy. Which clinical finding indicates the
therapy was successful?
A Bilateral PERRLA
B Serum bilirubin level of 7 mg/dl
C Axillary temperature of 36.7°C (98.0°F)
D Intact skin turgor

Question Explanation
Correct Answer is B

Page | 946
Rationale: A serum bilirubin level of 7 mg/dl is an expected finding after phototherapy.
Phototherapy is initiated when serum bilirubin levels are above 10 to 12 mg/dl in a newborn.
Pupils that are equal, round, and reactive to light and accommodation (PERRLA) are a normal
finding but unrelated to the intended effects of phototherapy. An axillary temperature of 36.7°C
(98.0°F) is a normal finding; however, phototherapy is not intended for this purpose. Intact skin
turgor is a normal finding and indicative of adequate hydration; however, this finding does not
evaluate the intended effects of phototherapy.
Concepts tested

Question 2416
The emergency department nurse is caring for a client after a fall with a head injury. Which
neurological assessment would the nurse complete first?
A Deep tendon reflexes
B Muscle strength
C Level of consciousness
D Cranial nerve assessments

Question Explanation
Correct Answer is C
Rationale: The client’s level of consciousness should be assessed prior to completing any other
neurological assessments. If the client is comatose, for example, the neurological assessment will
be different from someone who is alert.
Concepts tested

Question 2417
The nurse is assessing the abdominal incision of a client who is postoperative one week. Which
finding would indicate a delay in wound healing?
A Sanguineous drainage from the center of the incision is present.
B Incision edges are approximated.
C A scab has formed over the incision.
D There is slight tenderness around the incision line.

Question Explanation
Correct Answer is A
Rationale: Some manifestations of inflammation are to be expected (e.g., wound tenderness,
slight erythema, and edema); however, this should decrease over time, and there should be no
evidence of an infection at the wound site. Increased erythema and drainage are indicative of
infection. Pain that is controlled without narcotics is also to be expected.
Concepts tested

Question 2418
The nurse is assessing the skin of a client with dehydration. Which action by the nurse would
assess skin turgor?
A Push thumb into the skin and note the amount of time for the color to return
B Pinch the skin between thumb and finger to observe for tenting

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C Pull skin taut and detect temperature change
D Press skin between hands and identify any protrusions

Question Explanation
Correct Answer is B
Rationale: Turgor is the ability of the skin to return to place when pinched away from the body,
which assesses the skin’s elasticity. When the skin tents, or stands by itself, it is documented as
poor skin turgor and can indicate dehydration or extreme weight loss. Pushing a thumb into the
skin and noting the amount of time color returns measures blanching, which indicates perfusion
to the skin. Pulling the skin taut and checking for temperature and pressing skin between hands
to identify protrusions are techniques for assessing lesions or nodules.
Concepts tested

Question 2419
The nurse is caring for a client who is scheduled for an exercise stress test. Which statement
made by the client should indicate to the nurse that the client requires further teaching?
A "I'll take my heart medications the morning of my test."
B "I will not smoke prior to my test."
C "I will avoid eating for at least 8 hours.”
D "I'll skip my coffee the morning of my test."

Question Explanation
Correct Answer is A
Rationale: An exercise stress test is performed to assess the oxygen demand on the heart during
activity. A client with coronary artery disease, or blockages in the coronary arteries, will increase
the oxygen demand on the heart during exercise. The client should be instructed to avoid any
caffeine and smoking, which could cause vasoconstriction altering the results of the stress test.
The client should be NPO for at least 8 hours before the test. The client should be advised to hold
any medications that can cause vasodilation, which could alter the results of the test.
Concepts tested

Question 2420
The nurse is caring for a client with a pneumothorax who has a pleural chest tube connected to a
drainage system. Which of the following findings requires intervention?
A Bubbling in the water seal chamber during coughing
B Tidaling in the water seal chamber during inhalation and exhalation
C Absence of drainage in the drainage collection chamber
D Continuous bubbling in the suction control chamber

Question Explanation
Correct Answer is C
Rationale: It requires intervention if there is an absence of drainage in the drainage collection
chamber, which may indicate tube blockage or kinks which can result in a tension
pneumothorax. Bubbling in the water seal chamber during coughing, sneezing, or forceful
exhalation is expected, however, continuous bubbling may indicate an air leak and requires

Page | 948
follow-up. Tidaling in the water seal chamber and continuous gentle bubbling in the suction
control chamber indicate proper functioning of the chest tube.
Concepts tested

Question 2421
The nurse is assisting the healthcare provider administer a Tensilon test to a client with suspected
myasthenia gravis. Which medication should the nurse have at the bedside during the test?
A Metoprolol
B Diltiazem
C Atropine
D Digoxin

Question Explanation
Correct Answer is C
Rationale: To diagnosis myasthenia gravis, a Tensilon test is administered by the healthcare
provider. During the test, the client will receive an IV injection of edrophonium chloride which
is an anticholinesterase agent. Edrophonium can cause a decrease in heart rate, requiring atropine
at the bedside to counteract the effects of the anticholinesterase agent. Beta-blockers, calcium
channel blockers, and cardiac glycosides increase the effects of bradycardia.
Concepts tested

Question 2422
The nurse is assessing a client’s pulse rate and quality. Which of the following pulse sites should
the nurse avoid assessing bilaterally at the same time?
A Popliteal
B Carotid
C Femoral
D Brachial

Question Explanation
Correct Answer is B
Rationale: The carotid arteries should never be palpated at the same time due to occlusion of the
arteries that supply the brain. This action could cause impaired cerebral blood flow or stimulate a
vagal response and therefore reflex bradycardia and hypotension. Other pulse sites may be
palpated simultaneously to assess for equality.
Concepts tested

Question 2423
A nurse is assessing a client with suspected atrial fibrillation. The client’s apical and radial
pulses are inconsistent when palpated. Which finding does the nurse expect to observe on the
electrocardiogram (ECG)?
A Atrial rate of 150 beats/min
B ST elevation
C QRS complex of 0.24
D Absent P waves

Page | 949
Question Explanation
Correct Answer is D
Rationale: The absence of P waves on an electrocardiogram (ECG) is indicative of atrial
fibrillation. The P wave represents atrial contractions, which are ineffective in atrial fibrillation.
An atrial rate of 150 beats/min is not consistent with atrial fibrillation. In atrial fibrillation, the
atrial rate is often unmeasurable and can exceed 350 beats/min. A QRS complex of 0.24 is not
characteristic of atrial fibrillation. Prolonged QRS complexes are common with ventricular
dysrhythmias. ST elevation is not characteristic of atrial fibrillation; it is used to measure
ventricular conduction.
Concepts tested

Question 2424
A nurse is reviewing the results of an amniocentesis performed on a client who is 36-weeks
pregnant. Which finding indicates fetal lung maturity?
A Absence of PG
B hCG level of 5,400 mIU/ml
C L/S ratio of 2:1
D High AFP levels

Question Explanation
Correct Answer is C
Rationale: A lecithin/sphingomyelin (L/S) ratio of 2:1 indicates fetal lung maturity. L/S are
pulmonary surfactants found in amniotic fluid. An absence of phosphatidylglycerol (PG) is
indicative of respiratory distress. PG is a lipid found in pulmonary surfactants that helps prevent
alveolar collapse. A human chorionic gonadotropin (hCG) level of 5,400 mIU/ml is an expected
finding at 36 weeks gestation. Levels of hCG are not indicative of fetal lung maturity and are
determined by a blood test. High alpha-fetoprotein (AFP) levels are associated with fetal neural
tube defects.
Concepts tested

Question 2425
The nurse is reviewing laboratory results for a client with hepatic cirrhosis. Which of the
following findings is of greatest concern to the nurse?
A Elevated alkaline phosphatase (ALT) level
B Prothrombin time of 25 seconds
C Elevated serum bilirubin level
D Hemoglobin (Hgb) of 14 g/dl

Question Explanation
Correct Answer is B
Rationale: A prothrombin time of 25 seconds is elevated and indicates an increased risk of
bleeding due to hepatic cirrhosis. The client should be closely monitored for signs and symptoms
of hemorrhage. The ALT and bilirubin levels are elevated in hepatic cirrhosis, and this is an
expected finding. The Hgb level is within normal limits and indicates no active bleeding at this
time.
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Concepts tested

Question 2426
A nurse is obtaining an oropharyngeal swab from a client with a suspected respiratory infection.
Which action does the nurse perform while collecting the sample?
A Rotate the swab along the client’s buccal area
B Ensure the swab collects a sample from the client’s tongue
C Rub the swab over the client’s posterior throat
D Collect the sample along the client’s gumline

Question Explanation
Correct Answer is C
Rationale: The swab should be rubbed over the posterior pharynx and tonsillar pillars, if present
in the client, to ensure an adequate sample. The buccal area is not an appropriate collection site
for an oropharyngeal swab. The specimen should be collected from the back of the throat and
tonsillar area. A sample from the client’s tongue is not necessary for an oropharyngeal swab. The
tongue should be depressed to allow visualization of the back of the throat. The swab should not
touch the client’s teeth, tongue, or gums.
Concepts tested

Question 2427
A nurse is assessing a client with a percutaneous endoscopic gastrostomy (PEG) tube who is
receiving intermittent feedings. Which observation increases the client’s risk for aspiration?
A The client’s head of the bed is at 30 degrees.
B Bowel sounds are hypoactive upon auscultation.
C There are 450 ml of gastric residuals.
D The client’s abdomen appears rounded upon inspection.

Question Explanation
Correct Answer is C
Rationale: Gastric residuals above 250 milliliters are associated with an increased risk of
aspiration. The nurse should withhold feedings to avoid regurgitation. The head of the bed at 30
degrees is the proper placement for a client with a feeding tube. Hypoactive bowel sounds are
not associated with a higher risk of aspiration. The nurse should further assess the client for
possible constipation. A rounded abdomen is a normal finding. A distended abdomen is
indicative of poor toleration of feeds.
Concepts tested

Question 2428
The nurse is providing discharge teaching for a client who has a spinal cord injury. Which of the
following statements by the nurse should be included in the teaching?
A “Reduce your fluid intake to prevent episodes of incontinence.”
B “Complete range of motion exercises to prevent contractures.”
C “Your caregiver should do all of your self-care activities to prevent falls.”
D “Eat a diet low in protein to strengthen your immune system.”

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Question Explanation
Correct Answer is B
Rationale: Contractures occur due to the lack of use of the musculoskeletal system; therefore, it
is important to perform range of motion activities to reduce the risk of developing contractures.
Fluid intake should not be decreased, and the client’s diet should be high in protein. The client
should do as much self-care as they can to maintain independence.
Concepts tested

Question 2429
The nurse is assessing a client with diabetes type 2 who had a CT scan of the abdomen with
contrast dye. The nurse identifies that the client received the prescribed dose of metformin after
the diagnostic test. Which of the following laboratory findings indicates a complication?
A Elevated lactate level
B Decreased blood urea nitrogen (BUN) level
C Increased glomerular filtration rate (GFR)
D Low mixed venous oxygen saturation

Question Explanation
Correct Answer is A
Rationale: Clients taking metformin are at increased risk for acute kidney injury and lactic
acidosis with the use of iodinated contrast material for diagnostic studies; metformin should be
stopped 48 hours prior to and 48 hours after the use of contrast agent or until kidney function is
evaluated and normal. In kidney failure, BUN would increase and GFR would decrease. Mixed
venous oxygen saturation is used in clients with impaired tissue perfusion.
Concepts tested

Question 2430
The nurse is providing perineal care for the client with an indwelling urinary catheter. What
actions should be included in the care?
A Apply a new leg strap to the catheter
B Keep the drainage bag on the bed with the client
C Wash the external catheter surface with soap and water
D Lay the drainage bag on the floor to allow for maximum drainage through gravity

Question Explanation
Correct Answer is C
Rationale: The meatus should be gently washed with soap and water to remove obvious
encrustations from the external catheter surface. Leg straps are changed when soiled and are not
part of peri-care. To avoid the backflow of contaminated urine into the bladder, increasing the
chance of infection, don't raise the collection bag above the level of the client's bladder. To
prevent contamination of the closed system, never let the drainage bag touch the floor; hang it on
the bed in a dependent position.
Concepts tested

Question 2431
Page | 952
The nurse is caring for a client with a percutaneous feeding tube (PEG). Which of the following
actions requires intervention?
A Cleansing the site with alcohol-soaked gauze Correct Answer
B Drying the site thoroughly after cleansing
C Applying a split-drain dressing around the insertion site
D Flushing the tube with warm water for patency

Question Explanation
Correct Answer is A
Rationale: It requires intervention if the nurse is observed cleansing the site with alcohol, which
can cause skin irritation. PEG tube sites should routinely be cleansed with soap and warm water,
and occasional use of hydrogen peroxide or normal saline is permitted. Sites should be dried
thoroughly after cleansing, a split-drain dressing can be applied to provide comfort and prevent
skin breakdown, and warm water should be used to flush the tube for patency.
Concepts tested

Question 2432
The nurse is planning interventions to prevent autonomic dysreflexia for a client with spinal cord
injury at the level of T4. Which of the following, if included in the nursing plan, requires follow-
up?
A Monitor the client for fecal impaction and administer stool softeners as prescribed
B Apply antiembolism stockings for venous thromboembolism prophylaxis
C Monitor client for urinary retention and perform urinary catheterization as needed
D Apply lidocaine ointment to sacral pressure ulcer as prescribed for comfort

Question Explanation
Correct Answer is B
Rationale: It requires follow-up if the nurse implements antiembolism stockings, as one of the
precipitating factors for the development of autonomic dysreflexia is constrictive clothing, which
should be removed. It is correct to implement measures to reduce bladder distention, fecal
impaction, and tactile stimulus on the skin, such as pain from pressure ulcers, which are all
known triggers for autonomic dysreflexia.
Concepts tested

Question 2433
A nurse is preparing to feed a client with right hemiplegia and dysphagia. Which action will the
nurse perform to prevent aspiration
A Place the food tray on the client’s left side
B Raise the head of the bed to a high Fowler’s position
C Instruct the client to extend the neck back while swallowing
D Ensure the food on the tray is liquid consistency

Question Explanation
Correct Answer is B

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Rationale: Raising the head of the bed to a high Fowler’s position reduces the risk of
regurgitation and aspiration during meals. Placing the food tray on the client’s left side will
facilitate participation from the client during meals; however, this does not prevent aspiration.
The neck should be flexed slightly forward when swallowing to decrease the risk of aspiration.
Extending the neck back may cause choking. The consistency of the food should be determined
by the speech-language pathologist to minimize the risk of choking. Liquid food may need to be
thickened before administering.
Concepts tested

Question 2434
A nurse is assessing a client post small bowel resection with ileostomy placement. Which
clinical finding indicates a surgical complication?
A The client verbalizes abdominal pain upon palpation.
B The collection bag is empty.
C The stoma is pale pink and dry.
D The client reports nausea after a meal.

Question Explanation
Correct Answer is C
Rationale: A pale pink, dry stoma is indicative of ischemia. Decreased circulation to the area can
lead to necrosis. The nurse should report this finding promptly. Pain around the area of the stoma
is an expected finding after a surgical procedure. The nurse should administer prescribed
analgesics. An empty collection bag is not an abnormal finding after a small bowel resection. An
ileostomy drains 24 to 48 hours after surgical placement. Nausea after a surgical procedure is a
common finding. The nurse should monitor for vomiting and other gastrointestinal issues.
Concepts tested

Question 2435
The nurse is assessing a client and notes a left-sided facial droop that was not present during
their last interaction. Which of the following assessments should the nurse perform to evaluate
the client’s neurological status?
A Assess the client for arm drift
B Perform a swallow screen
C Obtain the client’s oxygen saturation
D Assess for orthostatic hypotension

Question Explanation
Correct Answer is A
Rationale: The client should be assessed prior to completing any other neurological assessments.
If the client is comatose, for example, the neurological assessment will be different from
someone who is alert.
Concepts tested

Question 2436

Page | 954
The nurse is caring for a client who had surgical wound debridement and vacuum-assisted
wound closure dressing applied to a stage 4 sacral pressure injury. Which finding should indicate
to the nurse that the client has an increased risk for delayed wound healing?
A Low serum albumin levels
B Serosanguinous drainage in the vac tubing
C Increased granulation tissue in the wound bed
D Elevation in white blood cell count

Question Explanation
Correct Answer is A
Rationale: Protein deficiency must be corrected to promote the healing of the pressure ulcer.
Carbohydrates are necessary to “spare” the protein and to provide an energy source. Vitamin C
and trace elements, especially zinc, are necessary for collagen formation and wound healing.
Vacuum-assisted closure (VAC) involves the use of a negative-pressure sponge dressing in the
wound to increase blood flow, increase the formation of granulation tissue and nutrient uptake,
and decrease bacterial load; therefore, increased granulation tissue indicates the therapy is
working. An elevation in white blood cell count is normal with a client who had surgery and has
a stage 4 sacral pressure injury from the inflammatory process.
Concepts tested

Question 2437
The nurse is assessing a client with glaucoma. To assess the client’s peripheral vision, which
technique should the nurse perform?
A Confrontation
B Gaze positions
C Corneal reflex
D Jaeger

Question Explanation
Correct Answer is A
Rationale: A client with glaucoma will have a decrease in peripheral vision, which can be tested
with the confrontation test. The nurse will have the client cover an eye while the nurse covers the
opposite eye. The nurse will then bring an object or their fingers slowly into the field of vision
midway between the client and the nurse. The corneal reflex is used to test pupillary response
and assess cranial nerve II. The Jaeger test is used to test visual acuity. The gaze positions are
used to test oculomotor function and cranial nerves III, IV, and VI.
Concepts tested

Question 2438
The nurse is discussing with a client who has a prescription for thyroid-stimulating level the
purpose of the diagnostic test. Which statement should the nurse make?
A “This test measures the function of your thyroid gland.”
B “This test detects if there are antithyroid antibodies in your blood.”
C “This test measures the rate of absorption of iodine by your thyroid gland.”
D “This test detects the amount of thyroid hormone circulating in your blood.”

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Question Explanation
Correct Answer is A
Rationale: The most reliable laboratory test for thyroid function is the thyroid-stimulating
hormone (TSH) level. The TSH measures if the thyroid is overactive (hyperthyroidism) or
underactive (hypothyroidism).
Concepts tested

Question 2439
The nurse is caring for a client with a chest tube in place. Which of the following findings
requires intervention?
A Continuous bubbling in the water seal chamber
B Tidaling in the water seal chamber during inhalation and exhalation
C Moderate amount of serosanguinous drainage in the drainage collection chamber
D Continuous bubbling in the suction control chamber

Question Explanation
Correct Answer is A
Rationale: It requires follow-up if there is continuous bubbling in the water seal chamber, as this
indicates a possible air leak which can lead to a tension pneumothorax. Tidaling in the water seal
chamber, continuous bubbling in the suction control chamber, and drainage in the drainage
collection chamber all indicate effective functioning of the chest tube.
Concepts tested

Question 2440
The nurse is assessing a client who is postoperative 8 hours from a left pneumonectomy for lung
cancer. Which finding should the nurse expect to observe?
A Diminished breath sounds bilaterally with auscultation
B Sternal incision with dressing
C Pleural chest tubes to suction
D Positioned on the unaffected side
Positioned on the unaffected side

Question Explanation
Correct Answer is C
Rationale: A pneumectomy is the removal of an entire lung. The client postoperatively will have
absent breath sounds on the affected side, chest tubes to suction, and a posterior incision. The
nurse should position the client on the operative side to facilitate lung expansion.
Concepts tested

Question 2441
The nurse has attended a staff education conference about
electroconvulsive therapy (ECT). Which of the following statements indicates a need for further
teaching?

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A “Clients will have 4 electrodes placed on their scalp, which deliver an electrical current and
monitor brain activity.”
B “General anesthesia is given during the procedure; therefore, cardiac and airway monitoring is
required.”
C “Clients may experience memory loss following the procedure, which may resolve over time.”
D “It is a medical emergency if the client experiences a seizure during the procedure.”

Question Explanation
Correct Answer is D
Rationale: It requires further teaching if the nurse states that it is a medical emergency if the
client experiences a seizure during the procedure. The goal of ECT is to induce seizure activity
in the brain that may improve depression and bipolar disorder by affecting chemicals and
neurons in the brain. Clients will have 4 electrodes placed on their scalp: 2 for monitoring brain
activity and 2 for delivering an electrical current. General anesthesia is provided during
the procedure, and clients should be monitored closely for airway or cardiovascular compromise.
Memory loss is a common and temporary side effect of ECT.
Concepts tested

Question 2442
The nurse in an urgent care clinic is observing unlicensed assistive personnel (UAP) obtain
temperature measurements for assigned clients. Which of the following actions by the UAP
requires intervention?
A Obtaining a rectal temperature for a 2-month-old client whose parent reports frequent
vomiting
B Obtaining a temporal artery temperature on a 4-year-old client who is reporting an earache
C Obtaining an oral temperature for a 56-year-old client who is reporting a headache and
fatigue
D Obtaining a tympanic temperature for an 86-year-old client whose family member is reporting
new onset of confusion

Question Explanation
Correct Answer is A
Rationale: It requires intervention if the UAP is observed obtaining a rectal temperature on a 2-
month-old client. Rectal temperatures are contraindicated in infants due to increased risk of
rectal perforation, as well as clients experiencing diarrhea, a history of rectal surgery, or bleeding
hemorrhoids. The other actions all indicate appropriate techniques for obtaining temperature
measurements for the clients' situations.
Concepts tested

Question 2443
A nurse is providing care to a client with suspected syphilis. The client’s rapid plasma reagin
(RPR) is reactive. Which positive diagnostic finding confirms the diagnosis?
A VDRL serum test

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B Western blot analysis
C FTA-ABS test
D Microscopic clue cells

Question Explanation
Correct Answer is C
Rationale: The fluorescent treponemal antibody absorption (FTA-ABS) is a confirmatory blood
test for syphilis. The FTA-ABS confirms the presence of antibodies to the bacteria that causes
syphilis. The venereal disease research laboratory (VDRL) serum test is a screening tool for
syphilis. A positive result does not confirm the infection and can be secondary to autoimmune
disorders. The Western blot analysis is used to confirm the presence of human immune
deficiency virus (HIV). Microscopic clue cells are not indicative of syphilis. Clue cells are
obtained from vaginal tissue and present in clients with bacterial vaginosis.
Concepts tested

Question 2444
A nurse is providing care to a client with a nasogastric tube receiving continuous feedings. The
nurse is informed by the healthcare provider that the client’s chest x-ray reveals areas of
consolidation in the lungs. Which action does the nurse expect to perform?
A Discontinue the nasogastric tube
B Switch to bolus feedings
C Irrigate the nasogastric tube
D Stop the continuous feedings

Question Explanation
Correct Answer is D
Rationale: Areas of consolidation on a chest x-ray indicate fluid or solid contents within the
lungs. A client receiving feedings via a nasogastric (NG) tube is at risk for aspiration. The nurse
should expect to stop the feedings. Discontinuing the NG tube is not indicated. An NG tube can
be repositioned if necessary. Switching to bolus feeds will not correct the problem of aspiration.
Irrigating the NG tube is contraindicated. Irrigation may cause further accumulation of fluid in
the lungs.
Concepts tested

Question 2445
The nurse has taught a client about arterial blood gas (ABG) testing. Which of the following
statements by the client indicates the need for further teaching?
A “This test will assist with measuring my respiratory function.”
B “I can have this test added on to my other laboratory results as needed.”
C “I will need to have pressure applied for several minutes to my puncture site following the
procedure.”
D “This test can determine the acidity of my blood and if my body is compensating
appropriately.”

Question Explanation

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Correct Answer is B
Rationale: The purpose of arterial blood gas testing is to determine respiratory function, gas
exchange, and acid-base balance in the body and determine any compensatory mechanisms that
are occurring. The test requires a separate lab draw involving an arterial stick and cannot be
added on to other standard venous laboratory testing. Since the test involves an arterial stick,
pressure must be applied for several minutes to ensure hemostasis.
Concepts tested

Question 2446
A nurse is preparing to collect a guaiac fecal occult blood test from a client with suspected
gastrointestinal bleeding. Which action does the nurse perform when collecting the sample?
A Collects two samples from different areas of the stool
B Uses one wooden applicator to smear the samples of stool on the test card
C Places a couple of drops of developer over the stool samples
D Obtains the stool samples from the toilet bowl

Question Explanation
Correct Answer is A
Rationale: Samples should be collected from different areas of the stool to increase the accuracy
of detecting occult blood. A different applicator should be used for each smear to ensure a fresh
sample is applied each time. The developer should be placed on the opposite side of the test card.
Samples should not include toilet bowl water as this can cause errors in the testing.
Concepts tested

Question 2447
A nurse is performing an initial assessment on a newly admitted client. Which finding increases
the client’s risk for aspiration?
A The client’s Glasgow Coma Scale is 14.
B Crepitus is present at the temporomandibular joint.
C The tonsils are a 1+.
D The client has an absent gag reflex.

Question Explanation
Correct Answer is D
Rationale: An absent gag reflex can impair the ability to swallow and increases the risk for
aspiration. A Glasgow Coma Scale (GCS) score of 14 is not indicative of a risk for aspiration.
The normal GCS is 15 based on eye, motor, and verbal responses. Crepitus at the
temporomandibular joint (TMJ) is not associated with a risk for aspiration. Crepitus is not an
indication of the inability to swallow. Tonsils with a grade of +1 is a normal finding. A grade of
+1 indicates the tonsils obstruct 0 to 25% to midline. This is not indicative of a risk for
aspiration.
Concepts tested

Question 2448
The nurse is educating clients at a community center about preventing complications of
hypertension. Which of the following statements should the nurse include in the teaching?
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A “Only take your medication if your blood pressure is high.”
B “Quitting smoking tobacco will reduce your risk of stroke.”
C “Increase your calorie intake to have more energy.”
D “Physical activity should be minimal to avoid cardiovascular stress.”

Question Explanation
Correct Answer is B
Rationale: Smoking and hypertension significantly increase the risk of cerebrovascular accidents;
therefore, the client who has high blood pressure should be educated on the importance of
smoking cessation. Blood pressure medications should be taken consistently to maintain normal
blood pressure. Calories should not be increased, and physical activity is beneficial for
hypertensive clients.
Concepts tested

Question 2449
The nurse is monitoring a client who is receiving moderate sedation during a colonoscopy.
Which finding would indicate to the nurse that the client is experiencing a complication of the
sedation?
A Blood pressure of 93/54
B Heart rate of 100
C Glasgow Coma Scale of 13
D Respiratory rate of 12

Question Explanation
Correct Answer is A
Rationale: The goal of moderate sedation is to depress a patient’s level of consciousness to
enable surgical, diagnostic, or therapeutic procedures. With moderate sedation, the patient is able
to maintain a patent airway, retain protective airway reflexes, and respond to verbal and physical
stimuli. A common adverse effect of moderate sedation is hypotension. The frequent assessment
of the patient’s vital signs, level of consciousness, and cardiac and respiratory function is an
essential component of moderate sedation.
Concepts tested

Question 2450
The nurse is caring for a client who is present for a third trimester prenatal visit. While lying on
the examination table in the supine position, the client reports feeling lightheaded and nauseous.
What action should be taken by the nurse?
A Change the client’s position to semi-Fowler's
B Have the client roll into the knee chest position
C Turn the client onto the left side Correct Answer
D Ask the client to sit up

Question Explanation
Correct Answer is C

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Rationale: The heavy uterus can fall back against the inferior vena cava in the supine position
resulting in vena cava compression, which reduces venous return and decreases cardiac output
and blood pressure. This change, called supine hypotensive syndrome, causes symptoms of
weakness, light-headedness, nausea, dizziness, or syncope. These changes are reversed in the
side-lying position, which displaces the uterus to the left and off the vena cava. Asking the client
to sit up may worsen the symptoms. Knee chest position is used when fetal distress occurs due to
cord compression. Semi-Fowler's positioning does not relieve vena cava compression.
Concepts tested

Question 2451
While inserting an indwelling urinary catheter into a male client, the nurse is met with resistance.
Which action should the nurse take?
A Press two fingers above the pubic bone
B Attempt to rotate the catheter
C Obtain a smaller size catheter
D Advise the client to hold their breath

Question Explanation
Correct Answer is B
Rationale: With male clients, the indwelling urinary catheter is inserted into the urinary meatus
and guided through the urethra. Resistance with insertion often occurs when guiding the catheter
through the urethra where the prostate lies. The prostate, which is the gland that surrounds the
urethra, can be enlarged. If resistance is met, the nurse should gently rotate the catheter and
instruct the client to take slow, deep breaths. If the catheter does not advance, then the nurse
should remove the catheter and contact the healthcare provider. For clients with a retracted penis,
the nurse will press two fingers above the pubic bone. A smaller catheter size may be needed if
there is urine leaking.
Concepts tested

Question 2452
The nurse has attended a staff education conference about maintenance of percutaneous feeding
tubes. Which of the following statements indicates a need for further teaching?
A “Tube sites should be cleansed with soap and warm water.”
B “Clients will experience mild leakage around the insertion site after feedings.”
C “Sites should be assessed for skin breakdown, warmth, and redness.”
D “Reports of pain during or after feeding should be reported immediately.”

Question Explanation
Correct Answer is B
Rationale: It requires further teaching if the nurse states that leakage around the insertion site is
to be expected. Any leakage around the site indicates possible tube malfunction and should be
reported immediately. It is the correct technique for tubes to be cleansed with soap and water, for
sites to be assessed for skin breakdown, warmth, and redness, and for pain with feeding or
medication administration to be reported immediately.
Concepts tested

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Question 2453
The nurse has taught a client who is scheduled for electroconvulsive therapy (ECT). Which of
the following statements by the client indicates the need for further teaching?
A “I should expect to see improvement in my symptoms after this first treatment.”
B “It is common to experience headaches or nausea following a treatment.”
C “I may feel confused for several hours following a treatment.”
D “It is possible to experience mild memory loss from events that occurred before my
treatment.”

Question Explanation
Correct Answer is A
Rationale: It requires further teaching if the client states that improvement in symptoms should
occur after the first treatment. ECT is often required for four to six treatments before
improvement in symptoms is noticed by clients. Clients may experience physical symptoms after
a treatment, such as headaches and nausea, or may experience confusion for minutes to hours
after a treatment. Some clients may experience memory loss related to events right before an
ECT therapy, and in some cases, forget events from weeks to months before treatment.
Concepts tested

Question 2454
A nurse is providing oral hygiene to a client who is unconscious. Which action will the nurse
perform to prevent aspiration?
A Gently brush the client’s teeth with a soft toothbrush
B Position the client supine with the head turned away
C Ensure suction set up is available at the bedside
D Place a finger on top of the client’s tongue while brushing

Question Explanation
Correct Answer is C
Rationale: Suction equipment should be available at the bedside when performing oral hygiene
on a client who is unconscious. The nurse should be prepared to suction oral secretions to
prevent aspiration. Brushing the client’s teeth with a soft toothbrush will protect a fragile oral
mucosa; however, it will not prevent aspiration. The client’s head should be turned towards the
nurse for better visualization of secretions. Fingers should never be placed into the mouth of a
client who is unconscious. The client may accidentally bite down and cause injury to the fingers.
Concepts tested

Question 2455
The nurse is assessing a client with left-sided heart failure. Which of the following findings
indicates that the client is experiencing a complication of this condition?
A Oliguria
B Pitting edema
C Peripheral neuropathy
D Orthopnea

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Question Explanation
Correct Answer is D
Rationale: A complication of left-sided heart failure is pulmonary congestion that can cause the
client to have dyspnea, orthopnea, crackles in the lungs, and low oxygen saturation. Pitting
edema is a complication of right-sided heart failure and neuropathy, and oliguria is not directly
affected by heart failure.
Concepts tested

Question 2456
The nurse is assessing a client who has amyotrophic lateral sclerosis. Which of the following
would be an abnormal neurological finding?
A Dilated pupils
B Weakness of the hands
C Brisk deep tendon reflexes
D Lack of coordinated movements

Question Explanation
Correct Answer is A
Rationale: Amyotrophic lateral sclerosis is a progressive condition that causes deterioration of
motor neurons. Expected findings include muscle weakness, loss of coordinated movements,
hyperactive reflexes, etc. Dilated pupils would be an abnormal finding and require further
assessment.
Concepts tested

Question 2457
The nurse is planning care for a group of clients who have had surgery. Which client should the
nurse understand has the highest risk for delayed wound healing?
A The client who had a mastectomy and who is receiving prescribed chemotherapy
B The client with diabetes type 1 who had a laparoscopic cholecystectomy
C The client with renal failure who had an atrioventricular graft placed
D The client who had a bowel resection and who is receiving prescribed IV antibiotics

Question Explanation
Correct Answer is A
Rationale: Combining other treatment methods, such as radiation and chemotherapy, with
surgery contributes to postoperative complications, such as infection, impaired wound healing,
altered pulmonary or renal function, and the development of venous thromboembolism (VTE).
The nurse completes a thorough preoperative assessment for factors that may affect the patient
undergoing the surgical procedure. While the other clients may have some immunosuppression,
the client receiving chemotherapeutics is at greatest risk for delayed wound healing.
Concepts tested

Question 2458
The nurse is preparing to assess a client who is recovering from abdominal surgery with general
anesthesia. Which is the priority assessment for the nurse to perform?

Page | 963
A Note the presence of any surgical drains
B Measure the client’s respiratory rate
C Observe the surgical incision
D Check the client’s IV site

Question Explanation
Correct Answer is B
Rationale: Frequent assessments of the patient’s airway, respiratory function, cardiovascular
function, skin color, level of consciousness, and ability to respond to commands are the
cornerstones of nursing care in the postoperative period. While the client may have been in the
post-anesthesia care unit, it is still a priority to assess these areas in the surgical unit as some
clients may clear anesthetics more slowly than others. Impaired neurological function from
anesthesia will affect the client’s ability to protect the airway from complications, such as
hypopharyngeal obstruction & aspiration, and ventilate adequately. While all other assessments
are appropriate, the airway is the priority.
Concepts tested

Question 2459
The nurse is providing discharge instructions about symptom management to a client newly
diagnosed with multiple sclerosis. Which statement should the nurse include in the instructions?
A “Wear an eye patch on the right eye at all times to prevent diplopia.”
B “Relaxing in a hot tub will help with your muscle spasticity.”
C “Implement a schedule to include periods of rest.”
D “Make sure you keep your immunizations up to date.”

Question Explanation
Correct Answer is C
Rationale: Clients with MS should be instructed on how to manage symptoms, which should
include implementing periods of rest to prevent muscle fatigue, increasing fiber in the diet,
avoiding extremes in temperature, and decreasing stress. Clients do not need to wear an eye
patch to prevent diplopia. Clients should be taught to identify triggers of exacerbations, such as
immunizations, trauma, and stress.
Concepts tested

Question 2460
The nurse is caring for a client who had a transurethral resection of the prostate (TURP) 1 day
ago and has continuous bladder irrigation in place. Which of the following findings requires
intervention?
A Pink-tinged urine is in the urinary drainage bag.
B The amount of drainage output in the urinary drainage bag is less than the irrigant input.
C Small amounts of blood clots are in the drainage bag.
D The client reports occasional bladder spasms while the irrigant is infusing.

Page | 964
Question Explanation
Correct Answer is B
Rationale: It requires intervention if the amount of output in the drainage bag is less than the
input, which may indicate a blockage in the system. The output should equal the input plus
regular urinary output and if not, the irrigation should be stopped, and the surgeon should be
notified. Clients may have clots in the drainage bag postoperatively, and irrigation should be
titrated to maintain pink-tinged urine. Occasional bladder spasms may occur due to irritation of
the bladder wall.
Concepts tested

Question 2461
The nurse is caring for a client who had a laparoscopic cholecystectomy. The client reports pain
in the shoulder. Which action should the nurse take first?
A Administer prescribed analgesia
B Instruct the client to use the incentive spirometer
C Auscultate bowel sounds
D Place client in left lateral Sims' position

Question Explanation
Correct Answer is D
Rationale: During a laparoscopic cholecystectomy, CO2 is introduced into the abdominal cavity
to allow for visualization. CO2 is irritating to the phrenic nerve and diaphragm resulting in the
client reporting pain in the shoulder. To help expel the CO2 gas, the nurse should place the client
in Sims' position, which will move the gas pocket away from the diaphragm. Then the nurse will
administer prescribed analgesia, encourage deep breathing, and auscultate bowel sounds.
Concepts tested

Question 2462
The nurse is observing unlicensed assistive personnel obtain pulse oximetry readings for
assigned clients. Which of the following actions by the UAP requires intervention?
A Changing the location of an adhesive finger sensor every 4 hours
B Applying the sensor to the forehead of a client who is taking vasoconstrictive medications
C Changing the location of a spring-tension oximeter every 2 hours
D Applying the sensor to the fingertip of a client with peripheral vascular disease

Question Explanation
Correct Answer is D
Rationale: It requires follow-up if the UAP is observed applying the oximeter sensor to the
fingertip of a client with peripheral vascular disease as the reduced circulation can cause
inaccurate measurements of pulse oximetry readings. Applying a sensor to a central location,
such as the forehead, for a client on a vasoconstrictive medication indicates the correct
technique. Adhesive oximeter probes should be rotated every 4 hours and spring-tension probes
every 2 hours in order to prevent skin breakdown.
Concepts tested

Page | 965
Question 2463
A nurse is preparing to obtain a blood glucose sample from a client with diabetes mellitus type 2.
The client informs the nurse that obtaining a blood sample from the right fingertips is usually
difficult. What action should the nurse perform to improve blood flow to the collection site?
A Elevate the client’s right hand
B Wrap the client’s right hand in a warm towel
C Clean the right fingertips with an alcohol swab
D Apply a tourniquet to the right wrist

Question Explanation
Correct Answer is B
Rationale: Wrapping the client’s hand in a warm towel will improve blood flow to the extremity
by promoting vasodilation. Elevating the client’s right hand will not improve blood flow to the
fingertips. The extremity should be held in a dependent position before puncturing to improve
the blood flow. Cleaning the site with an alcohol swab will not improve blood flow to the
extremity. Alcohol swabs are not recommended because they can interfere with the results of the
blood sample. Applying a tourniquet to the right wrist will impair circulation to the right hand
and may cause skin integrity issues in a client with diabetes. Tourniquets are indicated for
venipunctures.
Concepts tested

Question 2464
A nurse is providing care to a client admitted for chest pain. The client’s electrocardiogram
reveals an ST elevation. Which action does the nurse perform first?
A Positions the crash cart at the bedside
B Initiates intravenous lines
C Places the client on a cardiac monitor
D Administers oxygen to the client

Question Explanation
Correct Answer is D
Rationale: ST elevation on an electrocardiogram is indicative of myocardial infarction (MI). The
priority intervention is to administer oxygen to maintain perfusion. Positioning the crash cart at
the bedside ensures readiness if the client’s condition deteriorates. However, the nurse should
secure oxygenation first. At least two intravenous lines should be initiated on a client with an MI
to administer medications. However, the nurse should administer oxygen first. Placing the client
on a cardiac monitor is an expected intervention for a client experiencing an MI. However, the
nurse should secure the airway, breathing, and circulation first.
Concepts tested

Question 2465
The nurse has taught a female client about obtaining a clean catch urinalysis. Which of the
following statements by the client indicates the need for further teaching?
A “I will cleanse my perineum from back to front prior to obtaining the specimen.”
B “I will urinate a small amount into the toilet before urinating in the specimen cup.”

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C “I will remove the cup from my urine stream before I have finished urinating.”
D “I will use a new antiseptic swab each time I wipe to cleanse my perineum before the
procedure.”

Question Explanation
Correct Answer is A
Rationale: Correct technique for a female clean catch urine specimen includes cleansing the
perineum with a new wipe from front to back (cleanest to dirtiest) prior to urinating. The client
should urinate a small amount into the toilet prior to urinating into the cup to flush contaminants
from the urethra contaminating the specimen. The client should remove the cup from the urine
stream before finishing urinating, which eliminates contamination from skin flora.
Concepts tested

Question 2466
A nurse is obtaining a nasopharyngeal swab from a client with a suspected respiratory illness.
Which action does the nurse perform while obtaining the sample?
A Leaves the swab inside the nostril for several seconds before removing
B Instructs the client to deeply inhale while the swab is being inserted
C Inserts the swab upwards through the nostril until resistance is felt
D Obtains a cotton-tip swab applicator before collecting the specimen

Question Explanation
Correct Answer is A
Rationale: The swab should be left in place for several seconds before removing to ensure
secretions are well absorbed. Deep inhalation is not required to obtain a nasopharyngeal swab.
The client should breathe normally. The swab should be inserted parallel to the pharynx.
Inserting the swab upwards may cause tissue damage. The applicator should not include cotton
because it may contain substances that can alter the test results.
Concepts tested

Question 2467
A nurse is performing a neurological assessment on a client who is reporting dysphagia. Which
cranial nerve should the nurse assess?
A Vagus
B Accessory
C Trochlear
D Abducens

Question Explanation
Correct Answer is A
Rationale: The sensory component of the vagus nerve is evaluated by testing the gag reflex. An
absent gag reflex increases the risk for aspiration. The spinal accessory nerve does not evaluate
the ability to swallow. The spinal accessory nerve is responsible for shoulder movement. The
trochlear and abducens nerves are responsible for eye movement. A deficiency in these cranial
nerves does not increase the risk for aspiration.

Page | 967
Concepts tested

Question 2468
The nurse is completing a follow-up assessment on a client who was admitted for appendicitis.
Which of the following assessment findings indicates that the client’s condition has worsened?
A Constipation
B Anorexia
C Tenderness at McBurney’s point
D Abdominal rigidity

Question Explanation
Correct Answer is D
Rationale: A rigid, distended abdomen indicates that the client’s condition has worsened because
this finding indicates that the appendix may have ruptured. Anorexia and McBurney’s point
tenderness are expected findings. Constipation does not indicate worsening of appendicitis.
Concepts tested

Question 2469
The nurse is assessing a client receiving continuous enteral nutrition via nasogastric tube and
notes the presence of crackles when auscultating the lungs. Which of the following actions
should be taken first to prevent further injury?
A Check the client’s oxygen saturation
B Notify the client’s healthcare provider
C Measure the tube feeding residual volume
D Stop administering the continuous tube feeding

Question Explanation
Correct Answer is D
Rationale: To reduce the risk of injury to the client, tube feeding should immediately be stopped
until placement can be confirmed. All the other actions are appropriate but do not reduce the risk
of further injury to the client.
Concepts tested

Question 2470
The nurse is caring for a client who had a lumbar puncture. Immediately following the
procedure, the client will be placed in which of the following positions to reduce the risk of
complications?
A Prone
B Side-lying
C Supine
D Semi-Fowler's

Question Explanation

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Correct Answer is A
Rationale: Lumbar punctures are performed in the side-lying position with the knees pulled up to
the chest and the head flexed forward. Once completed, lying prone after a lumbar puncture
reduces the risk of a cerebrospinal fluid leak as it separates the alignment of the dural and
arachnoid needle punctures in the meninges. This is a similar concept to the z-track method of
IM injections. Cerebral spinal fluid (CSF) leaks result in severe headaches.
Concepts tested

Question 2471
A nurse is removing an IV catheter from a client who has an order to discontinue infusion of IV
fluids. Which is an appropriate action for the nurse to take?
A Apply firm pressure over the vein
B Leave the roller clamp slightly open
C Lift the hub upward away from skin.
D Pull the catheter straight from insertion site

Question Explanation
Correct Answer is D
Rationale: When removing an IV catheter, the nurse should pull the catheter straight from the
insertion site. This will ensure that the catheter remains intact and prevents trauma to the vein.
The nurse should keep the hub flush with the skin as lifting the hub will cause the catheter to
irritate the vein. Firm pressure over the vein can cause discomfort. The roller clamp should be
closed to prevent the backflow of blood.
Concepts tested

Question 2472
The nurse is performing interventions to regain patency of a percutaneous feeding tube. Which
of the following actions by the nurse requires intervention?
A Flushing the tube with a small amount of air
B Inserting a stylet to break up any clogs
C Instilling a small amount of warm water
D Aspirating any formula remaining in the tube

Question Explanation
Rationale: It requires intervention if the nurse is observed inserting a stylet into the tube to break
up a clog to regain patency. This can cause damage to the tube and stomach mucosa. Techniques
to regain patency include aspirating the remaining formula in the tube and flushing with either
air or warm water and repeating until the tube patency is regained.
Concepts tested

Question 2473
The nurse is caring for a client who is postoperative day four from a coronary artery bypass graft
and is scheduled to be discharged home during the shift. Which finding observed by the nurse
would require immediate intervention?
A The client pushes up with their arms when getting out of bed.

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B The client is sitting in the chair with legs elevated.
C The client inhales slow and deep while using the incentive spirometer.
D The client is taking a shower with assistance from family.

Question Explanation
Correct Answer is A
Rationale: During a CABG, the sternal is surgically cut and then sutured back with wires. Until
the sternum has healed completely, the client should be instructed to follow sternal precautions.
Sternal precautions include splinting a pillow against the chest when coughing and to avoid
lifting or pushing up with arms, which can increase the pressure on the sternum. The client who
is postoperative CABG should be taking a shower, sitting up in the chair, and using the incentive
spirometer by slowing inhaling.
Concepts tested

Question 2474
A nurse is providing care to a client with a cuffed tracheostomy. Which action does the nurse
perform to minimize the risk of aspiration?
A Ensure the cuff is inflated properly Correct Answer
B Clean the inner cannula as prescribed
C Secure the ties around the tracheostomy holder
D Instruct the client to verbalize any shortness of breath

Question Explanation
Correct Answer is A
A Rationale: A cuffed tube ensures secretions from the upper airway do not enter the lower
airways. A properly inflated balloon prevents aspiration. Cleaning the inner cannula, as
prescribed, prevents infection, not aspiration. Securing the tracheostomy holder prevents
dislodgement of the tube but does not prevent aspiration. Clients with a cuffed tracheostomy are
unable to speak. The client will not be able to alert the nurse if respiratory issues are occurring.
Concepts tested

Question 2475
The nurse is caring for a client with type 1 diabetes mellitus. Which of the following findings
indicates that the client is experiencing a complication of this condition?
A Bounding pulses
B Hematuria
C Kussmaul respirations
D Hypertension

Question Explanation
Correct Answer is C
Rationale: Diabetic ketoacidosis is a serious complication of diabetes and may be manifested by
Kussmaul respirations, fruity-smelling breath, hypotension, and gastrointestinal upset. Pulses
will be weak rather than bounding, and hematuria is not directly associated with diabetes
mellitus.

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Concepts tested

Question 2476
The nurse is assessing the neurological status of a client after recovery from a cerebrovascular
accident. Which of the following actions by the nurse is appropriate?
A Removing the client’s glasses while assessing cranial nerves
B Utilizing a walker while assessing the client’s gait
C Assessing strength of only the affected side
D Placing the client in a supine position for a swallow screen

Question Explanation
Correct Answer is B
Rationale: While assessing the gait of a client who may have weakness, the use of assistive
devices is recommended until a steady gait is achieved. The client should keep glasses on for
testing, strength should be assessed on both sides and compared, and swallow screens should be
performed while the client is in a high-Fowler's position.
Concepts tested

Question 2477
The nurse is caring for a client with a traumatic brain injury (TBI) and a Glasgow Coma Scale
score of 8. The client is being monitored for increased intracranial pressure. Which of the
following changes in the client’s condition requires prompt intervention?
A Urine output has increased to 250 mL per hour.
B The client’s ICP has decreased to 15 mmHg.
C The pupillary response is sluggish bilaterally.
D The systolic blood pressure has decreased to 110 mmHg.

Question Explanation
Correct Answer is A
Rationale: Diabetes insipidus (DI) is caused by decreased secretion of antidiuretic hormone
(ADH, vasopressin). TBI is commonly associated with abnormalities of the water and sodium
balance (SIADH and DI). If unrecognized, they can lead to severe electrolyte disturbances. High
volume urine output is the primary sign of DI. Cushing’s Triad includes the three primary signs
that often indicate an increase in intracranial pressure. They are a rise in systolic BP, decreased
pulse, and decreased respiration. The client has decreasing BP, which indicates an improvement
in ICP, which corresponds with the normal ICP of 15. The client has a GCS of 8, which
corresponds with sluggish pupils.
Concepts tested

Question 2478
The post-anesthesia care nurse is monitoring a client following a surgical procedure. Which
finding should the nurse report immediately to the healthcare provider?
A Clear emesis
B Redness at the incision site
C Cold skin

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D Client reports a sore throat

Question Explanation
Correct Answer is C
Rationale: When monitoring a post-operative client, the nurse should assess for alterations of
body systems. Cold, clammy skin could indicate that the client could be experiencing
hemorrhage, which should be reported immediately to the healthcare provider. Clear emesis and
redness at the incision site are expected findings. A sore throat could be related to irritation from
the breathing tube and is not the priority.
Concepts tested

Question 2479
The nurse is educating a client with diabetes type I about exercise and glucose control. Which
statement by the client would indicate to the nurse further teaching is required?
A “I will keep hard candy with me when I go to the gym.”
B “I can go for a walk if my blood glucose level is at 200 mg/dL."
C “I can eat a peanut butter on whole wheat bread before my bicycle ride."
D “I will increase my daily exercise when ketones are present in my urine."

Question Explanation
Correct Answer is D
Rationale: When teaching a client with diabetes type I about exercise, the nurse should explain
that exercise can occur if the client has a blood glucose level greater than 100 and less than 250.
Before exercising, the client should be instructed to eat a snack that has 30 grams of
carbohydrates and protein, such as peanut butter on whole-wheat bread. The client should be
advised to avoid exercise if ketones are present in urine, which means that fat is being used for
energy, which could lead to ketoacidosis. Hard candy should be available to the client during
exercise in case the client experiences hypoglycemia.
Concepts tested

Question 2480
The nurse is caring for a client who had a transurethral resection of the prostate (TRUP) 1 day
ago and has continuous bladder irrigation (CBI) in place. Which of the following findings
requires intervention?
A Pink-tinged urine is in the urinary drainage bag.
B The client reports dizziness and a headache.
C The client reports occasional bladder spasms and the urge to urinate.
D The amount of drainage output in the urinary drainage bag is greater than the irrigant input.

Question Explanation
Correct Answer is B
Rationale: It requires intervention if the client reports dizziness and headache, which are signs of
TURP syndrome, which is a serious complication of CBI caused by reabsorption of irrigant fluid
into the body. Pink-tinged urine, occasional bladder spasms, the urge to urinate, and output
greater than input are all normal findings with CBI.

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Concepts tested

Question 2481
The nurse is monitoring a client following an esophagogastroduodenoscopy (EGD). Which
finding should the nurse immediately report to the healthcare provider?
A The client’s voice is hoarse when speaking.
B The client has hypoactive bowel sounds.
C The client reports difficulty with swallowing.
D The client reports nausea.

Question Explanation
Correct Answer is C
Rationale: An EGD is a procedure that uses a flexible, fiberoptic scope to visualize the
esophagus, stomach, and upper duodenum. Following the EGD, the nurse should monitor the
client for signs of perforation, such as pain, difficulty swallowing, and vomiting blood. The
client should be instructed to expect a hoarse voice and sore throat for several days following the
procedure. Nausea is common after an EGD.
Concepts tested

Question 2482
The nurse is caring for a client who sustained a traumatic brain injury (TBI) and received
intravenous mannitol 15 minutes ago. Which of the following client findings indicates that the
treatment has been effective?
A Blood pressure has increased from 150/86 to 166/74 mmHg.
B Intracranial pressure (ICP) has decreased from 25 to 18 mmHg.
C Brain tissue oxygenation (PbtO2) has decreased from 30 to 15 mmHg.
D Cerebral perfusion pressure (CPP) has decreased from 60 to 50 mmHg.

Question Explanation
Correct Answer is B
Rationale: A decrease in ICP from 25 to 18 mmHg indicates effective treatment of intracranial
hypertension with mannitol. The goal ICP should be less than 20 mmHg, the CPP should be
greater than 60, and the brain tissue oxygen should be greater than 20. These values are not
within goal range and indicate further management is needed to control intracranial pressure and
brain oxygenation. The blood pressure change indicates a widening pulse pressure, which does
not indicate effective reduction in intracranial pressure.
Concepts tested

Question 2483
A nurse receives a prescription to obtain a sputum sample from a client with a respiratory
infection. Which nursing action is indicated for this procedure?
A Obtaining the sample before bedtime
B Waiting 15 minutes after meals to obtain the sample
C Performing chest physiotherapy prior to obtaining the sample
D Using a throat swab to obtain the sample

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Question Explanation
Correct Answer is C
Rationale: Chest physiotherapy (CPT) helps to mobilize secretions within the airways. CPT
facilitates obtaining a sputum sample. Sputum samples should be obtained in the morning.
Respiratory secretions are more concentrated with organisms earlier in the day. The nurse should
wait to obtain the sample 1 to 2 hours after meals to decrease the risk of vomiting or aspiration.
A throat swab is not indicated for a sputum sample. A greater amount of sputum is necessary for
analysis.
Concepts tested

Question 2484
A nurse is providing care to a client post esophagogastroduodenoscopy (EGD). The results
indicate gastric ulcers. Which intervention does the nurse expect to perform next?
A Request a type and crossmatch
B Prepare to administer intravenous pantoprazole
C Administer a bolus of normal saline solution
D Provide the client with a bland diet

Question Explanation
Correct Answer is B
Rationale: Pantoprazole is a proton pump inhibitor (PPI) that decreases gastric acid secretion.
PPIs are the preferred drug class for treating acid-related disorders. Requesting a type and
crossmatch is indicated for clients who exhibit signs of gastrointestinal bleeding. The client’s
diagnostic results are not indicative of an active bleed. Administering a bolus of normal saline is
not specifically indicated for a client with a gastric ulcer. A bland diet is indicated for a client
with a gastric ulcer. However, the client should be kept NPO (nothing by mouth) until the gag
reflex returns. An absent gag reflex can lead to aspiration.
Concepts tested

Question 2485
The nurse has taught a client about the purpose of collecting stool specimens for testing. Which
of the following statements by the client indicates the need for further teaching?
A "This test will determine if I have an intolerance to certain foods.”
B “This test can determine if I have certain microorganisms growing in my gastrointestinal
system.”
C “This test will measure if I have any bleeding in my gastrointestinal system.”
D “This test can determine if the treatment for my gastrointestinal system infection has been
effective.”

Question Explanation
Correct Answer is A
Rationale: It requires further teaching if the client states that a stool specimen sample will test for
food intolerances. Food allergies and intolerances require blood sampling and determination via
elimination diets, not by stool samples. Stool tests can determine the presence of specific

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microorganisms, the effectiveness of treatment for infections, and the presence of bleeding
within the gastrointestinal system.
Concepts tested

Question 2486
A nurse is reviewing laboratory results for a client with diabetes type 2. Which finding indicates
the client is effectively managing their disease?
A Glucose level of 200 mg/dL post glucose tolerance test
B Urine ketone level of 25 mg/dL
C Hemoglobin A1C level of 5.7%
D Fasting blood glucose level of 130 mg/dL

Question Explanation
Correct Answer is C
Rationale: The normal hemoglobin A1C level is 5.7% or below. Hemoglobin A1C measures the
average blood sugar over the last 3 months. A glucose level of 200 mg/dL post glucose tolerance
test is abnormal. The normal finding is a blood glucose level below 140 mg/dL. The presence of
ketones in the urine is an abnormal finding. Urine ketones are indicative of poorly controlled
diabetes. A fasting blood glucose level of 130 mg/dL is an abnormal finding. The normal fasting
blood glucose level is below 100 mg/dL.
Concepts tested

Question 2487
A nurse is assisting a client with their meal. Which observation does the nurse identify as a risk
for aspiration?
A The client belches several times during the meal.
B The client yawns repeatedly after the meal.
C The client chews their food for several seconds before swallowing.
D The client coughs every time they drink water.

Question Explanation
Correct Answer is D
Rationale: Frequent coughing while eating or drinking is an indication that the client is unable to
tolerate their oral secretions. The inability to handle oral secretions increases the risk for
aspiration. A yawn is not indicative of the inability to tolerate oral secretions. Yawning does not
increase the risk for aspiration. Belching is not associated with an increased risk for aspiration.
Belching is indicative of excess gas in the gastrointestinal tract. Chewing for a prolonged period
of time decreases the risk of aspiration. The client should be encouraged to chew their food
thoroughly before swallowing.
Concepts tested

Question 2488
The nurse is caring for a client who is taking antibiotics for a urinary tract infection. Which of
the following findings would indicate that the client’s condition is improving?
A Increase in urine output

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B Decrease in urinary frequency
C Increase in client’s body temperature
D Decrease in client’s blood pressure

Question Explanation
Correct Answer is B
Rationale: As a urinary tract infection improves, the nurse should expect to see a decrease in
urinary frequency and a decrease in dysuria. A decrease in blood pressure and an increase in
urine output do not necessarily indicate that the client is improving. An increase in body
temperature may indicate a worsening of the infection.
Concepts tested

Question 2489
The nurse is planning to ambulate a client with a history of falls. Which of the following actions
is most important to perform prior to getting the client out of bed?
A Assess for clear lung sounds
B Determine if the client has eaten today
C Review recently administered medications
D Ask the client if they need to void

Question Explanation
Correct Answer is C
Rationale: A client with a history of falls is at risk of falling again. Medications that are
psychoactive or vasoactive, for instance, may increase the risk. Therefore, the nurse should
assess for this first. Clients who have adventitious lung sounds may benefit from ambulation.
Assessing for intake and output is important but not the priority.
Concepts tested

Question 2490
The critical care nurse is planning care for a client who had a cardiac catheterization with
femoral artery access. The nurse should place the client in which position?
A Left lateral Sims'
B Supine in low-Fowler's
C Right lateral recumbent
D Reverse Trendelenburg

Question Explanation
Correct Answer is B
Rationale: When caring for a client who is post heart catheterization with femoral access, the
nurse will need to position the client supine in low-Fowler's. This position keeps the lower
extremities in a neutral position and avoids flexion at the hips, which will prevent the
development of bleeding at the access site. Reverse Trendelenburg is used to increase blood flow
to the heart. Right lateral recumbent is the recovery position after a client has had respiratory or
cardiac failure following CPR. Left lateral Sims' position is used when medication or enemas are
to be administered.

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Concepts tested

Question 2491
The nurse is initiating a peripheral IV infusion insertion in a selected vein. After puncturing the
skin, the nurse observes blood return in the flashback chamber of the IV catheter. Which action
should the nurse perform next?
A Secure the catheter to the skin with a transparent dressing
B Lower the catheter until it is almost flush with the skin
C Advance the catheter into the vein
D Remove the stylet slowly from the lumen of the catheter

Question Explanation
Correct Answer is B
Rationale: When inserting a peripheral IV, the nurse will select a vein and after cleaning the site,
will puncture the skin with the IV catheter. Once the skin is punctured and blood return is
observed in the flashback chamber, the nurse should then lower the catheter until it is flush with
the skin. Then the nurse will advance the catheter into the vein, remove the stylet, and secure the
catheter to the skin.
Concepts tested

Question 2492
The nurse has attended a staff education conference about monitoring for complications of
percutaneous feeding tubes. Which of the following statements indicates the need for further
teaching?
A “Insertion sites should be monitored for signs of infection, such as redness, warmth, and
drainage.”
B “Clients should be monitored for dehydration due to common complications, such as
diarrhea.”
C “Clients with enteral feedings should have the head of their bed elevated to reduce the risk of
complications, such as aspiration pneumonia.”
D “Clients with newly inserted percutaneous feeding tubes will report discomfort, such as a
board-like abdomen.”

Question Explanation
Correct Answer is D
Rationale: It requires further teaching if the nurse states that clients should experience pain and a
rigid, board-like abdomen, which are signs of complications of peritonitis. It is correct to monitor
the client for signs and symptoms of infection, to monitor for complications of diarrhea, and to
provide interventions to reduce the risk of aspiration pneumonia.
Concepts tested

Question 2493
The nurse is developing the plan of care for a group of assigned clients with drainage tubes.
Which of the following clients should the nurse identify as having a risk for hypokalemia?

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A The client who has a tracheostomy tube connected to humidified oxygen
B The client who has an indwelling urinary catheter to gravity drainage
C The client who has a pleural chest tube to water seal
D The client who has a nasogastric tube to intermittent suction

Question Explanation
Correct Answer is D
Rationale: Hypokalemia occurs when there is a loss of potassium from the body. GI losses, such
as through diarrhea and NG suction, renal losses through the use of diuretics, and skin losses,
such as diaphoresis, are the most common causes of hypokalemia. A tracheostomy tube, an
indwelling urinary catheter, and a pleural chest tube are not risk factors for potassium loss.
Concepts tested

Question 2494
A nurse is providing care to a client with a spinal cord injury at the level of T4. The client
suddenly verbalizes a severe headache, blurred vision, and nausea. The nurse suspects autonomic
dysreflexia. Which action should the nurse perform?
A Inspect the client for a distended bladder
B Lower the client to a supine position
C Prepare to administer prescribed vasopressors
D Place an abdominal binder on the client

Question Explanation
Correct Answer is A
Rationale: Autonomic dysreflexia occurs in clients with spinal cord injuries above the level of
T6. Autonomic dysreflexia is stimulation of the sympathetic nervous system without a
compensatory response by the parasympathetic nervous system. The most common cause is a
distended bladder that causes pressure in the lower part of the body. The client should be placed
in an upright position to decrease hypertension associated with autonomic dysreflexia.
Vasopressors increase blood pressure. Autonomic dysreflexia causes hypertension, not
hypotension. Tight garments can trigger a sympathetic response. Placing an abdominal binder
will worsen the condition.
Concepts tested

Question 2495
The nurse is caring for a client who has atrial fibrillation. Which of the following assessment
findings indicates a possible complication of this condition?
A Slurred speech
B Decreased respiratory drive
C Skin breakdown
D Muffled heart sounds

Question Explanation
Correct Answer is A

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Rationale: One of the most dangerous complications of atrial fibrillation is the possibility of
ischemic stroke. If the client exhibits slurred speech, the nurse should be concerned that a
cerebrovascular accident may be occurring. Respiratory drive and skin integrity are not directly
affected by atrial fibrillation. Muffled heart sounds would indicate cardiac tamponade but this is
not a complication of atrial fibrillation.
Concepts tested

Question 2496
The nurse is caring for a client who is seeking care for congestive heart failure. Which of the
following techniques should the nurse use to assess for peripheral edema?
A Palpate the dorsalis pedis pulse and release
B Pinch skin on the dorsal surface of the hand
C Use two fingers to depress the skin over the tibia
D Apply pressure to the client’s toe nails

Question Explanation
Correct Answer is C
Rationale: The nurse should assess for edema on the anterior surface of the tibia by depressing
the client’s skin for at least five seconds and releasing to look for indentations left by the fingers.
Pinching skin on the dorsal surface of the hand is assessing turgor, and applying pressure over
the client’s nail surface is capillary refill. The nurse will palpate the dorsalis pedis pulse to assess
perfusion in the extremity.
Concepts tested

Question 2497
The emergency room nurse is caring for the client who is homeless and was admitted during a
blizzard. The client has an elevated blood alcohol level, has a core temperature of 33.2°C
(91.8ºF), and is unable to feel the lower extremities. What is the priority action at this time?
A Apply a forced-air warming blanket
B Assess the lower extremities for frostbite
C Observe for signs of alcohol withdrawal
D Obtain a high-calorie meal

Question Explanation
Correct Answer is A
Rationale: Hypothermia is a condition in which the core (internal) temperature is 35°C (95°F) or
less as a result of exposure to cold or an inability to maintain body temperature in the absence of
low ambient temperatures. People who are homeless are particularly susceptible. Alcohol
ingestion increases susceptibility because it causes systemic vasodilation. The patient may also
have frostbite but hypothermia takes precedence in treatment.
Concepts tested

Question 2498
The nurse is caring for a client newly diagnosed with hypertension (HTN) and receiving their
first dose of prescribed lisinopril. The client reports dizziness with ambulation, and the nurse
notes the client's blood pressure (BP) to be 90/50 mm/Hg. Which action should the nurse take?
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A Instruct the client to remain on bedrest until the BP has increased
B Hold all prescribed anti-hypertensive medications until BP has improved
C Obtain a prescription for a bolus of 0.9% normal saline (NaCl)
D Encourage the client to increase oral fluid intake

Question Explanation
Correct Answer is C
Rationale: Lisinopril is an ACE inhibitor, which blocks the renin-angiotensin-aldosterone system
which causes peripheral vasodilation and diuresis. The therapeutic effect of an ACE inhibitor is a
decrease in blood pressure. Some clients may experience hypotension and dizziness when first
starting an ACE inhibitor. A client experiencing hypotension following the first dose will require
a bolus of fluids to increase blood pressure. Holding medications does not address the low blood
pressure. Encouraging fluid intake will not increase blood pressure. Remaining on bedrest could
increase the risk for hypotension.
Concepts tested

Question 2499
The nurse is reviewing discharge teaching for a client newly diagnosed with diabetes type 1
about sick day rules. Which statement made by the client would indicate to the nurse that further
teaching is required?
A “I should drink sugar-sweetened beverages if I experience vomiting.”
B "I should eat small meals of soup or gelatin six to eight times a day.”
C “I will need to increase my dose of insulin."
D "I should check my urine for ketones twice a day.”

Question Explanation
Correct Answer is C
Rationale: The nurse should teach the client with diabetes type I about sick day rules, which
focus on how to manage blood glucose levels and prevent complications when sick. The client
should be instructed to drink sugar-sweetened beverages when experiencing vomiting to
maintain a caloric intake. The client should eat small meals consisting of soft foods, such as
soups, gelatins, and puddings. The client should be advised to check urine for ketones at least
twice a day. The client will be taught to continue taking the prescribed insulin; however, the
client should not increase the dose but may need to decrease the dose.
Concepts tested

Question 2500
The nurse has provided preoperative teaching to a client who is scheduled for surgery in 1 week.
Which of the following statements by the client indicates a correct understanding of the
teaching?
A “I will need to refrain from drinking any clear liquids for at least 2 hours before my surgery."
B “I should arrive on the day of surgery with the site of surgery marked with a pen to avoid
surgical errors.”
C “I should stop all medications for 24 hours prior to my scheduled procedure.”
D “I will need to cleanse my skin using an antiseptic solution twice a day for the next week.”

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Question Explanation
Correct Answer is A
Rationale: When providing preoperative teaching, the nurse will include instructions on diet,
medication, and preparation. The nurse will teach the client that clear liquids will need to be
stopped at least 2 hours prior to the procedure and solid food typically must be stopped for a
longer period to prevent aspiration. The surgeon must mark the site of the surgical procedure to
reduce the risk of wrong-site surgical errors. The client should not stop all medications,
particularly cardiac and antidiabetic medications, and typically these can be taken with small sips
of water the morning of the procedure. The client may need to cleanse the skin with an antiseptic
solution once either 1 or 2 days prior to the surgical procedure.
Concepts tested

Question 2501
The nurse is caring for a client who is one day postoperative Roux-en-Y gastric bypass surgery.
Which finding would be a concern to the nurse?
A Diminished breath sounds
B Hypoactive bowel sounds
C Oral temperature of 100.1°F (38.4°C)
D Bedside glucose level 180 mg/dL

Question Explanation
Correct Answer is C
Clients who had a Roux-en-Y are at risk for developing a leak at the anastomosis site. A leak of
GI contents into the abdomen can cause an infection, which the nurse should monitor for signs of
fever. A bedside glucose level of 180 is elevated but normal in a gastric bypass client.
Hypoactive bowel sounds and diminished breath sounds are normal findings postop one day.
Concepts tested

Question 2502
The nurse is caring for a client with cerebral edema who has an intracranial pressure (ICP) that
has increased from 15 to 20 mmHg. Which of the following actions should the nurse take?
A Request a prescription to obtain a serum sodium level
B Increase the rate of the client’s intravenous sedation
C Request a prescription to discontinue the client’s hypertonic saline
D Place the client in a high-Fowler’s position

Question Explanation
Correct Answer is A
Rationale: The nurse should request a prescription to obtain a serum sodium level. Clients with
cerebral edema require careful monitoring and management of serum sodium levels with goal
ranges often much higher than normal serum sodium levels. The purpose of this is to induce an
osmotic effect and reduce cerebral edema by drawing water from the brain tissue into the
vascular space. By evaluating the client’s serum sodium status, further management can be made
to reduce cerebral edema and ICP. The nurse should not discontinue the hypertonic saline as this
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medication is needed to reduce cerebral edema and must be titrated according to serum sodium
levels. The nurse should not increase the rate of intravenous sedation based on ICP values and
should only increase sedation based on client agitation if present. The client should be
maintained with the head of the bed at 30 degrees, and care should be taken not to raise the head
of the bed too high, such as high- Fowler’s, as this can also decrease cerebral perfusion pressure
by decreasing systolic blood pressure.
Concepts tested

Question 2503
A nurse is preparing to collect a stool sample from a client. Which action will the nurse perform
when collecting the sample?
A Inform the client to defecate into the toilet
B Place 1 inch of formed stool into the specimen container
C Collect the specimen 30 minutes after the client defecates
D Instruct the client to clean the rectal area before providing a stool sample

Question Explanation
Correct Answer is B
Rationale: One inch of formed stool or 15 to 30 milliliters of liquid stool is a sufficient amount
for analysis. The stool sample should be collected from a sterile bedpan or a container to avoid
contamination of the specimen with toilet water. The specimen should be collected immediately
after the client defecates to obtain accurate results. Cleaning the rectal area with soap before
defecation may alter the test results.
Concepts tested

Question 2504
A nurse is performing a bladder scan on a postoperative client. The scan reveals a bladder
volume of 100 milliliters. Which intervention does the nurse expect to perform next?
A Insert an intermittent urinary catheter
B Keep the client on NPO status
C Administer a prescribed intravenous fluid bolus
D Request a prescription for a diuretic

Question Explanation
Correct Answer is C
Rationale: A result of 100 milliliters indicates a low volume of urine in the bladder. Urine
production is altered in postoperative clients. The nurse should expect to administer intravenous
fluids to increase urine production. Inserting an intermittent urinary catheter is not indicated for a
urine volume of 100 mL. There is no indication of urinary retention. Keeping the client on NPO
status will further decrease urine production. Requesting a prescription for a diuretic is not
indicated. A diuretic is administered in clients with fluid volume overload.
Concepts tested

Question 2505
The nurse has taught a client about the purpose of urinalysis testing. Which of the following
statements by the client indicates the need for further teaching?
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A “This test can measure if I potentially have issues with my kidney function.”
B “This test can determine which type of bacteria may be causing my urinary tract infections.”
C “This test can measure if my high blood sugar from diabetes is causing metabolic issues.”
D "This test can determine if I potentially have kidney stones.”

Question Explanation
Correct Answer is B
Rationale: A urinalysis can determine a wide variety of potential systemic issues by measuring
pH, glucose, ketones, protein, red and white blood cells, and bacterial counts. The presence of
protein may indicate glomerular disorders and warrants further kidney function work-up. A
urinalysis can measure the presence of bacteria; however, a urine culture is needed to identify the
specific organism to determine specific antimicrobial therapy. The presence of ketones in the
urine may indicate diabetic ketoacidosis and requires further monitoring. The presence of red
blood cells in the urine may indicate kidney stones and requires further work-up.
Concepts tested

Question 2506
A nurse is reviewing the laboratory date for a client with disseminated intravascular coagulation.
Which results should the nurse expect for this client?
A Hemoglobin level of 19 g/dL
B Platelet count of 100,000 mm³
C PT level of 10 seconds
D D-dimer of 0.2 mcg/mL

Question Explanation
Correct Answer is B
Rationale: A platelet count of 100,000 mm³ is expected in a client with disseminated
intravascular coagulation (DIC). The normal platelet count is 150,000 to 400,000 mm³. A
hemoglobin level of 19 g/dL is above normal. The hemoglobin level in a client with DIC is
expected to be below normal. The normal hemoglobin range is 12 to 18 g/dL. A prothrombin
level of 10 seconds is below the normal range. The prothrombin time in a client with DIC is
expected to be above normal. The normal clotting time is 11 to 12.5 seconds. A D-dimer of 0.2
mcg/mL is normal. The D-dimer level of a client with DIC is expected to be increased above 0.4
mcg/dL.
Concepts tested

Question 2507
A nurse is reviewing documentation for an assigned client. Which finding indicates a high risk
for skin breakdown?
A Braden scale score of 13
B GCS score of 14
C Norton scale score of 15
D FLACC score of 2

Question Explanation

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Correct Answer is A
Rationale: A Braden score of 13 is considered high risk for skin breakdown. The Braden scale
identifies the risk of developing pressure ulcers based on six categories including sensory
perception, activity, mobility, nutrition, friction, and moisture. A Glasgow coma scale (GCS)
score of 14 is not a high risk for skin breakdown. The GCS measures the level of consciousness.
The Norton scale assesses the risk for skin breakdown. Scores less than 14 are considered high
risk for pressure ulcer development. The face, legs, activity, crying, and consolability (FLACC)
scale is used to assess pain. A score of 2 indicates mild discomfort.
Concepts tested

Question 2508
The nurse is completing a follow-up assessment on a client who is one hour postoperative
following an abdominal surgery. Prior to surgery, the client was mildly hypertensive but all other
assessment findings were within normal limits. Which of the following findings requires action
by the nurse?
A Blood pressure 90/62 mmHg
B Heart rate 62 bpm
C Respiratory rate 22 bpm
D Oral temperature 37.2°C

Question Explanation
Correct Answer is A
Rationale: The blood pressure of 90/62 is a significant decrease if the client was mildly
hypertensive previously. The nurse should be concerned about the possibility of postoperative
bleeding when blood pressure decreases significantly. The heart rate and temperature are within
normal limits, and the respiratory rate is slightly elevated but not a cause for concern.
Concepts tested

Question 2509
The nurse is positioning the client on the left side in Sims' position prior to the administration of
an enema. How should the nurse place the right arm to prevent injury?
A Flexed on a pillow
B Extended behind the back
C Along the length of the torso
D In internal rotation

Question Explanation
Correct Answer is A
Rationale: In Sims' position, the client lies on their side with the lower arm behind the back and
the upper arm flexed. Both knees are flexed, with the upper leg more so. Careful positioning is
required to prevent damage to nerves and blood vessels as well as injury to the shoulder. It is
used to assess the rectum or vagina and perform interventions such as enemas and suppositories.
Concepts tested

Question 2510

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The nurse is preparing the client for a thoracentesis. Which position should the client be placed
in to reduce the risk of complications?
A Sitting on the edge of the bed with arms and head resting on and over the bed table
B Lying on the affected side with the head of the bed elevated
C Prone with the head on a pillow and arms above the head
D Turned on the unaffected side with the head of bed flat

Question Explanation
Correct Answer is A
Rationale: If possible, place the patient upright leaning over an over-the-bed table. The upright
position facilitates the removal of fluid that usually localizes at the base of the thorax. It expands
the ribs and widens the intercostal space to aid needle insertion. A position of comfort helps the
patient to relax and prevents patient movement that could contribute to potential complications.
The client may also lie on the unaffected side with the head of the bed elevated.
Concepts tested

Question 2511
The nurse is assessing the peripheral venous access for a client who reports pain at the site. The
nurse notes the presence of erythema at the site. Which action should the nurse take next?
A Remove the catheter at that site
B Apply warm moist packs to the site
C Document the findings in the chart
D Start a new peripheral line at a different site

Question Explanation
Correct Answer is A
Rationale: Removing the catheter is the first thing that needs to happen to prevent further
inflammation. After the removal, warm moist compresses can be applied to help with the
inflammatory response. A new site will need to be found if the client needs to continue to have
IV access. The documentation of the site condition, what was done for the client, and how the
client tolerated would happen last.
Concepts tested

Question 2512
The nurse is observing a newly hired nurse apply thigh-length sequential compression devices
(SCD) for a client. Which of the following observations requires intervention?
A Using the widest part of the thigh circumference to measure for size
B Securing the sleeves around the leg with 4 fingerbreadths between the leg and the sleeve
C Connecting the control unit tubing to the sleeves with the arrows in alignment
D Ensuring the control unit pressure is set between 35 to 55 mmHg

Question Explanation
Correct Answer is B
Rationale: It requires intervention if the nurse is observed securing the sleeves around the leg
with 4 fingerbreadths between the leg and the sleeve. The sleeve should have 2 fingerbreadths

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between the leg and the sleeve to ensure adequate compression during inflation while also
avoiding impairment in circulation while inflated if secured too tightly. It is the correct technique
to measure the thigh circumference for proper fitting, to align the arrows on the control unit to
avoid obstruction of the tubing by kinks or twists, and to maintain the pressure setting of the
device between 35 to 55 mmHg.
Concepts tested

Question 2513
The nurse is caring for a client with a tibia fracture who has a casted right lower extremity.
Which of the following client findings is a priority to follow up?
A Client reports pain rated 6 out of 10 in the right lower extremity.
B The right extremity skin is pallor in color.
C Small amounts of serous drainage are on the cast.
D Client has an oral temperature of 100.4°F.

Question Explanation
Correct Answer is B
Rationale: It is a priority for the nurse to follow up if the client has numbness, tingling, and
pallor of the affected extremity, which is a sign of the limb-threatening complication of
compartment syndrome. The client’s pain, low-grade temperature, and drainage can be addressed
after the priority findings of compartment syndrome.
Concepts tested

Question 2514
A nurse is assessing a client with a right lower extremity fracture who is on bed rest. The nurse
notes the client is unable to dorsiflex the right foot. Which action will the nurse perform to
prevent neurological complications?
A Secure a foot board behind the right foot
B Apply a heel protector on the right foot
C Position a trochanter roll outside the right hip
D Place a pillow beneath the right calf

Question Explanation
Correct Answer is A
Rationale: The client’s inability to dorsiflex the foot is indicative of foot drop. The nurse should
secure a foot board to maintain alignment of the foot while the client is on bedrest. Applying a
heel protector will prevent skin breakdown, not foot drop. A trochanter roll supports the hip and
prevents the outward movement of the femur. This does not prevent foot drop. Placing a pillow
beneath the right calf does not help the client maintain dorsiflexion of the foot. The elevation of
the leg may cause further plantar flexion.
Concepts tested

Question 2515
The nurse is caring for a client who has a prescription to use an incentive spirometer to prevent
postoperative atelectasis. Which of the following assessment findings indicates that the therapy
is effective?
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A Oxygen saturation of 91% on room air
B Clear breath sounds in all lobes
C Orthopnea
D Pulses 2+ in all extremities

Question Explanation
Correct Answer is A
Rationale: Atelectasis is manifested by dyspnea (especially while in the supine position), low
oxygen saturation, cough, crackles upon auscultation, and sputum production. The absence of
these findings indicates that the incentive spirometer is effective at preventing this postoperative
complication. Pulse strength is not directly affected by atelectasis.
Concepts tested

Question 2516
The nurse is assessing a client who is receiving intravenous hydration. Which of the following
actions by the nurse would be appropriate to assess for fluid volume excess?
A Assess for pitting edema
B Auscultate heart sounds
C Palpate for abdominal tenderness
D Obtain the client’s respiratory rate

Question Explanation
Correct Answer is A
Rationale: The nurse should assess the client for pitting edema, crackles in the lungs, turgor, and
bounding pulses to evaluate the client’s hydration status. All other responses do not assess fluid
volume.
Concepts tested

Question 2517
The nurse is caring for a client with decompensated heart failure. Which of the following
changes in the client’s condition would require intervention?
A Urine output has decreased to 15 mL/hr.
B Beta natriuretic peptide has decreased to 400pg/mL.
C Ejection fraction has increased to 40%.
D Systolic blood pressure has increased to 100 mmHg.

Question Explanation
Correct Answer is D
Rationale: Heart failure is a syndrome resulting from structural or functional disorders that
impair the ability of the ventricles to fill or eject blood. Decompensated heart failure is
characterized by increased symptoms, decreased CO, and low perfusion. Decreased urinary
output is a sign of impaired renal perfusion. Ejection fraction is the percentage of blood pumped
out of the heart with each beat. An increase indicates improved cardiac output. Beta natriuretic
peptide is secreted by the heart to regulate blood pressure and fluid balance. A decrease indicates

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an improvement in heart function and reduced distension. Increasing systolic BP indicates
improved cardiac output and tissue perfusion.
Concepts tested

Question 2518
The nurse is caring for a client who is postoperative 48 hours coronary artery bypass graft. The
nurse notes the client's telemetry monitor indicates the client is in atrial fibrillation. Which
laboratory test should the nurse obtain for this client?
A D-dimer
B Serum potassium
C Troponin I
D Arterial blood gas

Question Explanation
Correct Answer is B
Rationale: A client who is postoperative CABG is at risk for electrolyte imbalance, such as
hypokalemia. Clients with hypokalemia are at increased risk for dysrhythmias, such as atrial
fibrillation. D-dimer is used to evaluate the presence of clotting. Troponin I is used to evaluate a
myocardial infarction. ABG is used to evaluate acid-base balance.
Concepts tested

Question 2519
The nurse is educating a client who is newly diagnosed with Addison’s disease about preventing
complications. Which statement should the nurse include in the teaching?
A “Increase your physical activity by 10 minutes every day."
B “Reduce the amount of sodium in your diet."
C “Keep your legs elevated when you are sitting.”
D "Decrease your fluid intake to about 1.5 liters a day.”

Question Explanation
Correct Answer is C
Rationale: Addison’s disease is hypofunction of the adrenal cortex with results in a decrease in
the secretion of adrenal corticosteroids (glucocorticoids, mineralocorticoids, and androgens). The
client will have hyponatremia, so the client should increase their sodium intake. Addison’s
disease increases the risk of hypotension due to hypovolemia, so the nurse should instruct the
client to keep their legs elevated when sitting and increase fluid intake. The client with
Addison’s is at risk for decreased glucose levels and activity intolerance and should be instructed
to avoid excessive activity.
Concepts tested

Question 2520
The nurse has provided preoperative teaching to a client who is scheduled for an outpatient
surgery with anesthesia in 1 week. Which of the following statements by the client indicates a
correct understanding of the teaching?
A “I will need to refrain from drinking any clear liquids for 1 hour before my surgery.”

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B “I should arrive on the day of surgery with the site of surgery marked with a pen to avoid
surgical errors.”
C “I will need to have a ride home and should not drive or operate heavy machinery for 24
hours after my procedure.”
D “I will need to cleanse my skin using an antiseptic solution twice a day for the next week.”

Question Explanation
Correct Answer is C
Rationale: When providing preoperative teaching to a client, the nurse will include information
on diet, mediation, preparation, and discharge planning. The nurse should instruct the client that
they will need a ride home and cannot drive or operate heavy machinery for 24 hours after
sedation or anesthesia following procedures due to cognitive impairment. Clear liquids must be
held at least 2 hours prior to surgery and often much longer to reduce the risk of aspiration while
under anesthesia. The surgeon must mark the site of the surgical procedure to reduce the risk of
wrong-site surgical errors. The client may need to cleanse the skin with an antiseptic solution
once either 1 or 2 days prior to the surgical procedure.
Concepts tested

Question 2521
The nurse is preparing to administer prescribed oral medication to a client with aortic valve
stenosis who had a transesophageal echocardiogram (TEE) 4 hours ago. Which action should the
nurse take before administering the medication to this client?
A Encourage the client to use a drinking straw
B Have the client cough several times
C Assess gag reflex
D Hold all oral medications for 24 hours

Question Explanation
Correct Answer is C
Rationale: A TEE is a diagnostic test that uses a flexible endoscope inserted through the
esophagus which is used to visualize the heart and heart structures. Following a TEE, the nurse
should assess the client’s gag reflex has returned before administering any oral medication.
Concepts tested

Question 2522
The nurse is observing unlicensed assistive personnel (UAP) obtain blood pressure
measurements on assigned clients. Which of the following actions by UAP requires the nurse to
intervene?
A Obtaining a blood pressure on the left arm of a client with an arteriovenous fistula graft in the
left upper extremity
B Measuring the blood pressure on the right upper arm of a client who had a left-sided
mastectomy

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C Obtaining a blood pressure on the right lower extremity of a client with burns to bilateral
upper extremities
D Measuring the blood pressure on the left upper arm of a client who has a blood transfusion
infusing through a right hand peripheral intravenous catheter

Question Explanation
Correct Answer is A
Rationale: Blood pressure measurements should not be performed on a particular client’s limb in
the following situations: the presence of casts or bulky bandages, burns or trauma to the
extremity, surgical removal of lymph nodes such as mastectomy, an intravenous infusion in that
limb or an arteriovenous fistula for dialysis is present. It requires intervention if the UAP is
observed obtaining a blood pressure measurement in the same arm as an arteriovenous fistula.
All other actions are a correct technique for obtaining blood pressures in these clients.
Concepts tested

Question 2523
The nurse is caring for a client with hyperkalemia. Which of the following serum potassium
laboratory values is consistent with this diagnosis?
A 2.8 mEq/L
B 3.5 mEq/L
C 4.5 mEq/L
D 5.5 mEq/L

Question Explanation
Correct Answer is D
Rationale: Normal serum potassium levels are 3.5 to 5.0 mEq/L. A serum potassium level of 5.5
mEq/L indicates hyperkalemia.
Concepts tested

Question 2524
The nurse is educating a client who has peripheral vascular disease on how to prevent associated
complications. Which of the following statements should the nurse include in the teaching?
A “You should limit the amount of walking to minimize pain.”
B “Wear socks and shoes to avoid injury to your feet.”
C “Increase dietary lipids to promote circulation.”
D “Avoid vitamins A and C to reduce the risk of ulcers.”

Question Explanation
Correct Answeer is B
Rationale: Trauma to areas of poor circulation can create non-healing wounds; therefore,
properly fitted socks and shoes are an important part of the client’s plan of care. The client
should walk often, decrease lipid intake, and increase intake of vitamins A and C.
Concepts tested

Question 2525

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The nurse is planning care for a client who had a stroke earlier today. The client is alert,
cooperative and follows commands. The client has left-sided hemiplegia. Which interventions
should the nurse include in the client’s plan of care? Select all that apply.
A Anterior hip precautions
B Contact precautions
C Seizure precautions
D Swallow precautions
E Fall precautions

Question Explanation
Correct Answer is C, D, E
Rationale: Clients who have suffered a stroke can have neurological deficits. A client with
hemiplegia (unilateral weakness) is at risk for impaired swallowing, choking and aspiration. The
nurse should include a swallow screening/evaluation in the client's plan of care before allowing
the client to eat or drink. This client is also at risk for falls due to hemiplegia. Clients who have
suffered a stroke are at risk for seizures and should have seizure precautions in place (e.g.,
padded side rails, oxygen readily available, suction available). Anterior hip precautions are
appropriate for clients who have had a hip arthroplasty, not a stroke. Contact precautions are not
indicated for this client.
Concepts tested

Question 2526
The nurse is caring for a client who has a nasogastric tube in place that is being used for enteral
feeding and medication administration. Which method is most appropriate to confirm correct
placement of the tube?
A Auscultate the abdomen while instilling 10 mL of air into the tube
B Measure the length of tubing from the nose to the epigastrium.
C Place the end of the tube in water and observe for bubbling
D Measure the pH level of the aspirated gastric contents.

Question Explanation
Correct Answer is D
Rationale: Once the initial placement of the nasogastric (NG) tube has been confirmed by an X-
ray, the nurse should check the pH of the aspirated contents before administering medications or
feedings through the NG tube. An acidic pH of aspirated stomach contents confirms the NG tube
is in the stomach and is safe to use. This is the most appropriate method to confirm the NG
tube’s placement. The other methods are unreliable to determine NG tube placement.
Concepts tested

Question 2527
The telemetry nurse is caring for a client who was admitted with a diagnosis of diarrhea due to
norovirus infection. The nurse notes several premature ventricular contractions on the client's
cardiac monitor. The premature ventricular contractions are most likely related to which lab
result?
A Activated partial thromboplastin time of 30 seconds

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B Calcium level of 9 mg/dL
C Potassium level of 2.5 mEq/L
D Magnesium level of 2.4 mEq/dL

Question Explanation
Correct Answer is C
Rationale: Norovirus causes gastroenteritis and diarrhea. Diarrhea causes potassium loss through
the stool and leads to serum hypokalemia. Potassium is needed for cardiac conduction and the
normal value range for serum potassium is approximately 3.5 to 5.0 mEq/L. A low serum
potassium level can lead to ventricular dysrhythmias (e.g., premature ventricular contractions).
The other lab values are near or within normal ranges.
Concepts tested

Question 2528
The nurse is caring for a client with a small bowel obstruction. The health care provider orders
the nurse to insert a nasogastric tube. The nurse is unable to pass the tube into either of the
client's nostrils. Which action should the nurse take next?
A Insert the tube via the orogastric route instead.
B Stop the procedure and notify the health care provider.
C Apply oxygen to the client via nasal cannula.
D Perform nasotracheal suctioning on the client.

Question Explanation
Correct Answer is B
Rationale: If the nurse is unable to insert a nasogastric (NG) tube into either nostril, the nurse
should stop the procedure and notify the health care provider. The nurse should not insert the
tube orogastrically without first notifying the health care provider and obtaining an order for an
orogastric (OG) tube. Nasotracheal suctioning would not be advised as it may cause swelling in
the client's nasopharynx, further complicating the NG tube insertion. There is no indication the
client needs supplemental oxygen.
Concepts tested

Question 2529
The nurse is observing an unlicensed assistive person (UAP) perform a manual blood pressure
reading on a client’s right arm. As the UAP inflates the cuff, the cuff begins to unwrap from the
client's arm. Which action should the nurse take?
A Gently hold the cuff in place to help the UAP continue obtaining the blood pressure.
B Deflate the cuff completely, then re-inflate the cuff for a new blood pressure reading.
C Remove the cuff and check to see if it properly fits the client's arm size.
D Remove the cuff and take a new blood pressure from the client's other arm.

Question Explanation
Correct Answer is C
Rationale: A blood pressure (BP) measurement will be inaccurate if the cuff does not fit
properly. A sign of this can be if the cuff tends to come loose during inflation. A cuff that is too

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tight or too small will cause a falsely high BP reading. The nurse should remove a poorly fitting
BP cuff and obtain a cuff that is properly fitted for the client's extremity. To ensure accurate BP
measurement, the nurse should ensure the BP cuff is the proper size for the client's extremity.
The cuff can be selected using the guides marked on the inside of the cuff. Once selected, the
deflated cuff should be applied evenly and snugly around the extremity.
Concepts tested

Question 2530
The nurse is caring for a client who is receiving a continuous heparin infusion for the treatment
of a deep vein thrombosis. The nurse reviews the client’s most recent lab results. Which lab
value indicates the client may be experiencing a complication of heparin therapy?
A Platelet count of 50,000/mm3
B Hemoglobin level of 15 g/dL
C Partial thromboplastin time of 90 seconds
D White Blood Cell count of 8,000/µL

Question Explanation
Correct Answer is A
Rationale: Thrombocytopenia (low platelets) during heparin therapy is a complication referred
to as heparin-induced thrombocytopenia (HIT). HIT results from the creation of autoantibodies
directed against platelets in the blood. These can be present within 6 to 14 days after the
beginning of heparin treatment. The approximate normal range for platelets is 150,000 to
450,000/µL in adults, so a level of 50,000/mm3 may indicate the client is experiencing HIT. The
partial thromboplastin time (PTT) is used to monitor heparin therapy. The approximate normal
range in adults is 60 to 70 seconds, and 1.5 to 2.5 times the control value for clients who are
receiving heparin therapy. Although this client’s level is outside of the normal range, it is within
the expected range for a client who is receiving heparin therapy. The hemoglobin (Hgb) and
white blood cell (WBC) results for this client are within normal ranges. (The approximate
normal range for Hgb levels in adults is 14 to 18 g/dL in males and 12 to 16 g/dL in females. The
approximate normal range for WBC levels in adults is 5,000 to 10,000/mm3).
Concepts tested

Question 2531
The nurse is caring for a client who was admitted with a new onset of seizures. While the nurse
is assessing the client, the client begins having a generalized tonic-clonic seizure. Which action
should the nurse take first?
A Turn the client on their side.
B Pad the side rails of the client's bed.
C Apply oxygen to the client.
D Establish an IV saline lock.

Question Explanation
Correct Answer is A
Rationale: Seizures must be treated promptly and aggressively. The nurse should follow the
ABCs (airway, breathing and circulation) and first protect the client's airway by turning them on
their side. If possible, the nurse should also turn the client’s head to the side to prevent aspiration
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and allow secretions to drain out of their mouth. If necessary, a nasal airway is recommended for
a client having a seizure to establish a clear path for oxygen and ventilation. Nothing should be
inserted into the mouth of a client having a seizure. Then the nurse should administer oxygen
using a nasal cannula or face mask as indicated by the client’s condition. If not already in place,
an IV should be established for ready access in case IV medications need to be given to stop the
seizure. Finally, padding the side rails can be done to prevent the client from injury during the
seizure.
Concepts tested

Question 2532
The nurse is caring for a client who is being treated for hypokalemia. The client has an order to
receive an IV infusion of 40 mEq of potassium in 1,000 mL of 0.9% NaCl over 12 hours. Which
intervention should the nurse implement during the infusion?
A Obtain a set of arterial blood gases.
B Initiate continuous pulse oximetry monitoring.
C Place the client on bedrest during the infusion.
D Place the client on continuous cardiac monitoring.

Question Explanation
Correct Answer is D
Rationale: Continuous cardiac monitoring and a baseline electrocardiogram (ECG) is
recommended for clients with hypokalemia. Hypokalemia causes electrical conduction changes
in the heart (e.g., ST-segment depression, flat or inverted T waves, and U waves). Hypokalemia
can also cause dangerous and potentially life-threatening cardiac dysrhythmias. This client
should have continuous cardiac monitoring before, during and after the potassium replacement
infusion. There is no clinical indication for bedrest, arterial blood gases or continuous pulse
oximetry monitoring for a client receiving IV potassium replacement.
Concepts tested

Question 2533
A client with a history of hypertension and hyperlipidemia is being evaluated in the emergency
department for chest pain and shortness of breath. Which diagnostic tests should the nurse plan
for? Select all that apply.
A Electrocardiogram
B Complete blood count (CBC)
C Serum calcitonin
D Helicobacter pylori
E Cardiac enzyme panel

Question Explanation
Correct Answer is A, B, E
Rationale: Chest pain and shortness of breath are findings that could suggest the client is
experiencing an acute myocardial infarction. An electrocardiogram (ECG) should be acquired to
check the client's cardiac rhythm as well as any signs of acute myocardial ischemia (e.g., ST
segment elevation). Cardiac enzymes, including creatinine kinase, myoglobin and troponin, are

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indicated to determine if cardiac muscle damage has occurred. A complete blood count (CBC)
would check for low hemoglobin (Hgb), which can precipitate shortness of breath and chest pain
if there is not enough Hgb to deliver oxygen to the myocardium. Serum calcitonin
and Helicobacter pylori are not typically used with chest pain or shortness of breath.
Concepts tested

Question 2534
The nurse is teaching a client with a diagnosis of metastatic bone cancer about actions to prevent
hypercalcemia. Which statement by the client indicates the client understands the teaching?
A "I should exercise by walking for 20 to 30 minutes daily."
B "I should restrict my fluid intake to less than one liter per day."
C "I should increase my servings of dairy each day to five."
D "Calcium carbonate is the preferred antacid if I experience indigestion."

Question Explanation
Correct Answer is A
Rationale: Hypercalcemia (increased serum calcium level) occurs most often in clients with
bone metastasis. Cancer in the bone causes the bone to release calcium into the bloodstream. In
clients with cancer in other parts of the body (especially in the lung, head and neck, kidney or
lymph nodes), the tumor secretes parathyroid hormone causing the bones to release calcium into
the bloodstream. Decreased mobility and dehydration worsen hypercalcemia. Mobility should be
encouraged to prevent demineralization and breakdown of bones. Weight-bearing exercise, such
as walking, helps to prevent hypercalcemia and keeps the calcium in the bone. Good hydration is
important in hypercalcemia prevention as well, so clients should not restrict their oral fluid
intake. Dairy products contain high amounts of calcium, so the client should not increase their
dairy intake, as this would put them at an increased risk of hypercalcemia. Clients at risk for
hypercalcemia should not take calcium carbonate because it can increase their serum calcium
levels.
Concepts tested

Question 2535
The nurse is developing a plan of care for a client with chronic obstructive pulmonary disease
(COPD). Which interventions should the nurse include in the plan? Select all that apply.
A Provide high-protein, high-calorie meals to help maintain adequate nutrition.
B Schedule the client for an annual influenza vaccination.
C Instruct the client on the pursed lip breathing technique to reduce carbon dioxide (CO2)
retention.
D Instruct the client to engage in high-intensity aerobic exercise to increase activity tolerance.
E Educate the client about relaxation techniques to help with their anxiety.

Question Explanation
Correct Answer is A, B, C, E
Rationale: Diaphragmatic (abdominal) and pursed lip breathing help manage dyspneic episodes
that occur with COPD. Breathing through pursed lips creates mild resistance, which prolongs
exhalation and increases airway pressure. This technique delays airway compression and reduces

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air trapping prevalent with COPD. Clients with COPD tend to become anxious during acute
dyspneic episodes. The nurse will help the client manage dyspneic episodes and panic attacks
through the use of progressive relaxation, hypnosis therapy and biofeedback. For some clients,
anxiolytics may be needed. Pneumonia is a common complication of COPD, and the client
should receive the yearly influenza vaccine. Clients with COPD tend to feel too full to eat and
have poor appetite and meal-related dyspnea. The work of breathing raises the client's calorie
and protein needs, which can lead to protein-calorie malnutrition. It is important to urge the
client to eat small, frequent meals of high-calorie, high-protein foods. Exercise for conditioning
and pulmonary rehabilitation can improve function and activity tolerance in clients with COPD.
Each client's exercise program should be personalized to the client's limitations. The simplest
plan is to have the client walk daily at a self-paced rate, until symptoms limit further walking.
High-intensity aerobic exercise would not be appropriate for the client with COPD.
Concepts tested

Question 2536
The nurse is caring for a client with orders for oxygen (O2) per nasal cannula at 5 L/min.
Approximately what fraction of inspired oxygen (FiO2) is the client receiving?
A 28%
B 21%
C 40%
D 36%

Question Explanation
Correct Answer is C
Rationale: Room air has an O2 concentration of approximately 21%. Supplemental O2 therapy
is prescribed when the client's oxygenation needs are not met by room air. A nasal cannula can
provide O2 at 0.5 to 6 L/min, corresponding to a FiO2 range of 25% to 40%. At 5 L/min, the
client would be receiving approximately 40% O2. If the client's oxygenation needs are still not
met, the O2 delivery system should be changed from a low-flow system like a nasal cannula to a
high-flow system such as a nonrebreather mask.
Concepts tested

Question 2537
A client with a new tracheostomy is becoming frustrated because of being unable to speak.
Which nursing intervention would be the most effective to help the client to communicate?
A Provide the client with a communication board and check on them frequently.
B Reassure the client that in time they will get used to the speech difficulties.
C Explain to the client that their speech will be clear and distinct with a fenestrated tube.
D Place a sign above the client's bed indicating that the client cannot speak.

Question Explanation
Correct Answer is A
Rationale: The inability to talk is a major stressor for a client with a new tracheostomy. It is
important to maintain communication with the client. The nurse can use a writing tablet, a board
with pictures and letters, communication flash cards on a ring, hand signals and smartphones to
promote communication and decrease frustration from not being able to speak or be understood.
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The other interventions, while important, would not be as effective. The nurse should phrase
questions to solicit "yes" or "no" answers to help the client respond more easily and place a note
at the central call light system intercom to indicate that the client cannot speak.
Concepts tested

Question 2538
A client who has a wet chest drainage system following a thoracotomy develops continuous
bubbling in the water seal chamber of the collection device. What action should the nurse take?
A Adjust the dial on the wall regulator to decrease suction.
B Notify the health care provider of the presence of an air leak.
C Instruct the client to deep breathe and cough more frequently.
D Clamp the chest tube immediately.

Question Explanation
Correct Answer is B
Rationale: Continuous bubbling in the water seal chamber is indicative of an air leak. Clamping
the chest tube is contraindicated and can cause a pneumothorax. Increasing or decreasing the
vacuum source will not adjust the suction pressure. The amount of suction applied is regulated
by the amount of water in this chamber and not by the amount of suction applied to the system.
Instructing the client to deep breathe and cough is not an appropriate intervention in this
situation.
Concepts tested

Question 2539
The health care provider (HCP) of a client with opioid-induced constipation prescribed the
administration of a bisphosphate enema. After reviewing the client's medical record, the nurse
recognizes which contraindications for giving the enema? Select all that apply.
A The client has a history of syncopal episodes.
B The client has a history of thrombocytopenia purpura.
C The client has a history of hyperkalemia.
D The client has a history of substance use disorder (SUD).
E The client has a history of hepatitis A.
F The client has a history of hemorrhoidectomy.

Question Explanation
Correct Answer is A, B, F
Rationale: An enema can cause a vasovagal response and a temporary decrease in heart
rate and blood pressure, causing syncope. Because the client already has a history of
syncopal episodes, the nurse should clarify the order with the HCP first. The client's
history of hemorrhoidectomy implies that hemorrhoids could be present, even if none are
externally visible. If internal hemorrhoids are present, inserting the enema may cause
bleeding and discomfort. Therefore, the nurse should clarify the order with the HCP first.
Clients with thrombocytopenia (low platelet count) may begin bleeding from the rectum
due to the mechanical trauma of the enema and should be given stool softeners and

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laxatives instead. The other conditions do not represent contraindications for receiving an
enema.
Concepts tested

Question 2540
The nurse is reviewing the plan of care for a client with a sacral, stage III pressure ulcer who is
prescribed continuous negative-pressure wound therapy (NPWT). For which finding should the
nurse notify the health care provider (HCP) immediately?
A The client is incontinent of stool.
B The client is receiving enteral nutrition.
C The wound has extensive tunneling.
D The client is receiving apixaban.

Question Explanation
Correct Answer is D
Rationale: Apixaban is an anticoagulant (a direct factor Xa inhibitor) used to reduce the risk of
stroke and systemic embolism in clients with atrial fibrillation. Anticoagulant therapy is a
contraindication for NPWT due to the increased risk of bleeding in the wound. The other
findings do not contraindicate the use of NPWT.
Concepts tested

Question 2541
A client who had a wrist cast applied three days ago calls from home, reporting that the cast is
loose enough to slide off. How should the nurse respond?
A "You need a new cast now that the swelling is decreased."
B "Use an arm sling to keep the casted arm immobile."
C "Place several gauze bandages inside the cast to prevent it from sliding off."
D "As your muscles atrophy, the cast is expected to loosen."

Question Explanation
Correct Answer is A
Rationale: After a new fracture, the surrounding soft tissue may be significantly swollen when
the cast is initially applied. After the swelling has resolved, the cast may become loose. If the
cast is loose enough to permit more than one finger between the cast and the skin, the cast
probably needs to be replaced. The client should never place anything inside the cast. The client's
muscles should not have atrophied while in a cast for just three days. Keeping the arm immobile
does not solve the problem and therefore would not be appropriate. On the contrary,
immobilizing the arm above the casted fracture is not necessary and can cause contractures of the
upper extremity proximal to the fracture.
Concepts tested

Question 2542
A nurse working on the orthopedic unit has just received change-of-shift report. Which client
should the nurse evaluate first?
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A The client with osteomyelitis and a temperature of 100.5°F.
B The client who has not voided 10 hours after a laminectomy.
C The client with low back pain rated 8 out of 10.
D The client who is anxious about discharge to a rehabilitation facility.

Question Explanation
Correct Answer is B
Rationale: Inability to void may indicate damage to the spinal nerves from the laminectomy that
is affecting the bladder and causing urinary retention. This presents a medical emergency, which
should be evaluated and reported to the surgeon immediately. The nurse should then evaluate the
other clients, but the information about them does not indicate a need to be evaluated first.
Concepts tested

Question 2543
The nurse is caring for a client who received thrombolytic therapy for an acute myocardial
infarction (MI). Which information is most important for the nurse to communicate to the health
care provider (HCP)?
A A large bruise at the client's IV insertion site
B An increase in troponin levels from baseline
C No change in the client's reported level of chest pain
D A decrease in ST-segment elevation on the ECG

Question Explanation
Correct Answer is C
Rationale: Continued chest pain suggests myocardial ischemia and that the thrombolytic therapy
is not effective. Other coronary interventions may be needed, such as a stent. Bruising is a
possible side effect of thrombolytic therapy and should be monitored, but it is not more
important to report than the unrelieved chest pain. The decrease of the ST-segment elevation
indicates that perfusion is returning to the injured myocardium. An increase in troponin levels is
expected with reperfusion and is related to the release of cardiac biomarkers into the circulation
as the blocked vessel reopens.
Concepts tested

Question 2544
The nurse is caring for a client with anemia of chronic disease. The client's latest hemoglobin
level is 7.6 g/dL. Which clinical manifestations would the nurse expect to find? Select all that
apply.
A Pallor
B Hypertension
C Tachypnea
D Bradycardia
E Fatigue

Question Explanation
Correct Answer is A, C, E

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Rationale: A hemoglobin level of 7.6 is very low. Normal levels range from 12 to 16 g/dL for
females and 14 to 18 g/dL for males. Due to the low level of hemoglobin in the blood, the client
will exhibit signs of low tissue oxygenation or hypoxia, such as fatigue, activity intolerance,
shortness of breath, tachycardia, tachypnea and skin pallor (i.e., the skin is pale and cool to the
touch). The client would not have bradycardia or hypertension with such severe anemia. The
opposite is more likely, such as tachycardia.
Concepts tested

Question 2546
Which condition should the nurse correlate with the following arterial blood gas values: pH 7.48,
HCO3 22 mEq/L, PCO2 28 mm Hg, PO2 98 mm Hg?
A Chronic obstructive pulmonary disease
B Diarrhea and vomiting for 36 hours
C Diabetic ketoacidosis
D Anxiety-induced hyperventilation

Question Explanation
Correct Answer is D
Rationale: The elevated pH indicates alkalosis. The bicarbonate level is normal, and so is the
oxygen (O2) partial pressure. Loss of carbon dioxide (CO2) is the cause of the alkalosis, which
would occur in response to hyperventilation. Diarrhea and vomiting would cause metabolic
alterations. COPD would lead to respiratory acidosis due to retention of CO2. A client with
diabetic ketoacidosis, a metabolic acidosis, will have a pH less than 7.35. The client's arterial
blood gas (ABG) values indicate a respiratory alkalosis due to hyperventilation.
Concepts tested

Question 2547
When taking a client's blood pressure (BP) after a parathyroidectomy, the nurse notes that the
client's hand has gone into flexion contractions. Which laboratory result does the nurse correlate
with this condition?
A Serum calcium level of 6.9mg/dL
B Serum sodium level of 122 mEq/L
C Serum potassium level of 2.9 mEq/L
D Serum potassium level of 5.8 mEq/L

Question Explanation
Correct Answer is A
Rationale: The parathyroid glands maintain calcium and phosphate balance through release of
parathyroid hormone (PTH) that acts directly on the kidney, causing increased kidney
reabsorption of calcium and increased phosphorus excretion.

After surgical removal of the parathyroid glands, a hypocalcemic crisis can occur due to the
absence of PTH. Hypocalcemia destabilizes excitable membranes and can lead to muscle
twitches, spasms and tetany.

The flexion contractions that occur while measuring BP (Trousseau's sign) indicate
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hypocalcemia, not the other electrolyte imbalances, which include hypokalemia, hyperkalemia
and hyponatremia.
Concepts tested

Question 2548
A client presents with elevations in triiodothyronine (T3) and thyroxine (T4) and with normal
thyroid-stimulating hormone (TSH) levels. Which is the nurse's priority intervention?
A Check for Trousseau's sign.
B Administer levothyroxine.
C Administer propranolol.
D Monitor the apical pulse.

Question Explanation
Correct Answer is D
Rationale: The client's laboratory findings suggest that the client is experiencing
hyperthyroidism. The increased metabolic rate can cause an increase in the client's heart rate, and
the client should be monitored for the development of dysrhythmias. Placing the client on a
telemetry monitor might also be an appropriate precaution. Synthroid is given for
hypothyroidism. Propranolol is a beta blocker often used to lower sympathetic nervous system
activity in hyperthyroidism. Hyperthyroidism can cause a mild to moderate elevation in serum
calcium levels but Trousseau's sign is indicative of hypocalcemia not hypercalcemia.
Concepts tested

Question 2549
A client has a new order for an open magnetic resonance imaging (MRI) scan without contrast
to evaluate for osteomyelitis. Which information indicates that the nurse should consult with the
health care provider (HCP) before scheduling the MRI?
A The client wears prescription glasses.
B The client has a pacemaker.
C The client is claustrophobic.
D The client is allergic to shellfish.

Question Explanation
Correct Answer is B
Rationale: Clients with a pacemaker, an internal device made of metal, cannot have a MRI scan
done because of the force exerted by the magnetic field on metal objects. An open MRI scan is
unlikely to cause claustrophobia. The client will be instructed to remove the glasses before the
MRI scan, but this does not require consultation with the HCP. Because contrast medium will
not be used, a shellfish allergy is not a contraindication to the MRI scan.
Concepts tested

Question 2550
The nurse is conducting teaching with a client who was recently diagnosed with type 2 diabetes
mellitus. Which statement by the client indicates an understanding of the hemoglobin A1C test?
A "It indicates the level of insulin resistance of the cells in my body."

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B "It indicates how much insulin I should be administering to myself."
C "It is a measurement of how my kidneys are functioning."
D "It reflects my average blood glucose level for the past three months."

Question Explanation
Correct Answer is D
Rationale: Hemoglobin A1C (HbA1c) reflects the average glucose level for approximately 100
to 120 days prior to the blood test. The test is beneficial for evaluating the success of diabetic
treatment and client compliance. It can also be used to determine the duration of hyperglycemia
in clients who are newly diagnosed with diabetes. By testing the portion of the hemoglobin that
combines with glucose (glycosylated hemoglobin) it is possible to determine the average blood
glucose over the lifespan of the red blood cell, which is 120 days. The desired HbA1c target
value for clients with diabetes is around 7%. The other statements are incorrect.
Concepts tested

Question 2551
An older adult client is admitted to the hospital with a diagnosis of protein-energy malnutrition.
The nurse understands that which blood test reflects the client's overall protein status?
A Albumin level
B Myoglobin level
C Haptoglobin level
D Bilirubin level

Question Explanation
Correct Answer is A
Rationale: Albumin is a serum protein that is formed in the liver. A serum albumin level reflects
a client's overall protein status, and is used to diagnose, evaluate and monitor the disease course
in clients with impaired nutrition. Malnourished clients have decreased serum albumin levels.
The approximate normal range for serum albumin is 3.5 to 5.0 g/dL. A serum haptoglobin
measurement is primarily used to identify the presence of intravascular hemolysis. A serum
bilirubin test evaluates a client's liver function, and a serum myoglobin test is used to evaluate
muscle damage.
Concepts tested

Question 2552
During a routine clinic visit, the nurse reviews the laboratory results of an adult client. Which
laboratory result is most important to notify the health care provider about?
A Red blood cell level of 3.7 x 106/µL
B Low-density lipoprotein level of 160 mg/dL
C Serum potassium level of 2.5 mEq/L
D Fasting glucose level of 132 mg/dL

Question Explanation
Correct Answer is C

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Rationale: A serum potassium level less than 3.5 mEq/L indicates hypokalemia. The low serum
potassium level is the most important abnormal lab value because hypokalemia can lead to
serious cardiac complications, including life-threatening dysrhythmias. The nurse should notify
the health care provider about the abnormal potassium level. The other lab values are also
outside of the normal ranges but do not pose as immediate of a threat as the low potassium level.
Concepts tested

Question 2553
The nurse is reviewing the medical record of an inpatient client and notes a positive stool occult
blood test. The nurse recognizes which factors may have contributed to this positive
result? Select all that apply.
A Current naproxen sodium use
B Recent invasive dental procedure
C Amblyopia
D Daily consumption of red meat
E Hemiparesis
F Current corticosteroid use

Question Explanation
Correct Answer is A, B, D, F
Rationale: A fecal occult blood test is used to detect occult (i.e. hidden) blood from causes such
as colorectal cancer, gastric or duodenal ulcers, diverticulosis, or gastrointestinal (GI) bleeding.
Drugs that can cause GI bleeding include non-steroidal anti-inflammatory drugs (NSAIDs) (e.g.
naproxen sodium) and corticosteroids. Factors that may contribute to a false-positive result
include bleeding gums following a dental procedure (due to swallowed blood), and the ingestion
of red meat within three days before testing because red meat contains animal hemoglobin.
Amblyopia (i.e. poor vision in one eye) and hemiparesis (i.e. unilateral weakness) would not
directly contribute to a positive fecal occult blood test.
Concepts tested

Question 2554
The nurse is reviewing the medical record of a client who was admitted for poor oral intake and
dysphagia. Which blood test result is most important for the nurse to report to the health care
provider?
A Creatinine level of 3.5 mg/dL
B Sodium level of 148 mEq/L
C Chloride level of 108 mEq/L
D Hematocrit level of 55%

Question Explanation
Correct Answer is A
Rationale: Poor oral intake (caused by dysphagia) has likely caused a fluid volume deficit (i.e.,
hypovolemia) in this client. When there is decreased circulating blood volume, the blood is more
concentrated and acute kidney injury can occur. High creatinine levels (e.g., 3.5 mg/dL) indicate
acute renal failure. It is most important for the nurse to report this finding to the health care

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provider. The other lab values are also outside of the normal range which is most likely related to
hemoconcentration caused by the hypovolemia.
Concepts tested

Question 2555
The nurse is preparing to remove a client's nasogastric (NG) tube. Which action by the nurse
will reduce the risk of aspiration during the removal?
A Change the wall suction to high during the tube removal.
B Ask the client to hold their breath while steadily pulling the tube out.
C Have the client swallow sips of water during the tube removal.
D Pre-oxygenate the client with 100% oxygen prior to removing the tube.

Question Explanation
Correct Answer is B
Rationale: When discontinuing an NG tube, the nurse should ask the client to hold their breath.
This will close the client's epiglottis and help prevent the risk of aspiration during the removal of
the NG tube. Clients may be asked to sip water during insertion of an NG tube, but not during
the removal. Suction should be turned off and disconnected prior to NG tube removal. There is
no need to pre-oxygenate a client prior to removing an NG tube.
Concepts tested

Question 2556
The preoperative nurse is reviewing the medical record of a client who is scheduled for a surgery
with general anesthesia. Which information in the client's medical record should be reported to
the health care provider prior to surgery? Select all that apply.
A Latex allergy
B Anxiety
C Family history of malignant hyperthermia
D Vitiligo
E Anticoagulant use

Question Explanation
Correct Answer is A, C, E
Rationale: Clients who will be undergoing general anesthesia should be screened carefully to
prevent complications. Malignant hyperthermia is an acute, life-threatening complication of
certain drugs used for general anesthesia. A family history of malignant hyperthermia should be
reported to the health care provider because it is a genetic condition. A latex allergy should be
reported to the health care provider so products containing latex are avoided during the surgery.
Recent anticoagulant use increases the risk for bleeding during or after surgery, and should also
be reported to the health care provider prior to the surgery. Vitiligo is an autoimmune related

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skin pigment disorder with no contraindications for general anesthesia. Although anxiety is a
pertinent consideration, it would not be a contraindication for general anesthesia.
Concepts tested

Question 2557
The nurse is providing discharge teaching to a client who had a radiofrequency catheter ablation
for treatment of atrial fibrillation. Which information is most important to include in the
teaching?
A Schedule a follow-up appointment in two weeks.
B Take all cardiac medications as prescribed.
C Call the cardiologist's office with any questions.
D Maintain oral fluid intake of 2 to 3 liters daily.

Question Explanation
Correct Answer is B
Rationale: Radiofrequency catheter ablation is an invasive procedure performed to treat cardiac
arrythmias. Ablation is used to destroy any abnormal cardiac pacemaker cells so that erratic
electrical signals are normalized. After an ablation, the client will typically continue taking an
antiarrhythmic medication and possibly an anticoagulant as well. Therefore, it is most important
to teach the client to adhere to their prescribed medication regimen to avoid potentially life-
threatening cardiac complications (e.g., lethal arrhythmias) because the cardiac cells tend to be
irritable in the weeks following the procedure.
Concepts tested

Question 2558
The nurse is caring for a client who is admitted with pneumonia and has orders for a sputum
culture. The nurse observes the unlicensed assistive person (UAP) assisting the client in
collecting a sputum specimen. Which action by the UAP would require the nurse to intervene?
A The UAP lowers the head of the bed to stimulate coughing.
B The UAP asks the client to rinse their mouth with water prior to sputum collection.
C The UAP asks the client to spit 5 mL of saliva into the cup
D The UAP asks the client to take several deep breaths then cough.

Question Explanation
Correct Answer is C
Rationale: It is important that the proper sputum collection procedure is followed to obtain
accurate laboratory and microbiology results. The client should rinse their mouth with water
before expectorating the sputum to decrease contamination by particles in the oropharynx. The
client should be asked to take several deep breaths then cough. If the client is unable to produce a
sputum specimen, coughing can be stimulated by lowering the head of the bed. The client should
expectorate a sputum specimen directly into the sterile collection container. The sputum
specimen should be representative of pulmonary secretions, not saliva. The client should be
reminded not to use antiseptic mouthwash before sputum collection.
Concepts tested

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Question 2559
The nurse is providing care to an adult client in the post-anesthesia care unit who is recovering
from an emergency appendectomy. The client is sleepy, but arousable and reports zero pain on a
numeric pain scale. Which assessment finding requires immediate action by the nurse?
A A blood pressure of 100/60 mmHg
B A temperature of 99.1°F (37.3°C )
C A pulse oximetry reading of 92%
D A resting heart rate of 128 bpm

Question Explanation
Correct Answer is D
Rationale: Tachycardia (i.e., a heart rate greater than 100 beats per minute) is an early
physiological response to a number of potential postsurgical complications, especially in the
absence of obvious contributing factors such as pain or anxiety. A resting heart rate of 128 could
indicate hypovolemia due to internal bleeding from the surgery. The client's blood pressure and
oxygen saturation are within acceptable ranges. A low-grade fever (e.g., 99.1°F or 37.3°C) can
occur post-operatively and is typically not a cause for immediate concern. Therefore, the nurse
should notify the health care provider of the client's resting heart rate immediately.
Concepts tested

Question 2560
The nurse is teaching a client how to properly use their peak flow meter at home. Which
statement by the client indicates an understanding of the teaching?
A "I will take a deep breath and exhale slowly and steadily into the mouthpiece."
B "I will exhale completely then inhale quickly into the mouthpiece."
C "I will take a deep breath and then blow out hard and fast into the mouthpiece."
D "I will exhale completely then inhale slowly and steadily into the mouthpiece."

Question Explanation
Correct Answer is C
Rationale: The Peak Expiratory Flow Rate (PEFR) is the point of highest flow during maximal
expiration. The normal range is calculated for clients individually based on their height and
weight. The steps for correctly using the peak flow meter include: move the indicator to the
bottom of the numbered scale, stand up, take a deep breath, place the mouthpiece in mouth and
close lips around it, blow out hard and fast with a single blow, and record the number achieved
on the indicator. The steps should be repeated two more times, for a total of three attempts and
the highest peak flow reading of the three should be recorded.
Concepts tested

Question 2561
The nurse is reviewing the medical record of a client who is scheduled to have an intravenous
pyelogram tomorrow. Which item in the client's health history should the nurse report to the
health care provider?
A Iodine allergy
B Pacemaker

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C Claustrophobia
D Obesity

Question Explanation
Correct Answer is A
Rationale: An intravenous pyelogram (IVP) is a radiologic study in which intravenous
radiopaque contrast material is used to visualize the kidneys, renal pelvis, ureters and bladder.
Clients who are allergic to iodine or iodinated contrast dyes may need to be premedicated with
prednisone and diphenhydramine to prevent an allergic reaction. Therefore, the nurse should
notify the health care provider of the client's iodine allergy. Claustrophobia, the presence of a
pacemaker and obesity are not contraindications for this test.
Concepts tested

Question 2562
The nurse is caring for a client following a coronary angiography procedure. The client's medical
history includes type 2 diabetes mellitus and mild renal insufficiency. The nurse should
anticipate which post-procedural order from the health care provider?
A Place an indwelling urinary catheter.
B Monitor serum creatinine levels.
C Resume metformin 500 mg by mouth daily.
D Restrict oral fluid intake for 24 hours.

Question Explanation
Correct Answer is B
Rationale: Coronary angiography requires the use of an intravenous contrast dye. Clients with
diabetes and/or impaired kidney function are at an increased risk for developing contrast media-
induced nephrotoxicity (CIN). Therefore, creatinine levels should be closely monitored before
and after the procedure to monitor kidney function and possible development of CIN. After the
procedure, increased hydration is appropriate to help maintain renal blood flow and reduce the
time the contrast media is in contact with the renal tubules and, therefore, help prevent CIN.
Metformin is typically withheld for approximately 48 hours after the test because hypoglycemia
or acidosis may occur in clients who have received contrast dye and take metformin. Urine
output should be monitored after the procedure, however there is no indication for an indwelling
urinary catheter.
Concepts tested

Question 2563
The nurse is reviewing the medical record of a client who is scheduled for a computerized
tomography (CT) scan of the brain with contrast. For which information in the client's medical
record should the nurse notify the health care provider? Select all that apply.
A Client has a positive pregnancy test.
B Client has an iodine allergy
C Client takes anticonvulsant medication.
D Client has a mechanical heart valve
E Client is on hemodialysis.

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F Client has peripheral neuropathy.

Question Explanation
Correct Answer is A, B, E
Rationale: Contraindications for a CT scan of the brain with intravenous contrast dye include
pregnancy, renal failure (clients on hemodialysis) and an iodine allergy (iodinated contrast dye is
used). Peripheral neuropathy, anticonvulsant medications and the presence of an artificial, i.e.,
mechanical, heart valve are not contraindications for a CT scan of the brain with contrast.
Concepts tested

Question 2564
The nurse working on a surgical unit is caring for a client who had surgery earlier today. The
client's blood pressure is 80/51 mmHg and the heart rate is 128 bpm. Which intervention should
the nurse implement first?
A Ensure the client has a patent airway.
B Check the surgical dressing for bleeding.
C Increase the rate of the IV fluid infusion.
D Apply supplemental oxygen therapy.

Question Explanation
Correct Answer is A
Rationale: The client is exhibiting signs of hypovolemic shock (e.g. hypotension and
tachycardia). Hypovolemic shock can occur as a complication from surgery. The goals of
hypovolemic shock management are to maintain tissue oxygenation, increase vascular volume,
and support compensatory mechanisms. The nurse should follow the ABCs and first ensure the
client has a patent airway. Then the nurse should apply supplemental oxygen to promote tissue
oxygenation. The nurse should increase the rate of IV fluids to increase the client's vascular
volume. The nurse should assess the client's surgical dressing for bleeding. The clients condition
should be reported to the health care provider immediately.
Concepts tested

Question 2565
The nurse is performing routine daily cleaning of a client's tracheostomy. During the procedure,
the client coughs and displaces the tracheostomy tube out of the stoma. The nurse understands
that this outcome could have been avoided by which of the following actions?
A Apply clean tracheostomy ties before removal of old ties
B Placement of an obturator at the client's bedside
C Have another nurse assist with the procedure
D Place the client in a flat, supine position

Question Explanation
Correct Answer is A
Rationale: Fastening clean tracheostomy ties before removal of the old ones will ensure that the
tracheostomy is secured during the entire cleaning procedure. The obturator is useful to keep the
airway open only after the tracheostomy outer tube is coughed out. However, the question asks

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how to prevent the situation. A second nurse is not needed during the procedure. A change in the
position of the client does not prevent a dislodged tracheostomy.
Concepts tested

Question 2566
The nurse is caring for a client diagnosed with a fecal impaction. While preparing to manually
remove the impaction, what essential information should the nurse remember?The nurse is
caring for a client diagnosed with a fecal impaction. While preparing to manually remove the
impaction, what essential information should the nurse remember?
A Cardiac dysrhythmias can result during the process
B The procedure will require a mild sedative
C Increased dietary fiber can minimize such problems
D Family members should be taught the procedure

Question Explanation
Correct Answer is A
Rationale: Fecal impaction requires manual disimpaction or removal. While using a lubricated,
glove, the nurse inserted the index finger into the rectum and attempts to break up the hardened
stool using a circular or scissoring motion. This will allow the stool to be extracted. While
performing the procedure, it would be essential for the nurse to remember that cardiac
dysrhythmias could occur from vagal nerve stimulation. The other options are appropriate;
however, they are not the priority or essential consideration.
Concepts tested

Question 2567
The nurse is caring for a client admitted with a diagnosis of myocardial infarction (MI). Which
lab finding is most consistent with the client's diagnosis?
A Elevated proBNP
B Elevated troponin
C Elevated myoglobin
D Elevated creatine kinase

Question Explanation
Correct Answer is B
Rationale: All of these lab tests may be elevated during an MI. Although CK-MB (along with
total CK) is a very good test, it has been replaced by troponin. Elevation of troponin is the most
reliable because it is more specific to heart damage; it elevates within a few hours and remains
elevated for about 10 days. CK-MB is one of three separate forms (isoenzymes) of the enzyme
creatine kinase (CK); it is found mostly in heart muscle and rises when there is damage to the
heart. An elevated C-reactive protein is associated with a risk of cardiovascular disease.
Concepts tested

Question 2568

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The nurse is reviewing lab results for a client admitted with acute exacerbation of chronic
obstructive pulmonary disease. Which lab result should be of highest concern?
A Serum albumin level of 2.0 mg/dL
B Hematocrit level of 50%
C PaO2 level of 60 mm Hg
D PaCO2 level of 52 mm Hg

Question Explanation
Correct Answer is C
Rationale: COPD or chronic obstructive pulmonary disease is a chronic disease that causes
obstructed airflow in the lungs due to inflammatory processes. Obstructed airflow may cause
severe respiratory distress and affect a person's ability to exchange oxygen and carbon dioxide
efficiently. The PaO2 level is significantly decreased (normal 80 to 100 mm Hg), indicating
severe hypoxemia and should be of highest concern for the nurse. Clients with COPD
chronically retain PCO2; thus, an elevated level is to be expected. The hematocrit level is at the
upper end of the normal range. Although the albumin level is also significantly decreased,
indicating malnutrition, it it of a lower priority than the low PAO2 level.
Concepts tested

Question 2569
A client is scheduled to have a pulmonary artery catheter inserted (PAC). Prior to the procedure,
what information would be essential for the nurse to teach the client about a PAC?
A "The catheter is inserted through the groin into the left side of the heart.
B "You will be under general anesthesia for this procedure by an anesthesiologist."
C "The catheter will measure different pressures in the heart and lungs."
D "You will be unable to eat or drink anything for several hours after the procedure."

Question Explanation
Correct Answer is C
Rationale: A pulmonary artery catheter, also known as a Swan-Ganz catheter or right heart
catheterization, is inserted into the right side of the heart and into the arteries that lead to the
lungs. It is inserted either through the groin or neck, using conscious sedation and local
anesthetic, at the bedside (usually in an intensive care unit.) PAC can measure right atrial
pressure, pulmonary artery pressure, and pulmonary capillary wedge pressure; these
measurements can be used to assess oxygenation of the blood in the right heart and overall
cardiac output. Clients can eat or drink after the procedure.
Concepts tested

Question 2570
The visiting nurse is evaluating a 2-month-old child who had bilateral leg casts applied for the
treatment of clubfoot. Which nursing goal is the priority for this child?
A Muscle spasms will be relieved
B Tissue perfusion will be maintained
C Minimal pain with cast application
D Mobility will be managed as tolerated

Page | 1010
Question Explanation
Correct Answer is B
Rationale: Immediately following cast application, the priority goal is to maintain circulation and
tissue perfusion around the cast. Although most casts do not cause problems, the risk for
complications such as compartment syndrome does exist. Compartment syndrome means the
pressure in an extremity that can cause so much pressure that blood flow and tissue perfusion is
impaired. Permanent tissue damage can occur in the limb within a few hours, if perfusion is not
maintained. Therefore, assessment and monitoring of the extremity for the 6 Ps (pain,
paresthesia, pallor, paralysis, pulselessness) of poor tissue perfusion/ischemia is the most
important during this period.
Concepts tested

Question 2571
The nurse is caring for a client diagnosed with an aspirin overdose who is in respiratory
alkalosis. Which finding was most likely the cause of this imbalance?
A Hyperpyrexia
B Vomiting
C Tachypnea
D Hypokalemia

Question Explanation
Correct Answer is C
Rationale: The client is suffering from salicylate poisoning due to the over-consumption of
aspirin. Classic symptoms of salicylate poisoning are ringing in the ears, nausea, abdominal pain,
and fast breathing rate. The fast breathing rate, or tachypnea, is causing the client to
hyperventilate which is decreasing carbon dioxide (CO2) levels as the client blows out air. This
will eventually progress to hypoventilation and respiratory failure. Respiratory alkalosis is
characterized by a higher ph, low PaCO2, and normal bicarbonate (HCO3).
Concepts tested

Question 2572
A client has just returned from the post anesthesia care unit (PACU) to the surgical unit after a
cholecystectomy. When initial vital signs are taken the nurse notes a temperature of 94.8°F
(34.8°C). Which action should the nurse implement first?
A Ask the PACU nurse more details of what happened in PACU
B Call the health care provider and obtain further orders for warming
C Apply a warm blanket and check the temperature in 10 minutes
D Continue to monitor the vital signs as indicated

Question Explanation
Correct Answer is C
Rationale: A client’s postoperative temperature should be at least 95° F (35° C). Post-surgical
hypothermia can lead to cardiovascular complications, transfusion requirements, and risks of
infection. The first action of the nurse should be to apply a warm blanket and recheck the
temperature in 10 minutes. If the temperature does not increase after this time, the next step
Page | 1011
would be to call the health care provider for further actions, such as an electric warming blanket.
Postoperative hypothermia may be due to an effect of surgery due to anesthetic drugs or if the
client’s skin was exposed for a long period of time.
Concepts tested

Question 2573
The nurse in a pediatric intensive care unit is developing a plan of care for a 2-year-old child
scheduled for surgery to correct a congenital heart defect. Which nursing outcome is
the priority following the surgery?
A Effective pain management
B Prevention of respiratory complications
C Reduction of separation anxiety and emotional distress
D Maintenance of adequate cardiac output

Question Explanation
Correct Answer is B
Rationale: The nurse should use the airway-breathing-circulation (ABC) strategy to prioritize
nursing goals, interventions and outcomes; therefore, preventing respiratory complications is
the priority. Areas of atelectasis are common after surgery as a result of deflation of the lung
during cardiopulmonary bypass. Other pulmonary complications include pneumothorax,
pulmonary edema and pleural effusion. Frequent assessments of the child's respiratory status
should be performed and include auscultation, respiratory rate and effort, oxygen saturation, and
skin color.
Concepts tested

Question 2574
The nurse is providing care to a client who is receiving oxygen therapy via nasal cannula. During
the provision of care, which nursing intervention would be most appropriate?
A Maintain sterile technique when handling the tubing
B Inspect the nares and areas around the ears for skin breakdown
C Determine that adequate mist is supplied
D Lubricate the tips of the cannula before insertion in the nose

Question Explanation
Correct Answer is B
Rationale: Oxygen therapy by nasal cannula can cause drying of the nasal mucosa. Pressure
from the plastic tubing can cause skin irritation inside the nares or around the tops of the ears
(padding is available, which helps, but does not eliminate, the problem around the ears). Nasal
cannula tips for the administration of oxygen should be cleaned regularly and should never be
lubricated with petroleum jelly.
Concepts tested

Question 2575

Page | 1012
A client has a percutaneous endoscopic gastrostomy (PEG) tube that is used to administer
nutritional feedings and medications. Which nursing action is best to ensure patency of the tube?
A Warming nutrition feedings before administration
B Squeezing the tube to dislodge obstructions
C Adequately flushing the tube with water before and after use
D Completely crushing all medications prior to administration

Question Explanation
Correct Answer is C
Rationale: Prior to using the tube, it must be checked to make sure it is free from obstruction and
leaks. Milking the tube may help dislodge an obstruction, but flushing the tube before and after
use is the best way to ensure patency (while providing hydration). Liquid medication
preparations are best, but tablets and pills can be dissolved in water (and flushed with 30-50 mL
of water afterwards.) If the client experiences abdominal bloating, the nurse can encourage the
client to cough, which will speed up the removal of excessive air, but the tube still needs to be
flushed with water before and after use.
Concepts tested

Question 2576
The nurse explains an autograft to a client scheduled for excision of a skin tumor. Which
statement indicates that the client understands the nurse’s teaching?
A "I will receive tissue from a pig."
B "I will receive tissue from a tissue bank."
C "I will receive tissue from my thigh."
D "I will receive tissue from synthetic skin."

Question Explanation
Correct Answer is C
Rationale: Autografts are done with tissue transplanted from the client's own skin. Tissue from a
pig is called a xenograft or heterograft, which means it is transplanted from an organism of one
species to that of a different species. Cadaveric grafts are termed allografts, or homografts
because they are transplanted from one individual to another within the same species.
Concepts tested

Question 2577
The health care provider orders blood tests for a client diagnosed with acute hepatitis B (HBV).
Which lab finding should the nurse anticipate to be elevated?
A Albumin
B WBC (white blood cells)
C BUN (blood urea nitrogen)
D ALT (alanine aminotransferase)

Question Explanation
Correct Answer is D

Page | 1013
Rationale: ALT and AST (aspartate aminotransferase) are enzymes located in liver cells that can
leak out into the bloodstream when liver cells are injured. Elevated ALT (and AST) indicate liver
damage. One of the liver's jobs is to make albumin; low albumin can be a sign of liver disease.
Leukopenia (a decrease in the number of WBCs) is a common finding associated with HBV.
BUN and creatinine are used to evaluate kidney function.
Concepts tested

Question 2578
The nurse is caring for a newborn with hyperbilirubinemia who is being treated with a
biliblanket for phototherapy. Which intervention is most appropriate during this type of therapy?
A Provide frequent feedings of breast milk or formula
B Restrict holding the newborn during treatment
C Rotate the neonate to treat all of his/her skin
D Discontinue breastfeeding during treatment

Question Explanation
Correct Answer is A
Rationale: A biliblanket consists of a fiber-optic pad and a portable illuminator. This form of
phototherapy allows the baby to be diapered, clothed, held, and nursed during treatment.
Frequent feedings of breast milk or formula are necessary to help with bowel motility, which, in
turn, will increase excretion of bilirubin from the body. Discontinuing breastfeeding will disrupt
the establishment of milk production. It is not necessary to rotate the baby during treatment.
Concepts tested

Question 2579
The occupational health nurse is teaching a group of employees about prevention of carpal tunnel
syndrome. Which interventions should the nurse include? Select all that apply.
A Perform wrist exercises
B Request workstation modifications such as an ergonomic keyboard
C Regularly rest your hands throughout the workday
D Wear a brace or splint at night
E Request an endoscopic carpal tunnel release

Question Explanation
Correct Answer is A, B, C, D
Rationale: Carpal tunnel syndrome (CTS) is a type of repetitive strain injury (RSI) resulting from
prolonged force or repetitive movements. CTS is caused by compression of the median nerve,
which enters the hand at the wrist through the narrow carpal tunnel. The carpal tunnel is formed
by ligaments and bones. CTS is the most common RSI in the upper extremity. It is associated
with hobbies or work that require continuous wrist movement (e.g., musicians, carpenters,
computer operators). Preventative measures include identification of risk factors, stop
aggravating movement, resting the hand, ice, wrist immobilization with a hand splint,
nonsteroidal anti-inflammatory drugs, wrist exercises and physical therapy. A carpal tunnel
release is a surgical intervention, usually reserved until all noninvasive interventions have been
exhausted.

Page | 1014
Concepts tested

Question 2580
The nurse is caring for a client with a chest tube who is one day post-op following a
thoracotomy. While performing an assessment, the nurse observes bubbling in the water seal
chamber when the client coughs. Which intervention should the nurse do first?
A Continue to monitor the client to see if the bubbling increases
B Clamp one of the chest tubes and ask the client to cough again
C Call the surgeon immediately for potential return to surgery
D Instruct the client to avoid coughing for the next day

Question Explanation
Correct Answer is A
Rationale: Bubbling in the water seal chamber that is associated with coughing after lung surgery
is an expected finding within the first 48 hours postop. Small amounts of air escape into the
pleural space when pressures inside the chest increases with coughing. Monitoring for increases
or decreases in the bubbling with coughing is the only nursing action required at this time. The
client should be encouraged to deep breathe and cough every two hours minimally.
Concepts tested

Question 2581
The nurse is caring for a client following total knee replacement surgery. Which intervention will
be most effective in preventing the complication of deep vein thrombosis in this client?
A Use elastic stockings continuously
B Place pillows under the knees
C Encourage range of motion and ambulation
D Massage the legs twice daily

Question Explanation
Correct Answer is C
Rationale: Mobility reduces the risk of deep vein thrombosis (DVT) in the postsurgical client.
The postoperative client would wear either compression elastic stockings and/or external
pneumatic compression devices; elastic stockings should be removed at least once a shift to
assess skin integrity. Pillows should never be placed under the knees, as it can prevent
appropriate venous return.
Concepts tested

Question 2582
The nurse is caring for a client diagnosed with superficial thrombophlebitis of the left leg. While
developing a plan of care, the nurse should include which intervention?
A Maintain complete bed rest
B Place the leg in an immobilizer brace
C Elevate the affected leg
D Apply cool compresses

Page | 1015
Question Explanation
Correct Answer is C
Rationale: Unlike deep vein thrombosis, superficial thrombophlebitis involves a sudden
inflammatory reaction (redness, pain, swelling), but it rarely involves a thrombus. Treatment
consists of elevating the leg because dangling the extremity will increase the swelling and the
pain. Other treatment options include warm compresses and analgesics; sometimes a low-
molecular weight heparin is also prescribed. Clients do not need to be on bed rest or require an
immobilizer brace.
Concepts tested

Question 2583
A client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA). What
information would be essential for the nurse to know about this procedure when teaching the
client?
A The procedure involves surgical repair with an incision of a diseased coronary artery to
improve blood flow.
B The procedure involves placement of an automatic implanted cardiac defibrillator.
C The procedure is a noninvasive radiographic examination of the coronary arteries.
D The procedure compresses plaque against the wall of the diseased coronary artery to improve
blood flow.

Question Explanation
Correct Answer is D
Rationale: A percutaneous transluminal coronary angioplasty (PTCA) is an invasive procedure
performed to open blocked coronary arteries caused by coronary artery disease (CAD). The
procedure is performed during a cardiac catheterization and does not involve implanting a
cardiac defibrillator. A balloon is inflated once the catheter is in place in the diseased artery and
compresses fatty tissue resulting in improved blood flow. A coronary artery bypass graft
(CABG) is a surgical procedure that requires incisions to repair diseased coronary arteries.
Concepts tested

Question 2584
The nurse is caring for a client with orders for complete bed rest. Which action by the nurse
is most important in the prevention of the formation of deep vein thrombosis (DVT)?
A Elevate the foot of the bed
B Apply knee high support stockings
C Prevent pressure at back of the knees
D Encourage isometric leg muscle exercises

Question Explanation
Correct Answer is C
Rationale: Deep vein thrombosis (DVT) is a blood clot that forms in a vein in the body, typically
found in the lower extremities. DVTs can be caused by a variety of reasons. Prolonged bed rest
in the hospital setting puts this client at high risk for developing a DVT due to decreased venous
stasis or blood flow to the lower extremities. To prevent any obstruction in blood flow, the nurse
would want to prevent pressure at the back of the knees. Other actions that may be implemented
Page | 1016
after this action include elevating the foot of the bed, apply pneumatic stockings and/or applying
knee high support stockings, and encouraging the client to perform ankle pumps to promote
blood flow back through the body.
Concepts tested

Question 2585
The nurse is caring for a client who has undergone a cardiac catheterization procedure. Which of
the following complications should the nurse monitor for in the initial 24 hours after the
procedure?
A Thrombus formation
B Low blood pressure (BP)
C Dizziness with standing
D Decrease in appetite

Question Explanation
Correct Answer is D
Rationale: Thrombus formation in the coronary arteries is a potential problem in the initial 24
hours after a cardiac catheterization. A lowered BP may exist with hemorrhage of the insertion
site, which is at highest risk within the first 12 hours after the procedure if a local plug is not
used.
Concepts tested

Question 2586
The nurse is caring for a client with a venous insufficiency (stasis) ulcer on one leg. Which
intervention performed by the nurse would be most effective to promote healing?
A Initiate whirlpool bath therapy
B Apply dressings with the use of sterile technique
C Begin proteolytic debridement within 24 hours
D Improve the client’s nutritional status

Question Explanation
Correct Answer is D
Rationale: Venous insufficiency ulcers are caused due to malfunctioning venous valves resulting
in a pooling of blood and edema in the lower extremities. Venous ulcers are slow to heal. To
promote healing, good nutrition is essential. The other interventions are appropriate but of little
value if the client has poor nutrition.
Concepts tested

Question 2587
The nurse is preparing to give a tissue plasminogen activator (tPA) to a client after an ischemic
stroke. Which of the following lab values should the nurse assess prior to initiating the tPA?
A Blood urea nitrogen and creatinine
B Potassium and magnesium
C Prothrombin time and activated partial thromboplastin time
D Arterial blood gases and complete blood count

Page | 1017
Question Explanation
Correct Answer is C
Rationale: Tissue plasminogen activator (tPA) has been used to resolve some of the clinical
manifestations after an ischemic stroke. Tissue plasminogen activator is a thrombolytic or clot-
busting medication. One of the effects of the medication is abnormal bleeding. Thus, the nurse
should evaluate the prothrombin time and activated partial thromboplastin times prior to
administration. Prolonged clotting times may exclude the client from receiving the tPA. The
other lab values will be evaluated but do not impact the inclusion criteria to receive the tPA.
Concepts tested

Question 2588
The nurse is reviewing the medical record of a client who is receiving hemodialysis for end-stage
renal disease (ESRD). Which lab values are important to monitor for this client? Select all that
apply.
A Hemoglobin level
B Serum calcium
C Troponin level
D Serum potassium
E Serum creatinine

Question Explanation
Correct Answer is A, B, D, E
Rationale: Intermittent hemodialysis (HD) is the most common kidney replacement therapy used
for ESRD. Dialysis removes excess fluids and waste products and helps restore the body's fluid
and electrolyte balance. HD involves passing the client's blood through an artificial
semipermeable membrane to perform the kidney's filtering and excretion functions. Clients with
ESRD and on HD are often anemic, so it is important to monitor their hemoglobin level. The
creatinine level indicates kidney function, and the potassium and calcium levels are affected by
ESRD and dialysis and should also be closely monitored. Troponin pertains to the myocardium
and is not typically done for clients on dialysis.
Concepts tested

Question 2589
The nurse is assessing a 72-year-old client with a full-leg cast on his left leg three days after cast
application and finds bilateral pedal edema. Based on this finding, what condition should the
nurse consider?
A Heart failure
B Compartment syndrome
C Infection
D Thrombophlebitis

Question Explanation
Correct Answer is A

Page | 1018
Rationale: Swelling after injury or surgery and reduction usually peaks within 24 to 48 hours
with only minimal swelling expected afterward. If the client had pedal edema only on the casted
leg, the nurse should consider an extension of the initial injury/trauma, compartment syndrome,
or thrombophlebitis. However, with bilateral pedal edema, the nurse should consider right-sided
heart failure.
Concepts tested

Question 2590
Upon the return of a client from surgery after an open reduction internal fixation of a femur
fracture, the nurse notes a small bloodstain on the dressing and marks it. Four hours later the
nurse observes that the stain has doubled in size. What is the best action for the nurse to take?
A Remove the pneumatic compression device from the affected extremity
B Outline the new spot with a marker and continue to monitor
C Increase the rate of the IV fluid infusion
D Request a type and crossmatch from the blood bank

Question Explanation
Correct Answer is B
Rationale: To make a mark outlining the spot is a good way to monitor the amount of bleeding
over a period of time. In addition to outlining the spot, the nurse should note the date and time. If
the bleeding does not appear to be excessive, monitoring the drainage is appropriate since some
bleeding is expected after this type of surgery. The other actions are not appropriate or indicated
at this time.
Concepts tested

Question 2591
The nurse is planning care for a client following a stroke. Which approach would be most
effective in the prevention of skin breakdown?
A Reposition every two hours when in bed
B Pad the bony prominences
C Place client in the wheelchair for four hours daily
D Massage reddened bony prominences

Question Explanation
Correct Answer is A
Rationale: Following a stroke, clients often experience some degree of immobility, leading to an
increased risk for impaired skin integrity. By relieving the pressure over bony prominences at
frequent scheduled intervals, blood flow to areas of potential injury is maintained. Repositioning
the client every two hours while in bed would be most effective in preventing skin breakdown,
such as a pressure ulcer. If the client is in a wheelchair, a shift of the weight should be done
every hour. Massage of reddened bony prominences is no longer recommended to prevent
pressure ulcers or injuries.
Concepts tested

Question 2592

Page | 1019
A client in labor wishes to have an epidural. The nurse reviews the client's history and laboratory
results. Epidural placement is contraindicated with which of the following findings?
A White blood cell count is 8,000/mcL
B Platelet count is 95,000/mcL
C Sodium is 138 mg/dL (138 mmol/L)
D Hemoglobin is 11.2 g/dL (6.95 mmol/L)

Question Explanation
Correct Answer is B

Question 2593
The nurse is caring for a client admitted with a diagnosis of bacterial meningitis. In reviewing
the laboratory analysis of cerebrospinal fluid (CSF), the nurse should expect to see which result?
A Elevated sedimentation rate
B Increased glucose levels
C Clear cerebrospinal fluid
D High protein levels

Question Explanation
Correct Answer is D
Rationale: A positive CSF for bacterial meningitis would include the presence of protein, a
positive blood culture, decreased glucose, cloudy color with increased opening pressure, and an
elevated white blood cell count. If it was viral meningitis, the difference would be that the CSF
glucose would be within normal parameters.
Concepts tested

Question 2594
The medical-surgical nurse is performing an assessment on a client who is admitted for
community-acquired pneumonia. Assessment findings include a respiratory rate of 20 breaths per
minute, the skin is pink, and the client is receiving oxygen via nasal cannula at 6 liters per
minute. What action should the nurse take?
A Call the health care provider (HCP) about the client's condition
B Put the client in a more comfortable position
C Maintain the current oxygen therapy
D Lower the oxygen rate to 3 liters per minute

Question Explanation
Correct Answer is C
Rationale: Even though this client has a history of asthma, the condition of pneumonia requires
oxygenation. If the oxygen was at too high of a concentration, the hypoxic drive would be
eliminated, and the client's depth and rate of respiration will decrease. The client's rate is within
the higher limits of normal. Thus, there is no need at this time to change the rate of oxygen. The
client's condition is stable, and it is not necessary to notify the HCP. There is no evidence the
client is uncomfortable at this time.
Concepts tested

Page | 1020
Question 2595
The nurse is caring for a client admitted with diabetic ketoacidosis (DKA). Which lab finding is
the priority?
A Hematocrit of 60%
B PaO2 of 79 mm Hg
C pH of 7.34
D Potassium level of 5.0 mEq/L

Question Explanation
Correct Answer is A
Rationale: DKA is defined as a blood pH less than 7.30, bicarbonate level less than 18 mEq/L,
and blood glucose greater than 250 mg/dL. Hyperglycemia induces osmotic diuresis causing
water and electrolyte loss. The elevated hematocrit level (approx. normal range 38% to 55%)
confirms severe dehydration and is the priority lab finding for this client. The client will require
rehydration with intravenous fluids. The potassium level for this client is on the high end of
normal, and the PaO2 level is near the low end of normal (80-100 mm Hg).
Concepts tested

Question 2596
The nurse observes an unlicensed assistive personnel (UAP) providing care for a left unilateral
mastectomy. The nurse should intervene if the UAP is observed doing which action?
A Taking the blood pressure in the left arm
B Compressing the drainage device
C Reinforcing the client to restrict sodium intake
D Elevating the client's left arm above heart level

Question Explanation
Correct Answer is A
Rationale: To avoid the potential for lymphedema and tissue trauma to the post-operative area
post-mastectomy, the client should not have blood pressure taken or a tourniquet placed on the
arm of the operative side. It is acceptable for the client to elevate their arm above the heart level
as long as it does not cause pain. Restricting dietary sodium intake may reduce lymphedema.
Compressing the drain helps to maintain suction on the device and is appropriate.
Concepts tested

Question 2597
The nurse is reviewing the medical record of a client who has been hospitalized for a pulmonary
embolism 3 times in the past six months. The nurse understands that which potential intervention
is appropriate for this client?
A Lung resection surgery
B Hemodialysis
C Prophylactic alteplase infusion
D Inferior vena cava filter

Page | 1021
Question Explanation
Correct Answer is D
Rationale: For clients with recurrent deep vein thrombosis (DVT) or pulmonary emboli (PE), an
inferior vena cava (IVC) filter may be indicated. The filter is inserted by a surgeon or
interventional radiologist through the femoral or jugular vein. The IVC will trap emboli in the
inferior vena cava before they progress to the lungs. Holes in the device allow blood to pass
through, without interfering with the return of blood to the heart. Several new filter brands are
available that are designed for removal if and when DVT and PE risks diminish. The other
interventions are not appropriate for this client.
Concepts tested

Question 2598
A nurse is assessing a client who was placed on a volume-cycled ventilator. Which finding
indicates that the nurse needs to suction the client?
A Restlessness
B Report of nausea
C Heart rate of 82 BPM
D Drowsiness

Question Explanation
Correct Answer is A
Rationale: Restlessness suggests the client may be experiencing hypoxia due to the presence of
secretions in the airways. Other symptoms of hypoxia include tachycardia. The report of nausea
is not relevant to the need for suctioning. Drowsiness may occur if the pCO2 is high but is not an
indication for suctioning.
Concepts tested

Question 2599
The nurse is preparing a client for a kidney, ureter, bladder (KUB) radiograph test. Prior to the
test, which action should the nurse plan to take for this client?
A Keep the client NPO for eight hours before the examination
B Plan to have a fleets enema given prior to the examination
C Medicate the client with a PRN antihistamine prior to the examination
D Take no special actions before this examination

Question Explanation
Correct Answer is D
Rationale: A kidney, ureter, bladder X-ray is a simple X-ray requiring no special preparation.
Antihistamines are generally administered if there is an expectation of allergic reaction to
contrast; there is no contrast given for a KUB. Fleets enemas are sometimes given prior to
barium enemas. It is not necessary to keep the client NPO.
Concepts tested

Question 2600

Page | 1022
A child and the family were exposed to mycobacterium tuberculosis about two months ago. For
confirmation of the presence or absence of an infection in their system, it is important for all
family members to have which test?
A TB skin test or blood test
B Blood culture and sensitivity
C Sputum culture and sensitivity
D Chest X-ray without contrast

Question Explanation
Correct Answer is A
Rationale: After exposure to Mycobacterium tuberculosis, it is important to determine that no
infection has occurred. The client can have a TB skin test given intradermally or a TB spot blood
test to determine if exposure has occurred. A chest x-ray will be done if this test is positive. It is
not necessary for the client to have a sputum culture or blood culture.
Concepts tested

Question 2601
The nurse is caring for a client with a T-tube following a cholecystectomy on the first
postoperative day. The nurse would expect which color of drainage from the client's T-tube at
this time?
A Yellowish red
B Light lime greenish
C Yellowish brown
D Dark chocolate brown

Question Explanation
Correct Answer is C
Rationale: During a cholecystectomy, a T-tube may be inserted to collect bile. Bile is yellowish-
brown. Gastric contents may be green. Dark brown or a yellowish red color would be an
indication of some type of bleeding which would not be expected.
Concepts tested

Question 2602
The nurse is caring for a client in radiology receiving contrast medium for an intravenous
pyelogram (IVP). During the initial injection of the contrast medium, the client turns a ruddy red
color and says, "I can't seem to catch my breath." Which of the following interventions is the
nurse's first priority?
A Administer epinephrine and stop administering the contrast medium
B Ask the client to take two slow deep breaths
C Continue to assess vital skins and skin color
D Ask the technician to slow the rate of administration of the contrast medium

Question Explanation
Correct Answer is A

Page | 1023
Rationale: Most acute severe adverse reactions to intravenous contrast media (ICM) occur within
20 minutes of the injection. Infusion of the ICM should be stopped. When the client is
experiencing respiratory difficulty, epinephrine should be injected. The nurse should also prepare
for oxygen administration at 10-12 L/minute and possible intubation. Slowing the rate of the
contrast will not resolve the situation. The nurse will continue to assess the client, but this is not
the priority action. Asking the client to take slow deep breaths will not resolve the situation.
Concepts tested

Question 2603
The nurse is caring for a 60-year-old female client scheduled for abdominal surgery. Which
factor in the client's history indicates that the client is at an increased risk for deep vein
thrombosis (DVT) in the postoperative period?
A Past hypersensitivity to heparin
B Family history of uterine cancer
C Estrogen replacement therapy for the past three years
D History of acute hepatitis A

Question Explanation
Correct Answer is C
Rationale: Post-menopausal women using hormone replacement therapy have a higher risk of
DVT and pulmonary embolism. The estrogen in hormone replacement therapy (and in birth
control pills) can increase clotting factors in the blood, increasing the risk for the development of
a DVT. The other information in the client's history is unremarkable for postoperative
complications, such as DVT.
Concepts tested

Question 2604
A nurse is working in the emergency department caring for clients with intoxication. Which lab
value is important before treatment can begin for the intoxicated client?
A Ethanol/alcohol
B Hemoglobin
C Glucose
D Albumin

Question Explanation
Correct Answer is A
Rationale: A verbal report of alcohol consumption by the client is notoriously inaccurate (usually
on the lower side of ingestion), so blood alcohol levels are initially obtained to determine the
level of intoxication. The amount of alcohol consumed determines how much medication the
client needs for detoxification and treatment. The other lab values are important but are not the
priority.
Concepts tested

Question 2605
A nurse is caring for a 20 lb (9 kg) 6-month-old infant with a three-day history of diarrhea,
occasional vomiting, and fever. Peripheral intravenous therapy has been initiated with 5%
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dextrose in 0.45% normal saline with 20 mEq of potassium per liter infusing at 35 mL/hr. Which
finding should the nurse report to the health care provider immediately?
A No measurable voiding in four hours
B Three episodes of vomiting in one hour
C Periodic crying and irritability
D Vigorous sucking on a pacifier

Question Explanation
Correct Answer is A
Rationale: With no measurable urine output, the infant may experience hyperkalemia, which
could occur with continued IV potassium administration because potassium is excreted via the
kidneys. Periodic crying and irritability are normal for a 6-month-old who is sick. Vigorous
sucking on a pacifier may be soothing to the infant. The infant was admitted with vomiting, and
though the nurse would be concerned about the frequency, the absence of urine output is a higher
concern.
Concepts tested

Question 2606
The nurse will plan to include information about prophylactic antibiotics before dental
procedures for which client?
A Client admitted with an acute myocardial infarction
B Client admitted for mitral valve replacement with a mechanical valve
C Client admitted for cardioversion of rapid atrial fibrillation
D Client admitted with exacerbation of heart failure

Question Explanation
Correct Answer is B
Rationale: The use of prophylactic antibiotics before dental procedures is indicated for clients at
risk for infective endocarditis (IE). IE occurs primarily in clients who abuse IV drugs, have had
valve replacements, have experienced systemic alterations in immunity, or have structural
cardiac defects. Possible ports of entry for infecting organisms include the oral cavity (especially
if dental procedures have been performed), skin rashes, lesions or abscesses, infections
(cutaneous, genitourinary, gastrointestinal, or systemic), and surgery or invasive procedures,
including intravenous line placement. Therefore, current guidelines recommend the use of
prophylactic antibiotics before dental procedures for clients with prosthetic heart valves to
prevent IE.
Concepts tested

Question 2607
The nurse has received the laboratory results for a client who developed chest pain 4 hours ago
and may be having a myocardial infarction. Which laboratory result will be most important to
review?
A Low-density lipoprotein level
B Creatine kinase-MB level
C Troponin T and I levels

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D Myoglobin level

Question Explanation
Correct Answer is C
Rationale: Cardiac troponins start to elevate 4 to 6 hours after myocardial injury and are highly
specific to myocardium. They are the preferred diagnostic marker for myocardial infarction and
therefore the most important lab value for the nurse to review. Myoglobin rises in response to
myocardial injury within 30 to 60 minutes. It is rapidly cleared from the body thus limiting its
use in the diagnosis of myocardial infarction. The low-density lipoprotein (LDL) cholesterol
level is useful in assessing cardiovascular risk but is not helpful in determining whether a client
is having an acute myocardial infarction. The creatine kinase-MB level is also specific to
myocardial injury and infarction and increases 4 to 6 hours after the infarction occurs. It is often
trended with troponin levels.
Concepts tested

Question 2608
A client with a history of chronic alcohol use disorder is admitted to the inpatient unit with a
serum magnesium level of 1.0 mEq/L. Which intervention should the nurse implement first?
A Obtain the client's heart rate and oxygen saturation
B Assess the client's deep tendon reflexes
C Place the client on fall risk and seizure precautions
D Order the client a meal with foods high in magnesium

Question Explanation
Correct Answer is A
Rationale: A normal serum magnesium level ranges from 1.5 to 2.5 mEq/L. Causes of
hypomagnesemia include alcohol abuse, medication use (i.e., diuretics), and lack of intake of
magnesium-containing foods. Clients with hypomagnesemia can present with tremors, tetany,
hyperactive reflexes, arrhythmias, and confusion. Although it is important to check the client's
reflexes, hyperreflexia is to be expected. The most appropriate action to take first is to evaluate
the client's heart rate, rhythm, and oxygen saturation. The client should be placed on continuous
cardiac monitoring until the magnesium level returns to normal. The other interventions should
also be implemented but not until after evaluating the client's cardiac and respiratory status first.
Concepts tested

Question 2609
The nurse is evaluating whether teaching a client with dysphagia about preventing aspiration was
effective. Which action by the client indicates that additional teaching is required?
A The client alternates solids with liquids.
B The client is sitting in a chair during meals.
C The client tucks in the chin while swallowing.
D The client uses a straw to drink.

Question Explanation
Correct Answer is D

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Rationale: Dysphagia means difficulties with swallowing that can cause food and/or liquids to be
aspirated into the lungs. Strategies to reduce the risk of aspiration include sitting up in a chair
while eating, cutting up food into small, bite-size pieces, chewing food thoroughly, drinking
liquids separate from solid food, performing a chin tuck while swallowing, dry swallowing
several times, and avoiding the use of a straw. Drinking through a straw tends to propel fluids
into the back of the mouth faster increasing the risk for aspiration.
Concepts tested

Question 2610
The nurse is preparing a client for a pulmonary CT angiogram with contrast to rule out a
pulmonary embolism. For which laboratory result should the nurse notify the health care
provider immediately?
A Serum troponin level of 0.1 mg/mL
B D-dimer level of 1.2 mcg/mL
C Serum creatinine level of 2.8 mg/dL
D Arterial blood gas PaO2 level of 80 mmHg

Question Explanation
Correct Answer is C
Rationale: Pulmonary embolism means the blockage of a pulmonary artery by a thrombus. A
spiral CT scan, i.e., CT angiography, is the test most frequently used to confirm a pulmonary
embolism (PE). An intravenous injection of contrast media (dye) is required to visualize the
pulmonary vasculature. The dye has the potential to cause renal failure and should be used with
caution in clients with impaired renal function. The client's creatinine level is significantly
elevated (normal creatinine level is 0.8 to 1.2 mg/dL), placing the client at risk for dye-induced
renal failure, and the nurse should notify the health care provider of this lab result immediately.
The elevated D-dimer level is to be expected. The PaO2 and troponin levels are within normal
limits.
Concepts tested

Question 2611
When planning care for a client at risk for pulmonary embolism, the nurse shall make which
intervention a priority?
A Encourage client to cough and deep breathe
B Maintain client on bedrest
C Instruct client on how to use the incentive spirometer
D Apply sequential compression devices to the legs

Question Explanation
Correct Answer is D
Rationale: Deep vein thrombosis (DVT) is the primary cause of pulmonary embolism (PE).
Preventing a DVT with the use of sequential compression devices, early ambulation, and
prophylactic use of anticoagulant medications should be priority nursing interventions. Bedrest

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will increase the risk for a DVT and PE. Pulmonary hygiene interventions do not prevent a DVT
or PE from occurring.
Concepts tested

Question 2612
A client's arterial blood gas shows a pH of 7.30, pCO2 of 53, and HCO3 of 24. The nurse
recognizes which acid-base imbalance?
A Metabolic alkalosis
B Metabolic acidosis
C Respiratory alkalosis
D Respiratory acidosis

Question Explanation
Correct Answer is D
Rationale: A normal pH ranges from 7.35 to 7.45. A pH of 7.30 is low and indicates acidosis.
Next, the nurse should look at the partial pressure of carbon dioxide (PCO2) level. Normally,
carbon dioxide (CO2) levels range between 35 to 45 mm Hg. A level of 53 is high, and since
CO2 is an acid, it is causing respiratory acidosis. The kidneys manage the balance of hydrogen
and bicarbonate ions and will attempt to balance the CO2 imbalance by producing more
bicarbonate, a base. This renal compensatory response takes time. A normal bicarbonate (HCO3)
level ranges from 21 to 28 mmol or mEq/L. Since the HCO3 level for this client is still normal,
compensation has not yet occurred. Therefore, the client has uncompensated respiratory acidosis.
Concepts tested

Question 2613
A client with dyspnea due to exacerbation of COPD is becoming very anxious. An arterial blood
gas shows a PaO2 of 93 mm Hg. What action by the nurse is best?
A Assist the client with relaxation techniques
B Administer an antianxiety medication
C Administer a bronchodilator
D Increase the oxygen flow rate

Question Explanation
Correct Answer is A
Rationale: A normal partial pressure of arterial oxygen (PaO2) level ranges from 80 to 100
mmHg. A level of 93 is normal, and therefore it is not necessary to increase the oxygen or
administer a bronchodilator. However, both of these interventions would be appropriate if the
client were hypoxic. A client with respiratory problems should not take an antianxiety
medication as a first-line intervention because this may decrease their respiratory rate and/or
alertness. The best intervention at this time is to assist the client with relaxation techniques.
Concepts tested

Question 2614
The nurse is evaluating an adult client who is receiving continuous enteral nutrition (EN) through
a nasogastric tube. Which findings indicate that the client may be experiencing a complication
from the EN? Select all that apply.
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A 200 mL dark yellow urine voided in the last eight hours
B Pale and dry oral mucous membranes
C Gastric residual volume of 100 mL
D New onset adventitious lung sounds
E Aspirated gastric fluid has a pH of 4
F A weight loss of 2 kg in 24 hours

Question Explanation
Correct Answer is A, B, D, F
Rationale: Pulmonary aspiration of enteral feeding formula is a risk for clients receiving EN.
New onset of adventitious or abnormal lung sounds on auscultation in a client receiving EN are
indicative of possible aspiration. Due to the nutrient-dense, hypertonic composition of enteral
feeding formulas, clients on EN are at risk for developing hyperosmolar dehydration. Signs and
symptoms of clinical dehydration include weight loss, postural hypotension, tachycardia, thready
pulse, dry mucous membranes, poor skin turgor, slow vein filling, flat neck veins when supine,
and dark yellow urine. If the dehydration is severe, the symptoms will include thirst, restlessness,
confusion, hypotension, oliguria (urine output below 30 mL/hr), and cold, clammy skin.
Concepts tested

Question 2615
The nurse is caring for a child who requires chest physiotherapy (CPT). Which nursing action is
appropriate?
A Confine the percussion to the rib cage area
B Schedule the therapy 30 minutes after meals
C Teach the child not to cough during the treatment
D Place the child in a prone position for the duration of the therapy

Question Explanation
Correct Answer is A
Rationale: Percussion (clapping) should be done in the area of the rib cage anterior and posterior.
This often requires various positions to remove all secretions. This therapy should be done one
hour prior or two hours after meals. Children are encouraged to cough during treatments to help
expel mucus.
Concepts tested

Question 2616
The nurse is providing education for a client who has asthma. Which factor is a priority for the
client to monitor daily?
A Pulse oximetry
B Respiratory rate
C Respiratory effort
D Peak air flow volumes

Question Explanation
Correct Answer is D

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Rationale: The peak airflow volume decreases about 24 hours before clinical manifestations of
exacerbation of asthma. Note that the question asks for a priority, so all of the options would be
monitored. However, peak airflow is the priority.
Concepts tested

Question 2617
The nurse is caring for a postoperative client who had a laparotomy six hours ago. Which
nursing intervention is the most effective in preventing atelectasis from developing?
A Assist the client to slowly deep breathe and cough
B Splint the incision with a pillow
C Maintain adequate hydration
D Ambulate the client within 24 hours postoperative

Question Explanation
Correct Answer is A
Rationale: Deep air excursion by slow deep breathing and coughing expands the lungs and
stimulates surfactant production. This is the priority to prevent pulmonary complications along
with the use of an incentive spirometer. The nurse should instruct the client on how to splint the
abdomen when coughing. Maintaining hydration is also an important role in preventing
atelectasis. Postoperative patients should be encouraged to ambulate early to promote bowel
motility and lung expansion.
Concepts tested

Question 2618
The nurse has completed discharge teaching to a client who had a total hip arthroplasty. Which
statement made by the client indicates further teaching is needed?
A "When I go home, I should not stand for long periods."
B "If my hip pain gets worse I should call my doctor."
C "Now I will be able to bend forward to tie my shoes without pain."
D "I'll use an electric razor to shave."

Question Explanation
Correct Answer is C
Rationale: Someone who had a total hip replacement should not sit or stand for prolonged
periods of time to help prevent thromboembolism and muscle fatigue. Because anticoagulants
are typically used postoperatively, the use of an electric razor is indicated. Any increase in hip
pain must be evaluated for complications. Following hip replacement surgery, a person should
never bend at the waist more than 90 degrees, which would mean the person should not bend
over to tie shoes.
Concepts tested

Question 2619
A client is admitted with a pressure ulcer in the sacral area. The partial-thickness wound is
approximately 1.5 x 2.7 inches (4 cm x 7 cm) in size, the wound base is red and moist with no
exudate, and the surrounding skin is intact. Which wound dressing should the nurse select for
this wound?
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A Dry, sterile dressing with antibiotic ointment
B Occlusive, moist dressing
C Transparent dressing
D Leave open to air

Question Explanation
Correct Answer is B
Rationale: The wound as described has granulation tissue present (red and moist wound base
without exudate), which indicates that the wound is healing, and this new tissue must be
protected. The use of an occlusive, moist dressing is the best choice because this type of dressing
will protect the wound and new tissue, and the moisture will support continued wound healing.
Concepts tested

Question 2620
When admitting a client to the ambulatory surgery unit, the nurse notices the client has painted
fingernails. The nurse reviews the pre-op orders and notes that pulse oximetry is prescribed.
Which statement by the nurse is appropriate?
A "I am sorry. All of your nail polish must be removed."
B "I will ask your health care provider if we can discontinue the pulse oximetry."
C "May I remove the polish from at least two nails?"
D "We can monitor your oxygen levels with lab work instead of pulse oximetry."

Question Explanation
Correct Answer is C
Rationale: In order to effectively measure pulse oximetry, there can be no nail polish on the
finger fitted with the reading device. The client should be approached using therapeutic
communication skills. The other options are inappropriate.
Concepts tested

Question 2621
A client is being prepared for an above-the-knee amputation. Which actions by the nurse would
represent appropriate care of this client? Select all that apply.
A Explain the procedure, including any risks, before the client signs the surgical consent form
B Verify that the informed consent form is signed
C Verify the surgical leg is marked with indelible marker over, or as close as possible to, the
surgical incision site
D Have the client confirm his or her identity, the surgical site, and the procedure before
administration of any medications
E Verify any allergies

Question Explanation
Correct Answer is B, C, D, E

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Rationale: Prior to surgery, the nurse can witness the client's signature on the consent form, but
the explanation of the procedure, including risks and benefits, needs to come from the health care
provider. Any allergies must be noted and verified prior to surgery. The surgeon must use an
indelible marker on the surgical leg to indicate the incision site; sometimes the nonsurgical leg
will be marked with a "NO." In the operating room, a surgical checklist is completed with a
nurse and anesthesiologist. Prior to administration of anesthesia, there is another check with the
client to verify identify, the correct surgical site, and the procedure.
Concepts tested

Question 2622
The nurse is preparing to suction a client's tracheostomy. Which interventions should the nurse
implement? Select all that apply.
A Use a sterile suction catheter
B Explain the procedure to the client
C Hyperoxygenate the client prior to suctioning
D Administer a mild sedative prior to suctioning
E Instill a small amount of saline prior to inserting the catheter
F Auscultate lung sounds before and after

Question Explanation
Correct Answer is A, B, C, F
Rationale: Suctioning a tracheostomy should be done with a sterile catheter unless the client has
a closed suction system connected to the tracheostomy. Hyperoxygenation for a few minutes
prior to suctioning is recommended to prevent hypoxia during the procedure. The nurse should
assess the client's lung sounds before and after and should explain to the client what the nurse is
about to do. According to evidence-based practice, the use of saline is no longer recommended
during routine suctioning. A sedative is not routinely given for suctioning a tracheostomy.
Concepts tested

Question 2623
The pediatric nurse is teaching the parents of a 6-year-old child with recurrent otitis media about
tympanostomy tubes. Which instructions should the nurse include?
A "The tubes are sutured in place to prevent them from falling out."
B "You will continue to see ear drainage for up to 7 days."
C "The tubes will have to be surgically removed in a few years."
D "Your child should not swim in the pool while the tubes are in place."

Question Explanation
Correct Answer is B
Rationale: Tympanostomy tubes are pressure equalization devices (grommets) that facilitate
drainage and ventilation of the middle ear. Their placement may be indicated with chronic otitis
media (OM) (three episodes in 6 months or four episodes in 1 year). Most children's hearing
improves right after placement, and ear drainage is common up to 1 week after insertion. They
are not sutured in place. The tube is eventually pushed out of the eardrum usually 8 to 18 months
after tube placement. Parents should be aware of the appearance of a tympanostomy tube

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(usually a tiny plastic spool-shaped tube), so they can recognize it if it falls out. Most clients,
including very young children, typically do not require special water precautions.
Concepts tested

Question 2624
The nurse is caring for a client who is unconscious and receiving gastric tube feedings. Which
assessment finding requires immediate action from the nurse?
A Formula residual volume of 100 mL
B Decreased breath sounds in the right lower lobe Correct Answer
C Urine output of 250 mL in the past eight hours
D Decreased bowel sounds in all quadrants

Question Explanation
Correct Answer is B
Rationale: The most common problem associated with enteral feedings is aspiration with
resulting atelectasis and pneumonia. A nursing action should be to maintain clients at a minimum
of 30 degrees of head elevation during feedings and up to two hours afterward. The nurse should
verify tube placement prior to each feeding or every four to eight hours if the client receives a
continuous feeding.
Concepts tested

Question 2625
A postoperative client is admitted to the post-anesthesia care unit (PACU). The anesthetist
reports that malignant hyperthermia occurred during surgery. The nurse should approach the care
of this client with what knowledge about this complication?
A It is an allergic response to general anesthesia.
B A genetic predisposition acts as the stimulus to such a reaction.
C A pre-existing bacterial infection precipitated the situation.
D Selected surgical procedures place clients at a higher risk for this complication.

Question Explanation
Correct Answer is B
Rationale: Malignant hyperthermia is a rare, potentially fatal adverse reaction to inhaled
anesthetics. There is a genetic predisposition to this disorder. Findings include a rapid rise in
temperature to 105°F (40.5°C) or higher, muscle rigidity and stiffness, dark brown urine, and
muscle aches without a history of obvious exercise to explain sore muscles.
Concepts tested

Question 2626
A 5-year-old child is rushed to the emergency department approximately six hours after
ingesting an undetermined amount of acetaminophen. Which lab test should
receive priority attention from the nurse?
A Serum acetaminophen concentration (APAP)
B Alanine transaminase test (ALT) and aspartate transaminase test (AST)
C Electrolytes and blood urea nitrogen (BUN)

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D Prothrombin time (PT) and INR

Question Explanation
Correct Answer is A
Rationale: Emergency treatment of acetaminophen overdose involves checking the client's 4-, 6-,
and 8-hour acetaminophen concentration (APAP) levels. These levels will determine N-
acetylcysteine (NAC) therapy (the antidote). Clients who ingest an acute overdose and have
NAC therapy initiated within 8 hours usually do well and do not develop liver failure. However,
because acetaminophen poisoning can lead to liver failure, it is important to evaluate
hepatotoxicity; ALT and AST will help determine the degree of liver cell damage. PT (or INR)
may also be used to detect impaired liver function. BUN and electrolytes may show renal
impairment or acidosis.
Concepts tested

Question 2627
A client who has cirrhosis of the liver underwent a paracentesis yesterday. Today, the unlicensed
assistive personnel (UAP) reports the client is lethargic and has musty-smelling breath. Which
assessment should the nurse perform next?
A Measure the abdominal girth changes
B Auscultate the upper abdomen for bruits
C Monitor the client's clotting status
D Assess for flap-like tremors of the hands

Question Explanation
Correct Answer is D
Rationale: Subtle changes in mental status and a musty odor to the breath are findings associated
with hepatic encephalopathy. Hepatic encephalopathy is often seen in people with chronic liver
disease (cirrhosis or hepatitis). A classic sign of this disorder is flapping tremors of the hands
(asterixis).
Concepts tested

Question 2628
The nurse compares the third postoperative assessment findings to the first two postoperative
assessments. Which action should the nurse take to provide optimal care for this client? Select all
that apply.

Blood Pressure Pulse

1st Postop Assessment 110/80 mmHg 80
2nd Postop Assessment 100/72 mmHg 88
3rd Postop Assessment 92/64 mmHg 106

A Elevate the client's lower extremities

B Administer pain medication

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C Assist the client to use the incentive spirometer
D Administer an intravenous fluid bolus
E Inspect the surgical incision site
F Move the bed into Trendelenburg position

Question Explanation
Correct Answer is A, D, E
Rationale: Hypovolemia due to blood loss should be considered in the postoperative client who
develops tachycardia and hypotension (a systolic BP reading below 90 in an adult indicates
possible shock.) The nurse should check the incision site and any area dependent on the site for
any blood loss. Evidence supports elevating the lower extremities in hypotensive episodes to
bring fluid from the lower body to the core; there is no evidence to support using the
Trendelenburg position. An IV fluid bolus can also be used to increase volume. Although
hypotension and tachycardia may also indicate pain, the nurse should ensure that the client's
ABCs are stable before medicating for pain. Assisting the client to use the incentive spirometer
can be done later.
Concepts tested

Question 2629
A client has been taking isoniazid and rifampin for several months. Which laboratory test should
the nurse monitor with this client?
A Liver enzymes
B Sputum culture
C Cardiac enzymes
D Creatinine clearance

Question Explanation
Correct Answer is A
Rationale: INH and rifampin are used to treat tuberculosis and both are hepatotoxic. Isoniazid
can cause hepatocellular injury and multilobular necrosis and is believed to result from the
production of a toxic isoniazid metabolite. Rifampin is also toxic to the liver posing a risk of
jaundice and even hepatitis. Asymptomatic elevation of liver enzymes occurs in about 14% of
patients. Hepatotoxicity is most likely in people who abuse alcohol and in clients with pre-
existing liver disease. These individuals should be monitored closely for signs of liver
dysfunction. Tests of liver function (serum aminotransferase levels) should be made before
treatment and every 2 to 4 weeks thereafter. The other lab tests are not specific to the
medications the client is taking.
Concepts tested

Question 2630
The nurse in an orthopedics office is evaluating a client with an arm cast who reports worsening,
unrelieved pain underneath the cast. Which action should the nurse take first?
A Notify the health care provider
B Prepare for removal of the cast
C Assess color, temperature, and movement of the exposed fingers

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D Apply an ice pack to the area of the fracture

Question Explanation
Correct Answer is C
Rationale: The nurse should follow the nursing process and first assess the client by checking the
5 Ps that can indicate compartment syndrome: pain, pallor, pulselessness, paresthesia, and
paralysis of the arm with the cast. Compartment syndrome is a potential complication of a cast
and refers to swelling (edema) that causes increased pressure within a limited space (muscle
compartment). The edema can create enough pressure to obstruct circulation and cause venous
occlusion, which further increases edema. Arterial flow is eventually compromised causing
ischemia in the extremity. Prompt diagnosis of compartment syndrome is critical.
Concepts tested

Question 2631
The nurse is caring for a client who had a thoracotomy with a right upper lobectomy. The nurse
should focus on pain management for which reason postoperatively?
A Deep breathing and coughing
B Maintain full range of motion
C Internal incisional healing
D Relaxation and sleep

Question Explanation
Correct Answer is A
Rationale: A lobectomy is often performed to treat tuberculosis, bronchiectasis, and cancer.
Postoperatively, the focus of care is to prevent respiratory complications, such as atelectasis and
pneumonia. Without proper pain management, clients will be reluctant to cough and deep
breathe, which will predispose them to these and other complications.
Concepts tested

Question 2632
The client, who is 12-hours post gastric bypass surgery, is restless and reports increasing back
and shoulder pain unrelieved by pain medication. Which action should the nurse take first?
A Roll the client to side-lying position to ensure the epidural analgesia catheter is still in place
B Report the complaint to the surgeon immediately
C Place the client in Trendelenburg position
D Check the nasogastric (NG) tube for patency and reposition the tube

Question Explanation
Correct Answer is B
Rationale: Anastomotic leak is the most serious complication after bariatric surgery and the most
common cause of death. Clients should be monitored for increased back, shoulder, or abdominal
pain, restlessness, unexplained tachycardia, and oliguria; these findings should be immediately
reported to the surgeon. A nasogastric tube should not be manipulated postoperatively because it
could damage the surgical site. In order to reduce intra-abdominal pressure on the diaphragm and
improve tidal volumes, the head of the bed should be elevated 30 to 45 degrees, preferably in

Page | 1036
reverse Trendelenburg position. Patient-controlled analgesia is used for pain management;
epidural analgesia is not often used because of the difficulty of locating exact spinal segments for
the proper insertion of a catheter.
Concepts tested

Question 2633
A client who had a vasectomy is in the post-anesthesia care unit (PACU) at an outpatient clinic.
Which point is most important for the nurse to reinforce?
A "Until the health care provider has determined that your ejaculate doesn't contain sperm,
continue to use another form of contraception."
B "This procedure doesn't impede the production of male hormones or the production of sperm
in the testicles."
C "After your vasectomy, strenuous activity needs to be avoided for at least 48 hours."
D "The health care provider recommends rest, ice, an athletic supporter, or over-the-counter pain
medication to relieve any discomfort."

Question Explanation
Correct Answer is A
Rationale: All of these options are correct information. The most important point to reinforce is
the continued need to take additional action for birth control until it is determined that no risk is
present for a possible pregnancy outcome.
Concepts tested

Question 2634
The nurse is caring for a client who had a full leg cast applied during surgery. What is the
purpose for elevating the client's casted leg postoperatively?
A Reduce the cast drying time
B Improve venous return
C Promote the client's comfort
D Help with fracture healing

Question Explanation
Correct Answer is B
Rationale: Elevating the leg on one or two pillows will improve venous return, which will reduce
the amount of swelling in the extremity. Elevating the leg will have little effect on cast drying
time, fracture healing, or pain.
Concepts tested

Question 2635
A client with a spontaneous pneumothorax requires the insertion of a chest tube with a flutter
valve. Which statement is the best explanation that the nurse should provide to the client?
A "The amount of air that enters your chest will be controlled by the flutter valve."
B "The tube will drain fluid from your chest."
C "The excess air from your chest will be removed by the tube."
D "The hole in your lung will be sealed with this tube insertion."

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Question Explanation
Correct Answer is C
Rationale: The purpose of the chest tube is to create negative pressure to allow the passive
removal of the air that has accumulated in the pleural space. The flutter valve is a one-way valve
that allows the air to leave the pleural space. It blocks any air reentry. The use of a flutter valve
with a spontaneous pneumothorax allows for increased mobility without the use of a chest seal
drainage system.
Concepts tested

Question 2636
A client has a new order for an open magnetic resonance imaging (MRI) scan to evaluate for
osteomyelitis. Which information indicates that the nurse should consult with the health care
provider before scheduling the MRI?
A The client is allergic to shellfish.
B The client is claustrophobic.
C The client has a pacemaker.
D The client wears prescription glasses.

Question Explanation
Correct Answer is C
Rationale: Clients with permanent pacemakers cannot have an MRI because of the force exerted
by the magnetic field on metal objects. An open MRI will not cause claustrophobia. The client
will need to be instructed to remove the glasses before the MRI, but this does not require
consultation with the health care provider. Should contrast medium be used, a shellfish allergy is
no longer considered a contraindication.
Concepts tested

Question 2637
The nurse is caring for a client who complains of pain in the epigastric region. The client has a
history of peptic ulcer disease. Which finding should the nurse immediately report to the health
care provider?
A White blood cell count of 8,000/µL
B Platelet count of 220,000 mm3
C Positive test result for Helicobacter pylori
D Hemoglobin level of 7.4 g/dL

Question Explanation
Correct Answer is D
Rationale: Peptic ulcer disease (PUD) results when gastric mucosal defenses become impaired
and no longer protect the epithelium from the effects of acid and pepsin. A peptic ulcer is a
mucosal lesion in the stomach or duodenum. The most serious complication of PUD is
hemorrhage. The serum hemoglobin (Hgb) level will drop as a result of bleeding. The normal
range for Hgb is 14 to 18 g/dL in males and 12 to 16 g/dL in females. This client's level is 7.4
g/dL, which is low and indicates possible hemorrhage. The normal range for white blood cell
count (WBC) is 5,000 to 10,000/µL. The normal range for platelet count (PLT) is 150,000 to
Page | 1038
400,000 mm3. Helicobacter pylori infection plays a role in the development of gastric ulcers.
While a positive Helicobacter pylori test is pertinent to the client's history of PUD, possible
hemorrhage is the most serious problem for this client and should be reported to the health care
provider (HCP) immediately.
Concepts tested

Question 2638
A woman who is 26-weeks pregnant is admitted for painless vaginal bleeding. The nurse should
prepare the client for which procedure or test?
A Serum hCG level
B Leopold maneuvers
C Transvaginal ultrasound
D Non-stress test

Question Explanation
Correct Answer is C
Rationale: The most common cause of painless vaginal bleeding involves a problem with the
placenta, such as placenta previa. A transvaginal ultrasound (an ultrasound device inserted into
the vagina) is the test of choice to confirm placenta previa. Serum hCG is used to screen for
pregnancy. A fetal non-stress test is used in pregnancies over 28 weeks to measure fetal heart
rate and contractions. Leopold maneuvers are a stepwise method of abdominal palpation used
after about 34 weeks gestation to determine fetal lie and presentation.
Concepts tested

Question 2639
The nurse is caring for a client with a calcium imbalance related to hypoparathyroidism. The
nurse should anticipate which clinical manifestation in this client?
A Decreased neuromuscular excitability
B Bounding peripheral pulses in the lower extremities
C Decreased gastrointestinal activity and constipation
D Facial twitching when the region over cranial nerve VII is tapped

Question Explanation
Correct Answer is D
Rationale: Clinical manifestations of hypoparathyroidism are associated with electrolyte
imbalances, such as hypocalcemia. Hypocalcemia is characterized by increased neuromuscular
excitability, such as a positive Chvostek's sign when cranial nerve VII is stimulated. Decreased
neuromuscular excitability, decreased gastrointestinal activity, and bounding pulses are
associated with hypercalcemia, which is a condition related to hyperparathyroidism.
Concepts tested

Question 2640
The nurse on the inpatient unit is expecting the admission of a client with a new onset of seizures
and instructs the unlicensed assistive person (UAP) to prepare the client's room. Which piece of
equipment should the UAP make sure to place in the room?

Page | 1039
A A bedside commode
B Soft wrist restraints
C Pads to be placed over the bed's side rails
D An oral airway

Question Explanation
Correct Answer is C
Rationale: Maintaining safety is the primary concern for the health care team when caring for a
client with seizures. The room should be set up with equipment to have readily available in case
the client has a seizure. Soft pads placed over the bed's side rails will help protect the client from
injury should a seizure occur while the client is in bed. The other pieces of equipment are not
appropriate or indicated for seizure precautions.
Concepts tested

Question 2641
The nurse in the ambulatory care center is assisting in the discharge of a client following a
colonoscopy. Which statement by the client requires additional teaching?
A "I expect to pass gas over the next few hours."
B "I should rest at home for the remainder of today."
C "I know fullness and mild abdominal cramping are expected."
D "I will be careful when I drive myself home."

Question Explanation
Correct Answer is D
Rationale: A colonoscopy is an endoscopic examination of the entire large bowel. The procedure
is performed under sedation. Due to the anesthetics used during the procedure, the client
should not drive themselves home. Other teaching that should be given to the client includes
reminding the client that fullness, mild abdominal cramping, and passage of flatus are expected.
Since air is instilled in the bowel during the procedure, it is normal and encouraged for a client to
pass flatus after the procedure. The client should rest for the remainder of the day since they have
received a sedative medication.
Concepts tested

Question 2642
A nurse is caring for a client with chronic kidney disease who is in fluid overload after being
given an intravenous fluid bolus. Which assessment finding should the nurse anticipate?
A S3 heart sound
B Flattened neck veins
C Hypoventilation
D Thready pulse

Question Explanation
Correct Answer is A
Rationale: Chronic kidney disease is characterized by a gradual loss of kidney function and
decreases the body’s ability to excrete wastes and fluids efficiently. When receiving a large

Page | 1040
about of intravenous fluids, the poorly functioning kidneys are unable to excrete properly, and
the fluid builds up in the body. Symptoms the nurse should anticipate are shortness of breath,
crackles in the lungs, swelling in the arms or legs (edema), distended neck veins, and bounding
pulse. Auscultation of the heart will also reveal an S3 heart sound as this is an early sign of
volume overload and heart failure due to the excessive fluid left in the ventricles.
Concepts tested

Question 2643
The nurse is assessing a client who received procedural sedation for a cardioversion. The client's
respirations are 10 breaths/min. Which action should the nurse take next?
A Activate the rapid response team
B Evaluate breathing for depth and effort Correct Answer
C Notify the health care provider immediately
D Obtain a pulse oximeter reading

Question Explanation
Correct Answer is B
Rationale: Procedural sedation, also called moderate or conscious sedation, involves the
administration of a short-acting sedative such as midazolam, a benzodiazepine, or a similar drug.
This class of drugs tends to depress the central nervous system causing respiratory depression. In
addition to the respiratory rate, the nurse should next assess the client's respiratory effort and
depth since those will provide additional data for the nurse to determine if the client's respiratory
efforts are adequate. A pulse oximeter reading would indicate how well the client is oxygenating,
but it does not help with assessing if the client's breathing is insufficient. That would be more
appropriately measured with capnography. The other actions are premature at this time.
Concepts tested

Question 2644
A nurse is reviewing the medication administration record (MAR) for a 72-year-old client
scheduled to have a cardioversion. Prior to the procedure, the nurse should notify the health care
provider if the client received which medication during the preceding 24 hours?
A Digoxin
B Nitroglycerin ointment
C Diltiazem
D Metoprolol

Question Explanation
Correct Answer is A
Rationale: Digoxin increases ventricular irritability and increases the risk of ventricular
fibrillation during and after cardioversion. The other medications do not increase ventricular
irritability.
Concepts tested

Question 2645

Page | 1041
The nurse is caring for a 4-year-old child admitted after being burned over more than 50% of the
body. Which of the following laboratory data should be reviewed by the nurse as a priority in the
initial 24 hours after the burn?
A Blood urea nitrogen
B Hematocrit
C Blood glucose
D White blood count

Question Explanation
Correct Answer is A
Rationale: Glomerular filtration is decreased in the initial response to severe burns. A fluid shift
occurs from the loss of fluid from the burned areas. Kidney function must be monitored closely,
or renal failure may follow in a few days from a lack of circulating volume. In the initial 48
hours, fluids are given IV at high rates to maintain circulation. After this, the clients are
evaluated for fluid overload and heart failure, as well as infection.
Concepts tested

Question 2646
The nurse in an intensive care unit is reviewing the laboratory results for several clients. Which
laboratory result indicates that the client has a partially compensated metabolic acidosis?
A PaCO2 of 30 mmHg
B HCO3 of 28 mEq/L
C pH of 7.48
D Chloride of 100 mEq/L

Question Explanation
Correct Answer is A
Rationale: With metabolic acidosis, the nurse should expect to see a low pH (less than 7.35) and
a low HCO3 (less than 22 mEq/L). Compensation means that the body is trying to get the pH
back to a normal range of 7.35 to 7.45. A pure metabolic acidosis will elicit a compensatory
response by the lungs in form of a decrease in PaCO2 (normal range is 35 to 45 mm Hg).
Therefore, the PaCO2 level of 30 mm Hg indicates a partially compensated metabolic acidosis.
A pH of 7.48 indicates an alkalosis and the chloride level does not pertain to the acid-base
imbalance or compensation.
Concepts tested

Question 2647
The client is scheduled for a coronary artery bypass procedure. When conducting pre-operative
teaching with the client, which action should the nurse perform first?
A Tour the coronary intensive care unit.
B Assess the client's learning style.
C Mail a videotape to the home.
D Administer a written pre-test.

Question Explanation

Page | 1042
Correct Answer is B
Rationale: The first step in the teaching process consists of assessing how the client learns best.
That way, the nurse increases success of the teaching by delivering the education in a format that
the client understands and prefers. Therefore, the nurse should first assess the client's preferred
learning style (e.g., reading a handout or watching a video).
Concepts tested

Question 2648
A nurse is reviewing laboratory results for a client diagnosed with acute renal failure. Which
result should be reported to the primary health care provider immediately?
A Hemoglobin of 9.3 g/dL
B Venous blood pH of 7.30
C Serum potassium of 6 mEq/L
D Blood urea nitrogen of 50 mg/dL

Question Explanation
Correct Answer is C
Rationale: Although all of these findings are abnormal, the elevated potassium level is a life-
threatening finding and must be reported immediately. Serious consequences of hyperkalemia
include heart block, asystole and life-threatening ventricular dysrhythmias. Anemia (approximate
hemoglobin less than 13 g/dL in men or less than 12 mg/dL in women) is common with kidney
disease. Blood urea nitrogen (BUN) is expected to be increased in acute renal failure (7 to 30
mg/dL is considered normal).
Concepts tested

Question 2649
The nurse is caring for a client who underwent a cardiac catheterization 2 hours ago. Which
finding would indicate that the client is experiencing a potential complication from the
procedure?
A Increased blood pressure
B Increased heart rate
C Absent pedal pulse in the affected extremity
D Decreased urine output

Question Explanation
Correct Answer is C
Rationale: Loss of the pulse in the extremity where the catheterization was performed would
indicate a potential severe spasm of the artery or clot formation/occlusion below the site of
insertion. It is common for the pulse to be intermittently weaker from the baseline. However, a
total loss of the pulse is a medical emergency. The primary health care provider (HCP) should be
notified immediately.
Concepts tested

Question 2650
The respiratory therapist arrives to draw blood from a client for an arterial blood gas analysis.
What should the nurse understand about the collection procedure?
Page | 1043
A The femoral artery is the preferred sample site.
B Supplemental oxygen should be turned off 30 minutes prior to collecting the sample.
C The blood sample must be kept at room temperature and delivered to the lab as soon as
possible.
D Firm pressure should be applied over the puncture site for at least 5 minutes after the sample is
drawn.

Question Explanation
Correct Answer is D
Rationale: After drawing the sample, it is very important to press a gauze pad firmly over the
puncture site until bleeding stops or for at least 5 minutes. The client should not be asked to hold
the pad because if insufficient pressure is used, a large painful hematoma may form. The radial
artery is preferred; the second choice is the brachial artery and then the femoral artery. If a client
is receiving oxygen, it should not be turned off unless ordered. The sample of arterial blood must
be kept cold, preferably on ice, to minimize chemical reactions in the blood.
Concepts tested

Question 2651
A client has had a positive reaction to a purified protein derivative (PPD) skin test. The client
asks the nurse what the test result means. How should the nurse respond?
A "You most likely have a natural immunity to tuberculosis."
B "You most likely have a resistant form of tuberculosis."
C "This means you have been exposed to tuberculosis"
D "This means you have active tuberculosis."

Question Explanation
Correct Answer is C
Rationale: The purified protein derivative (PPD) skin test is used to determine the presence of
tuberculosis (TB) antibodies. In an otherwise healthy person, an induration greater than or equal
to 15 mm is considered a positive test result. This indicates the client has been exposed to the
organism Mycobacterium tuberculosis. Additional tests such as a chest X-ray and a sputum
culture will be needed to determine if active TB is present. The sputum cytology test is the only
definitive test to confirm a diagnosis of active TB.
Concepts tested

Question 2652
The nurse is caring for a client who received 2 units of packed red blood cells after an episode of
gastrointestinal bleeding. Which laboratory value should the nurse monitor closely?
A White blood cells
B Bleeding time
C Platelets
D Hematocrit

Question Explanation
Correct Answer is D

Page | 1044
Rationale: The hematocrit is an indirect measurement of red blood cells (RBCs) number and
volume. It is used as a rapid measurement of RBC count. It is used to determine the degree of
anemia in a client and evaluate effectiveness of treatment such as a blood transfusion. It is
performed in combination with a hemoglobin level, commonly referred to as an 'H&H'. A
follow-up hemoglobin and hematocrit should be checked around 4 to 6 hours after the
transfusion is completed.
Concepts tested

Question 2653
The nurse is caring for a client who had an extracorporeal shockwave lithotripsy procedure for
kidney stones. Which statement by the nurse demonstrates appropriate client teaching?
A "Limit your intake of sodium to no more than 2 grams a day."
B "Avoid the intake of citrus fruits for the next 2 months."
C "Drink at least 3000 to 4000 mL of fluids each day." Correct Answer
D "Increase your intake of milk and dairy products."

Question Explanation
Correct Answer is C
Rationale: An extracorporeal shockwave lithotripsy (ESWL) procedure is a non-invasive
method for treating stones in the kidney or ureter. It utilizes an energy source which generates a
shock wave that is directed at the stone, breaking it up and allowing it to be flushed out of the
kidney or ureter. After an ESWL, the client should drink 3 to 4 quarts (3,000 to 4,000 mL) of
fluids each day. This extra hydration will aid in the passage of fragments of the broken up renal
calculi and help prevent formation of new calculi. The other instructions are not appropriate or
required after an ESWL.
Concepts tested

Question 2654
A community health nurse has been caring for a woman who is 22 weeks pregnant and has a
history of morbid obesity, asthma and hypertension. Which of these lab reports should be
communicated to the primary health care provider immediately?
A Blood urea nitrogen 28 mg/dL and Glucose 225 mg/dL
B Magnesium 0.8 mEq/L and Creatinine 3 mg/dL
C Hemoglobin 13 g/dL and Calcium 5.1 mg/dL
D Hematocrit 35% and platelets 200,000/mm3

Question Explanation
Correct Answer is B
Rationale: The lab reports of highest concern are the magnesium and creatinine. The magnesium
level is low and the creatinine level is high, indicating acute renal failure, most likely related to
gestational hypertension or preeclampsia. Hypomagnesemia can lead to seizure activity. These
lab reports should be communicated to the primary health care provider (HCP) immediately.
Concepts tested

Question 2655

Page | 1045
The client is having an intravenous pyelogram procedure. After the contrast material is injected,
which client reaction should be acted upon by the nurse immediately?
A Hives with severe itching all over the body.
B Face turning a deep ruddy red color.
C An excessive salty taste in the mouth.
D A feeling of excessive warmth.

Question Explanation
Correct Answer is A
Rationale: Hives over the body with severe itching is a sign of anaphylaxis and should be acted
upon with the administration of epinephrine immediately. The other reactions are considered
normal after the dye injection. Prior to any dye injection procedure clients should be informed
that these symptoms may occur.
Concepts tested

Question 2656
The nurse is caring for a 15-month-old child who is diagnosed with iron-deficiency anemia. The
child's parent asks the nurse what anemia is. How should the nurse respond?
A "The health care provider would need to discuss the results with you."
B "The blood cells that carry oxygen are sickle-shaped."
C "The blood cells that carry nutrients to the cells are too large."
D "Your child has fewer red blood cells that carry oxygen."

Question Explanation
Correct Answer is D
Rationale: The most common causes of iron-deficiency anemia include inadequate nutritional
intake along with rapid growth, low birth weight and excessive consumption of cow's milk.
Children with iron-deficiency anemia will present with pallor, fatigue, decreased exercise
tolerance, tachycardia and loss of appetite. The results of a complete red blood cell count in
clients with iron-deficiency anemia will show decreased red blood cell numbers, a low
hemoglobin and microcytic, hypochromic red blood cells. It would be appropriate to tell the
parents that their child has fewer red blood cells, as this is a simple and clear explanation of
anemia. There is no reason to defer answering the question to the health care provider.
Concepts tested

Question 2657
The home health nurse is working with a client who was recently discharged from the hospital
and is diagnosed with orthostatic hypotension. Which client statement indicates that additional
teaching is needed?
A "I should take my time getting out of bed in the morning."
B "I should check my blood pressure before taking my morning medications."
C "I will purchase a home blood pressure machine."
D "I should drink no more than six glasses of water per day."

Question Explanation

Page | 1046
Correct Answer is D
Rationale: Orthostatic hypotension occurs when there is a precipitous decrease in blood pressure
upon a change in position, such as sitting or standing. For this reason, clients must stay
adequately hydrated, and should assure adequate time for acclimation when changing position.
Restricting fluid intake to less than six glasses of water per day may exacerbate orthostatic
hypotension and is an incorrect statement that requires additional teaching. Clients should
monitor vital signs prior to taking any medications that can lower blood pressure to avoid
worsening orthostatic hypotension.
Concepts tested

Question 2658
A client has returned to the unit after having a renal biopsy. Which of these nursing interventions
is appropriate?
A Change the dressing every eight hours
B Ambulate the client four hours after procedure
C Maintain client on NPO status for 24 hours
D Monitor vital signs more frequently

Question Explanation
Correct Answer is D
Rationale: The potential complication after this procedure is active bleeding from the site of the
biopsy. Monitoring vital signs is critical to detect early indications of active bleeding. The other
options are incorrect. There is no reason to ambulate every four hours or withhold food and
fluids for a day.
Concepts tested

Question 2659
The nurse is preparing a client for a scheduled myelogram. For which statement by the client
should the nurse notify the radiologist immediately?
A "I suffer from claustrophobia and hate loud noises."
B "I think I may be allergic to shellfish."
C "I had a severe headache after a spinal tap last year."
D "I took my regular dose of warfarin last night."

Question Explanation
Correct Answer is D
Rationale: A myelogram is a spinal X-ray used to determine the cause of pain, numbness, or
weakness in the back, arms or legs. During the exam, contrast material is injected into the spinal
canal to provide an outline of the spinal cord. Relative contraindications to myelography include
a history of an adverse reaction to the iodine-based contrast media. A history of an allergy to
shellfish is no longer considered a contraindication. Clients who are on anticoagulant therapy
such as warfarin, are supposed to discontinue these medications prior to undergoing
myelography for about 48 hours before and 24 hours after the myelogram. Therefore, since the
client took warfarin last night, there is a high risk for bleeding into the spinal column and the
radiologist should be notified immediately. Claustrophobia and an aversion to loud noises would
be an issue for someone undergoing an magnetic resonance imaging (MRI), not a myelogram.
Page | 1047
Concepts tested

Question 2660
The nurse is reviewing the assessment data of a client suspected of having diabetes insipidus.
Which of the following findings should the nurse expect after a water deprivation test?
A Increased edema and weight gain
B Unchanged urine specific gravity
C Decreased serum potassium
D Rapid protein excretion

Question Explanation
Correct Answer is B
Rationale: Diabetes insipidus (DI) is a condition in which the kidneys are unable to conserve
water. Symptoms of DI are excessive thirst and excessive urine output. Even when fluids are
restricted, as with the fluid deprivation test, the client continues to excrete large amounts of
urine. Normally, urine becomes more concentrated in situations of reduced fluid intake. Clients
with DI do not have an increase in edema or weight gain. Due to the excessive urine output,
these clients would be more apt to lose weight. Although clients who have DI are at risk for
hypokalemia, participating in a water deprivation test would not alter the client's potassium level.
If an individual was deprived of water, their specific gravity level should increase. This is a
normal response. However, if a client suffers from DI, their specific gravity level would
remained unchanged if they were deprived of water. Rapid protein excretion does not occur in a
water deprivation test with clients who have DI.
Concepts tested

Question 2661
The nurse is caring for a 7-year-old child hospitalized for acute glomerulonephritis. Which is
the priority intervention to include in the client's plan of care?
A Encourage rest periods
B Monitor for increased urinary output
C Monitor for increased blood pressure
D Assess for generalized edema

Question Explanation
Correct Answer is C
Rationale: Acute glomerulonephritis (AGN) is the inflammation of the glomeruli and nephrons
caused by an immune response secondary to a previous infection. Clients with AGN lose protein
and red blood cells in their urine. Clients with AGN will have a decrease in urine output, not an
increase in urine output, due to the decrease in glomerular filtration rate (GFR). This decreased
in GFR is related to the inflammation of the glomeruli. The priority is the evaluation of
hypertension because clients with AGN are at risk for hypertension due to the decrease in urine
output and sodium retention. Although rest periods are important for a client with AGN, focusing
on the client's blood pressure is the highest priority. Clients with AGN will have edema that is
mild. However, assessing for edema is not as high of a priority as hypertension.
Concepts tested
Page | 1048
Question 2662
The nurse is caring for a client with suspected infective endocarditis. Which laboratory test is
the priority?
A Complete blood count
B Blood culture
C C-reactive protein
D Sedimentation rate

Question Explanation
Correct Answer is B
Rationale: Infective endocarditis (IE) is an infection of the endocardium caused by bacteria,
fungi or viruses. The most common cause of IE is Staphylococcus aureus in the blood. The key
to making a diagnosis of IE is two blood cultures collected at two different sites with two
separate venipunctures. A variety of other baseline blood tests are also ordered, however, these
blood tests are not specific or they might not be specific enough to diagnose IE specifically and
identify the causative organism. Therefore, blood cultures are the priority lab tests to obtain.
Concepts tested

Question 2663
The nurse instructs a client on how to collect a stool specimen at home using the guaiac test. The
nurse also instructs the client to avoid certain substances prior to obtaining the stool specimens.
Which of the following substances should the client avoid? Select all that apply.
A Sirloin steak
B Broiled salmon
C Marinated cauliflower
D Oranges
E Pork chops
F Acetaminophen

Question Explanation
Correct Answer is A, C, D
Rationale: A guiac specimen checks to see if there is microscopic blood in the stool. There are
various factors and substances that can create a false positive or negative result. Clients should
limit their intake of vitamin C because too much can lead to a false negative result. Fruits and
vegetables with high peroxidase activity, such as broccoli and cauliflower should be avoided
several days prior to obtaining the specimen. Food like beef, which contain hemoglobin, will
result in a false positive test and should be avoided for at least 3 days before the fecal occult
blood test is performed. Chicken, pork and seafood can be consumed. Aspirin and other
nonsteroidal anti-inflammatory drugs can cause bleeding and should be avoided at least 7 days
before the test. Acetaminophen does not affect the results of the fecal occult blood test.
Concepts tested

Question 2664

Page | 1049
The nursery nurse is caring for a newborn male infant with hypospadias. The infant's parents
request for the infant to be circumcised before leaving the hospital. How should the nurse
respond?
A "Circumcision is delayed so the foreskin can be used to correct the defect."
B "Circumcision should be performed as soon as the newborn is stable."
C "Circumcision is not medically indicated for any child."
D "Circumcision is contraindicated because of the permanent defect."

Question Explanation
Correct Answer is A
Rationale: Hypospadias is an abnormality of the penis in which the urethral opening is located on
the ventral aspect of the penis , roximal to the tip of the glans penis. Hypospadias is a congenital
defect that is thought to occur between 8 and 20 weeks' gestation. Hypospadias is generally
repaired for functional and cosmetic reasons, typically between 6 and 18 months of age. Boys
who are born with hypospadias should not be circumcised immediately after birth. The extra
tissue of the foreskin may be needed to repair the hypospadias during surgery. The client can
have a circumcision performed at a later age.
Concepts tested

Question 2665
The nurse is caring for a client after an acute myocardial infarction, who is receiving
supplemental oxygen. What is the purpose of the oxygen therapy?
A Prevent pneumonia
B Increase myocardial tissue perfusion
C Reduce cardiac afterload
D Decrease client's anxiety

Question Explanation
Correct Answer is B
Rationale: The tissue around the myocardium is injured due to a lack of blood flow to the
myocardium; thus, the overall purpose of oxygen is to increase the oxygen concentration to the
damaged myocardium. Current evidence and recommendations for oxygen administration in
clients with an acute MI are to keep oxygen saturation greater than 90%. The other actions are
not the purpose for or are helped by oxygen therapy.
Concepts tested

Question 2666
The nurse is reviewing the laboratory results for a client diagnosed with dehydration. Which
result is most important to communicate to the health care provider?
A Serum hemoglobin level of 15.7 g/dL
B Serum potassium level of 5.0 mEq/L
C Blood glucose level of 146 mg/dL
D Serum creatinine level of 2.8 mg/dL

Question Explanation

Page | 1050
Correct Answer is D
Rationale: The client with dehydration will show certain increased lab values that are due
to hemoconcentration – an imbalance in the ratio of plasma to solutes in the blood. Dehydration
will cause a decrease in fluid, i.e., plasma, in the blood. This decrease will make the
concentration of solutes such as glucose, potassium and hemoglobin appear higher than they
actually are. Creatinine is excreted solely by the kidneys and is proportional to renal function.
Thus, with normally functioning kidneys, the creatinine level should remain within a normal
range of 0.5 to 1.2 mg/dL in adults. Dehydration can contribute to impaired renal function. A
creatinine level of 2.8 mg/dL is significantly elevated and indicative of renal impairment.
Therefore, the creatinine value is the most important result for the nurse to report to the HCP.
Concepts tested

Question 2667
The nurse is reinforcing foot care instructions for a client with a history of arterial insufficiency
in the legs. Which client statement should indicate to the nurse the need for further teaching?
A "I will use Epsom salt to remove any corns and calluses."
B "I will ask a family member to help inspect my feet."
C "I should not walk barefoot around my house."
D "I should wear absorbent cotton socks."

Question Explanation
Correct Answer is A
Rationale: Clients who have peripheral arterial vascular disease suffer from decreased
circulation and sensation to the lower legs and feet. Appropriate and regular foot care is very
important to prevent integumentary complications. The client should not use commercial
preparations or home remedies such as magnesium sulfate, the active ingredient in Epsom salt, to
remove calluses or corns. Whenever possible, the client should have a professional inspect and
remove any calluses or corns.
Concepts tested

Question 2668
The nurse is assessing the mental status of a client. Which option would best evaluate the
functioning of the client's short-term memory?
A Ask the client to calculate a simple arithmetic operation.
B Ask the client to copy an image of two simple, intersecting geometric shapes.
C Ask the client to recall three words the nurse had previously asked the client to remember.
D Ask the client to name the last four presidents.

Question Explanation
Correct Answer is C
Rationale: Short-term memory refers to the temporary storage of information in the memory and
the management of the information so that it can be used for more complex cognitive tasks. Tests
of cognitive function evaluate cognitive impairment. The Mini-Mental Status Exam (MMSE),
for example, measures orientation to time and place, calculation, language, short-term verbal
memory and immediate recall. Asking the client to recall three words that the client had
previously been asked to remember is the best approach to determine short-term memory
Page | 1051
function. Asking the client to recall facts from history would assess long-term memory. Asking
the client to copy an image assesses visual-spatial skills and complex commands. Simple
arithmetic operations, such as counting backward from 100 by sevens, evaluates attention and
calculation.
Concepts tested

Question 2669
A client who is scheduled for a diagnostic mammography asks the nurse about the cancer risk
from radiation exposure. Which response is most appropriate by the nurse?
A "You have nothing to worry about; it is less than tanning in the nude."
B "The radiation from mammography is equivalent to one hour of sun exposure."
C "A chest X-ray gives you more radiation exposure."
D "This exam does not use radiation, and it is not dangerous."

Question Explanation
Correct Answer is B
Rationale: A diagnostic mammogram is used when the clinical findings of a breast examination
or on a screening mammogram are suspicious. The additional views of a diagnostic digital
mammogram provide an adequate assessment by the health care provider and are the current
method of diagnosing breast lesions. A client would need to have several mammograms in a year
to be at risk for cancer. The radiation exposure from one mammogram session is thought to be
equivalent to being out in natural sunlight for one hour. This answer is concise and gives the
client a point of reference. Comparing the radiation exposure between diagnostic tests is not
therapeutic and may cause greater concern by the client. Additionally, mammograms do pose a
(very small) risk due to some radiation exposure.
Concepts tested

Question 2670
The home health nurse is performing a daily dressing change on a client who has a diabetic ulcer.
Which intervention is most important for the nurse to implement to meet the goal of wound
healing?
A Arrange for a referral to a diabetic educator.
B Involve the client in making heath care decisions.
C Evaluate the client's understanding of appropriate foot care.
D Schedule regular visits to monitor wound healing.

Question Explanation
Correct Answer is B
Rationale: Although all of these interventions may benefit the client, the involvement of the
client in making health care decisions is the most important intervention to meet the outcomes.
The client will be more motivated to adhere to the nurse's recommendations if they are involved
in the process of setting priorities and making decisions. Regular assessments, evaluating the
client's understanding of foot care and referring the client to a diabetic educator may be follow-
up interventions. However, client involvement in treatment decisions and care is essential for
providing client-centered nursing care.
Concepts tested
Page | 1052
Question 2671
A nurse witnesses a child lose consciousness from choking on a hotdog in a public park. What
should the nurse do first?
A Attempt a single finger sweep to remove the food.
B Start 100 to 120 chest compressions per minute.
C Open the airway and give two rescue breaths.
D Activate the emergency response system.

Question Explanation
Correct Answer is D
Rationale: Activating the emergency response system should be done first, so that emergency
medical services (EMS) personnel can arrive quickly and support the nurse's resuscitation
efforts.
Concepts tested

Question 2672
The nurse is caring for a client who suddenly develops slurred speech and a facial droop. What
diagnostic test would the nurse expect to be performed first?
A Computerized tomography scan
B Chest X-ray
C Echocardiogram
D Arterial blood gas

Question Explanation
Correct Answer is A
Rationale: The client's symptoms are indicative of an acute stroke. The nurse would anticipate
that a non-contrast computerized tomography (CT) of the head will be done first because time is
of the essence with an acute stroke. The other tests may or may not be indicated for this client.
Concepts tested

Question 2673
The nurse is performing an assessment on a client with ulcerative colitis. Which of the following
findings should the nurse anticipate? Select all that apply.
A Weight gain related to intake of high-fat foods
B Abdominal cramping with frequent watery diarrhea
C Elevated white blood cell count and erythrocyte sedimentation rate (ESR)
D Family history of ulcerative colitis
E Low urine output and temperature of 101.3° F (38.5° C)

Question Explanation
Correct Answer is B, C, D
Rationale: Ulcerative colitis is one of two different types of inflammatory bowel disease. It
causes inflammation and ulcers in the lining of the colon and rectum. An elevated white blood

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count and erythrocyte sedimentation rate (ESR) indicate inflammation. The hallmark
manifestation of ulcerative colitis is severe watery diarrhea with abdominal cramping. Family
history is one of the biggest risk factors for ulcerative colitis. Clients with ulcerative colitis do
not gain weight, but instead they lose weight secondary to malabsorption related to severe
diarrhea. Clients with ulcerative colitis are at risk for dehydration secondary to the diarrhea. As a
result, their urine output would be low. Because ulcerative colitis is an inflammatory condition,
clients will often manifest with an elevated temperature.
Concepts tested

Question 2674
The nurse is caring for a client who underwent an open cholecystectomy 72 hours ago. Which
assessment finding requires the nurse's immediate action?
A Client complains of right shoulder pain
B Spots of blood found on gauze dressings
C Client complains of nausea
D Temperature of 101.8°F (38.8°C)

Question Explanation
Correct Answer is D
Rationale: A cholecystectomy is the removal of a client's gallbladder. 'Open' means that the
gallbladder was removed through an abdominal incision vs. using laparoscopy. A temperature of
101.8°F three days after surgery may indicate a post-op or surgical-site infection. The
temperature should be reported to the health care provider immediately. Nausea after surgery
may be common secondary to anesthesia and pain medications. Spots of blood can be expected
and shoulder pain from the use of CO2 gas is generally only seen with a laparoscopic
cholecystectomy.
Concepts tested

Question 2675
The nurse is assessing a client in the postoperative area following a thyroidectomy. Which
assessment finding should the nurse report immediately to the health care provider?
A Mild sore throat and hoarseness
B Headache and nausea
C Tetany and paresthesia
D Irritability and insomnia

Question Explanation
Rationale: A thyroidectomy is the removal of the thyroid gland. Complications of a Correct
Answer is C
thyroidectomy include bleeding, infection, airway obstruction, hypoparathyroidism and
hypocalcemia. Manifestations of hypocalcemia include tetany and paresthesia. Tetany
(involuntary muscle contractions) and paresthesia (numbness and tingling) are indicative of a
dangerously low serum calcium level; therefore, the nurse should notify the health care
provider immediately of those findings.
Concepts tested

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Question 2676
The nurse is caring for an unconscious client. In order to prevent exposure keratitis, which of the
following interventions would be most appropriate for the nurse to implement?
A Apply warm compresses to both eyes daily
B Initiate the administration of topical antibiotics to both eyes
C Tape upper eyelids in both eyes closed
D Apply lanolin alcohol (Lacri-lube) to the inside of the eyelids

Question Explanation
Correct Answer is D
Rationale: Exposure keratitis is the inflammation and dryness of the cornea; which is secondary
to air exposure due to incomplete eyelid closure. Clients who are at greatest risk for this
condition, are those admitted to a critical care unit. Additional risk factors for exposure keratitis
include mechanical ventilation, fluid overload and the administration of sedatives and
neuromuscular blockade agents. Although the literature does mention tapping eyelids closed as a
method for preventing exposure keratitis, additional evidence suggests that this practice also
places the client at risk for developing corneal abrasions. There is no evidence that suggests
applying warm compresses to a client's eye, prevents exposure keratitis. In cases where exposure
keratitis is identified, topical antibiotics may be initiated if bacterial keratitis is suspected and/or
diagnosed. The most appropriate intervention that prevents the development of exposure
keratitis, is the use of moisturizing eye drops or ointments to the exposed cornea.
Concepts tested

Question 2677
The perioperative nurse must place the anesthetized client into the lithotomy position for a
cystoscopic procedure. What is the safest technique for moving the client into this position?
A Rotate hips and flex knees one at a time before placing in stirrup
B Abduct legs, then flex knee of one leg before placing in stirrup; repeat with other leg
C Raise one leg, flex the knee, and place leg in stirrup; repeat with other leg
D Ask for assistance to raise both legs simultaneously, then to flex both knees and place legs in
padded stirrups

Question Explanation
Correct Answer is D
Rationale: Proper positioning of the client during a surgical procedure, is a way to help prevent
intraoperative nerve injury. The client can become injured while being placed in the lithotomy
position. Positioning the client for surgical procedures is the responsibility of the nurse. In some
cases, a client under anesthesia may lose some of their protective reflexes and cannot feel or
express sensation that might reveal a potential nerve injury. When placing the client in this
position, both legs should be moved at the same time to avoid overstretching the nerves of the
lumbosacral plexus. Stirrups should be padded so that the client's legs don't touch the poles of the
stirrups directly. Compression along the medial and lateral aspects of the calf can damage the
saphenous nerve and peroneal nerve. This may lead to weakness in the lower extremities during
the postoperative period.
Concepts tested

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Question 2678
The nurse is caring for a client with cardiogenic shock due to an acute myocardial infarction. The
client's urine output has decreased from 60 to 70 mL per hour to 20 mL per hour. Which
laboratory test is the priority to monitor?
A Troponin
B Hematocrit
C Serum sodium
D Serum creatinine

Question Explanation
Correct Answer is D
Rationale: Cardiogenic shock occurs when either systolic or diastolic dysfunction of the heart's
pumping action results in reduced cardiac output, stroke volume and blood pressure, leading to
insufficient perfusion of vital organs such as the kidneys. The drop in urine output is indicative
of impaired renal tissue perfusion secondary to the low cardiac output. The serum creatinine
level is an important clinical indicator of kidney function and, therefore, is the priority to
monitor.
Concepts tested

Question 2679
The nurse is preparing to obtain an aerobic wound culture from a stage IV pressure ulcer. After
removing the wound dressing, the nurse observes a moderate amount of purulent, foul-smelling
exudate. Which action should the nurse take to ensure the best specimen?
A Using a dry gauze pad, gently pat the wound to remove the exudate.
B Using a culture swab, obtain a scraping of tissue from the edges of the wound.
C Using soap and water, wash the wound edges and wound bed first.
D Using a piston syringe, gently irrigate the wound with sterile normal saline.

Question Explanation
Correct Answer is D
Rationale: Due to the presence of purulent exudate, the wound should first be irrigated with
sterile normal saline to remove surface pathogens and exudate that will alter the wound culture.
This is the best approach to obtain a noncontaminated specimen. Using dry gauze to remove the
exudate can irritate the wound bed and cause bleeding. The specimen should ideally be taken
from the wound bed, not the edges. Washing a stage IV pressure ulcer is not appropriate.
Concepts tested

Question 2680
The nurse is caring for a school-aged child with a diagnosis of secondary hyperparathyroidism
after treatment for chronic renal disease. Which serum lab data should receive priority attention
by the nurse?
A Glucose and potassium
B Blood urea nitrogen and magnesium
C Osmolality and sodium
D Calcium and phosphorus

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Question Explanation
Correct Answer is D
Rationale: The parathyroid gland regulates calcium and phosphorous levels. Clients with
hyperparathyroidism often present with an elevation in both calcium and phosphorous levels. In
clients with hypoparathyroidism, calcium and phosphorous serum levels may be low.
Concepts tested

Question 2681
The nurse has an order to insert an indwelling urinary catheter for a male client. What is
the best reason for lubricating the tip of the catheter prior to insertion?
A Diminish the leakage of urine around the catheter
B Prevent bladder distention
C Reduce the friction within the urethra
D Minimize risk for infection

Question Explanation
Correct Answer is C
Rationale: Due to the somewhat long length of the male urethra, lubrication reduces potential
discomfort and localized tissue irritation as the catheter is passed.
Concepts tested

Question 2682
The nurse is working with clients who are diagnosed with eating disorders. Which eating
disorder would the nurse expect to cause the greatest fluctuation in serum potassium levels?
A Bulimia nervosa
B Dysthymic disorder
C Anorexia nervosa
D Binge eating disorder

Question Explanation
Correct Answer is A
Rationale: Hypokalemia can be caused by prolonged fasting and starvation, but is more common
in those who exhibit binging and purging behaviors. Binging and purging, common in bulimia
nervosa, result in dehydration and potassium loss. Hypokalemia can result in weakness,
abdominal cramping and arrhythmias.
Concepts tested

Question 2683
The client is diagnosed with a large spontaneous pneumothorax. The nurse anticipates that a
chest tube will be inserted. The nurse understands that chest tubes are used to treat pneumothorax
for which reason?
A Increase intrathoracic pressure to allow both lungs to expand equally
B Prevent an accumulation of blood and other drainage into the pleural cavity
C Drain air from the pleural cavity and restore normal intrathoracic pressure

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D Drain the purulent drainage from the empyema that caused the problem

Question Explanation
Correct Answer is C
Rationale: There are no clinical signs or symptoms in primary spontaneous pneumothorax until
a cyst or small sac (bleb) ruptures. When air enters the pleural space, the pressure in the space
equals the pressure outside the body; the vacuum is lost and the lung collapses. This causes acute
onset chest pain and shortness of breath. A small pneumothorax without underlying lung disease
may resolve on its own. A larger pneumothorax requires aspiration of the free air and/or
placement of a chest tube to evacuate the air.
Concepts tested

Question 2684
The pediatric nurse is screening a child for suspected lead poisoning. Which assessment finding
would support this diagnosis?
A Excessive perspiration
B Obesity
C Developmental delays
D Enuresis

Question Explanation
Correct Answer is C
Rationale: Lead can affect any part of the body, including the renal, hematologic, and neurologic
systems. Of most concern for young children is the developing brain and nervous system. The
lead levels identified in children have declined since the initiation of screening for children at
risk for lead poisoning. Long-term neurocognitive signs of lead poisoning include developmental
delays, lowered intelligence quotient (IQ), reading skill deficits, visual-spatial problems, visual-
motor problems, learning disabilities, and lower academic success. The other findings are not
typically seen with lead poisoning.
Concepts tested

Question 2685
The nurse is providing preprocedural education to the client preparing for a barium enema. What
statement made by the client indicates a need for further education?
A "I will need to drink plenty of fluids and eat foods high in fiber after the procedure."
B "I will not eat or drink anything after midnight before the procedure."
C "I will use the prescribed laxative before the procedure."
D "A barium enema is used to examine the upper and lower GI tracts."

Question Explanation
Correct Answer is D
Rationale: A barium enema involves filling the large intestine (lower GI tract) with diluted
barium liquid while X-ray images are taken. After the procedure, a small amount of barium will
be immediately expelled and the remainder will be excreted in the stool. Because barium liquid

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may cause constipation, clients should eat foods high in fiber and drink plenty of fluids to help
expel the barium from the body.
Concepts tested

Question 2686
A client has a history of chronic obstructive pulmonary disease (COPD). The nurse enters the
client's room to find that the nasal cannula is in proper position with the oxygen set at 6 liters per
minute, the client's color is flushed, and the client's respirations are 8 breaths per minute. What
should the nurse do first?
A Remove the nasal cannula for at least five minutes
B Place client in a higher sitting position
C Lower the oxygen's flow rate
D Check the client's pulse for strength and rate

Question Explanation
Correct Answer is A
Rationale: The client has findings of oxygen toxicity so the nurse should first remove the
cannula for a least five minutes. Then the nurse should perform these next sequence of actions:
pulse assessment, change of position and then lower the oxygen flow rate and reapply if
respirations are within normal parameters. A higher concentration of supplemental oxygen
removes the hypoxic drive to breathe and leads to increased hypoventilation, respiratory
decompensation, and the development or worsening of respiratory acidosis.
Concepts tested

Question 2687
A client who underwent surgery 12 hours ago becomes confused and says: "Giant sharks are
swimming across the ceiling." Which assessment should the nurse complete first?
A Peripheral glucose stick
B Pupillary response
C Pulse oximetry
D Cardiac rhythm strip

Question Explanation
Correct Answer is C
Rationale: A sudden change in mental status in any postop client should trigger a nursing
intervention directed toward evaluation of the client's respiratory status. Pulse oximetry would be
the initial assessment. If available, arterial blood gases would be better. Acute respiratory failure
is the sudden inability of the respiratory system to maintain adequate gas exchange, which may
result in hypercapnia and/or hypoxemia. Clinical findings of hypoxemia include these findings,
which are listed in order of initial to later findings: restlessness, irritability, agitation, dyspnea,
disorientation, confusion, delirium, hallucinations and loss of consciousness. While there may be
other factors influencing the client's behavior, the first nursing action should be directed toward
maintaining oxygenation. Once respiratory or oxygenation issues are ruled out, then significant
changes in glucose would be evaluated.
Concepts tested

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Question 2688
The nurse working in a primary care clinic is reviewing a client's blood glucose log and notices
that the client is not consistently monitoring their blood glucose. Which diagnostic test would
assist the nurse in evaluating the client's overall diabetes management?
A Hemoglobin A1C
B Fasting blood sugar
C White blood cell count
D Hemoglobin

Question Explanation
Correct Answer is A
Rationale: The hemoglobin A1C is the best indicator of glycemic control because it reflects an
average of the blood sugar over the life of a red blood cell (approximately 90 to 120 days). The
fasting blood sugar will only evaluate the client's blood sugar at that specific testing time.
Hemoglobin and a white blood cell count are not used to determine blood sugar levels.
Concepts tested

Question 2689
The nurse observes cloudy drainage from an abdominal catheter that was inserted two days ago
for peritoneal dialysis. What other data should the nurse assess?
A Urine output
B Temperature
C Bowel sounds
D Breath sounds

Question Explanation
Correct Answer is B
Rationale: Cloudy drainage may indicate a peritoneal infection, so it is essential to evaluate the
client's temperature before notifying the health care provider. In a client on dialysis for renal
failure little to no urine output would be an expected finding.
Concepts tested
Question 2690
The nurse is evaluating a stage III pressure ulcer. Which assessment finding would indicate that
the prescribed treatment is working?
A The periwound texture is moist and soft
B The edge of the wound appears rolled or curled under
C The size of the wound is decreasing
D Soft yellow tissue seen in wound bed

Question Explanation
Correct Answer is C
Rationale: A wound that is decreasing in size is healing. "Slough" is yellow, tan or green tissue
that is not healing. Soft and denuded tissue in the periwound area indicate tissue breakdown due
to excessive moisture from wound drainage. Curled or rolled wound edges (epibole) prevents
epithelial cells from migrating to close the wound, preventing the wound from healing.

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Concepts tested

Question 2691
The nurse is caring for a client with left ventricular heart failure. The client's ejection fraction is
40%. Which assessment finding is an early indication of inadequate tissue perfusion?
A Distended jugular veins
B Use of accessory muscles
C Confusion and restlessness
D Crackles in the lungs

Question Explanation
Correct Answer is C
Rationale: Neurological changes, including impaired mental status, are early signs of inadequate
tissue perfusion due to decreased oxygenation of brain tissues. Other signs of low ejection
fraction (EF) include shortness of breath, dependent edema, and arrhythmias. The low EF
indicates that this client has severe damage to the left ventricle. Normal EF is about 55-70%.
Concepts tested

Question 2692
A client had an open reduction and internal fixation (ORIF) of a femur fracture. During a routine
assessment 36 hours after surgery, the nurse finds the client disoriented, short of breath, and
warm to the touch. The client's temperature is 102.4°F (39°C). What assessment should the nurse
perform next?
A Measure oxygen saturation using a pulse oximeter
B Perform a neurologic check of bilateral distal extremities
C Remove the splint and inspect the incision
D Assess orientation to time, person and place

Question Explanation
Correct Answer is A
Rationale: Based on the client's history and assessment findings, the nurse should suspect fat
embolism syndrome (FES). Neurologic changes and respiratory distress are two of the classic
findings of FES (the third finding is a characteristic petechial rash.) The nurse should activate the
rapid response team. While waiting for the team, the nurse will measure the client's SpO2, as
well as pulse and blood pressure, and auscultate the lungs. The nurse will also administer
supplemental oxygen and ensure venous access.
Concepts tested

Question 2693
The nurse is caring for a 4-year-old child two hours after a tonsillectomy and adenoidectomy.
Which finding must be reported to the health care provider immediately?
A Apical heart rate of 110
B Increased restlessness
C Complaints of throat pain
D Vomiting of dark emesis

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Question Explanation
Correct Answer is B
Rationale: Increased restlessness with increased respiratory and heart rates are often early signs
of active bleeding. The other options are expected findings at this time in the postop period for
this surgery. The dark emesis indicates old blood that most likely was swallowed during surgery.
Concepts tested

Question 2694
The nurse is caring for a 17-month-old child diagnosed with acetaminophen poisoning. Which of
these lab reports should the nurse review first?
A Red blood cell and white blood cell counts
B Blood urea nitrogen (BUN) and creatinine clearance
C Aspartate aminotransferase (AST) and Alanine transaminase (ALT)
D Prothrombin Time (PT) and partial thromboplastin time (PTT)

Question Explanation
Correct Answer is C
Rationale: Acetaminophen is toxic to the liver and causes hepatic cellular necrosis. This causes
the liver enzymes AST and ALT to be released into the blood stream, which elevates serum
levels. The next lab values to review are those associated with coagulation, then the blood counts
and lastly the renal-associated labs, including BUN and creatinine.
Concepts tested

Question 2695
The client underwent a laparoscopic removal of the appendix. Which post-operative instructions
will the nurse reinforce? Select all that apply.
A Gently scrub off the "skin glue" when you feel able
B Maintain bedrest for 24 hours before gradually resuming regular activities
C Some shoulder discomfort can be expected
D Restrict diet to bland, easily digestible food for a few days
E Use 2 tablespoons of Milk of Magnesia (MOM) if no bowel movement (BM) 3 days after
surgery
F No showering for 48 hours after surgery

Question Explanation
Correct Answer is C, D, E, F
Rationale: Laparoscopic surgery involves using carbon dioxide gas to open the inside of the
abdomen, which pushes up the diaphragm; this may cause shoulder discomfort postoperatively.
Clients should keep the dressings clean and dry for 48 hours before they can shower, but no tub
baths for a few weeks. If "skin glue" is used over the incision(s), the client should not try to
scrub it off because it will wear off on its own. Clients may resume normal activities as soon as
they are able but no heavy lifting or aerobic exercise for about 2 weeks. If they do not have a BM
after 2-3 days, clients can take 2 tablespoons of MOM several times a day until they have a BM.

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Diet can be advanced as tolerated but it's best to stick to non-greasy, non-spicy foods for a few
days.
Concepts tested

Question 2696
The nurse is caring for a client with suspected tuberculosis (TB). The nurse is aware of
diagnostic tests to evaluate for active TB. Which should the nurse anticipate be ordered to
evaluate for the presence of active TB?
A Chest X-ray anterior/posterior and lateral
B White blood cell count
C Sputum culture for cytology
D Tuberculin skin testing

Question Explanation
Correct Answer is C
Rationale: The sputum culture is the method for determining if active TB is present. Tuberculin
skin testing can demonstrate false positives, and chest X-rays cannot differentiate live from latent
TB. White blood cell count can indicate infection, but is not specific to TB.
Concepts tested

Question 2697
The nurse is assessing a 4-year-old child who is in skeletal traction 24 hours after surgical repair
of a fractured femur. The child is crying and appears to be having severe pain. The foot on the
affected extremity is pale, cool to touch and the pulse is barely palpable. What action should the
nurse take?
A Notify the primary health care provider.
B Readjust the traction for comfort.
C Reassess the affected extremity in 15 minutes.
D Administer the ordered PRN pain medications.

Question Explanation
Correct Answer is A
Rationale: The pain and absence of a pulse suggests compartment syndrome. This condition
occurs when there is a buildup of pressure within the muscles. This pressure decreases blood
flow and can cause muscle, tissue, and nerve damage. Compartment syndrome is a medical
emergency. Delaying treatment can lead to permanent damage to the extremity. Therefore, the
nurse should contact the primary health care provider (HCP) immediately.
Concepts tested

Question 2698
A 57-year-old male client has a hemoglobin of 10 g/dL (6.21 mmol/L) and a hematocrit of 32%
(0.32). What would be the most appropriate follow-up by a home care nurse?
A Call 911 and send the client to the emergency department
B Refer the client to schedule an appointment with a hematologist

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C Ask the client if the client has noticed any bleeding or dark stools
D Schedule a repeat hemoglobin and hematocrit in one month

Question Explanation
Correct ARationale: Normal hemoglobin for males is 14-18 g/dL (8.69-11.17 mmol/L). Normal
hematocrit for males is 42-52% (0.42-0.52). The lab values for this client are below normal and
indicate mild anemia. The nurse should ask if the client has noticed any bleeding or change in
stools that could indicate bleeding from the GI tract.
Concepts tested

Question 2699
The nurse checks lab results for an adult client with suspected cancer prior to a liver biopsy.
Which finding requires immediate notification of the health care provider?
A Elevated blood urea nitrogen (BUN) and creatinine
B Activated partial thromboplastin time (aPTT) of 50 seconds
C Increased serum ammonia
D Hemoglobin of 11 g/dL (110 g/L)

Question Explanation
Correct Answer is B
Rationale: Because the liver is a vascular organ and a biopsy is an invasive procedure, bleeding
is one of the risks. An elevated aPTT increases the risk of bleeding. Abnormal findings in the
other labs would not increase the client's risk of complications following a liver biopsy.
Concepts tested

Question 2700
The client returned from the cardiac catheterization lab four hours ago. The groin was used as the
insertion site. Which assessment finding would the nurse immediately report to the health care
provider? Select all that apply.
A Nonpalpable pedal pulse on the affected limb
B Capillary refill 6 seconds on the affected toes
C Bruising or lump at the insertion site
D Pale color of the affected limb
E Trace amount of serosanguineous drainage on the groin dressing

Question Explanation
Correct Answer is A, B, D
Rationale: A trace of serosanguineous drainage on the dressing is common. Some bruising or a
small lump is expected at the insertion site. Reportable conditions include significant reports of
pain; abnormal lab values; abnormal ECG strip; post-procedure bleeding or swelling; color,
temperature or pulse changes, especially to the affected limb. Capillary refill should be about 3
seconds.
Concepts tested

Question 2701

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The nurse is teaching a client with asthma how to use a peak flow meter. The nurse explains that
peak flow meters are used to achieve which outcome?
A Monitor atmosphere for presence of allergens
B Determine the client's oxygen saturation
C Provide metered doses for inhaled bronchodilator
D Measure forced expiratory volumes

Question Explanation
Correct Answer is D
Rationale: The peak flow meter is used to measure peak expiratory flow volumes. It provides
useful information about the presence and/or severity of airway obstruction. If the result falls in
the green, the client is good without any problems. If it falls into the yellow or red category,
immediate action is required. The specific action should be determined with the health care
provider ahead of time before this happens. Often the clients are advised to use a bronchodilator
inhaler and then recheck for improvement. When teaching the colors for the peak flow meters,
nurses often associated the colors and actions with those of a traffic light. Green = go; yellow =
proceed with caution; and red = stop and get help.
Concepts tested

Question 2702
The nurse is assessing a postoperative client following femoral popliteal bypass surgery for
peripheral arterial disease. The surgical dressing is saturated with bright red blood. Which action
should the nurse take first?
A Stop the heparin sodium infusion
B Obtain a set of vital signs
C Apply a pressure dressing over the surgical dressing
D Increase the rate of the normal saline IV infusion

Question Explanation
Correct Answer is A
Rationale: The presence of bright red blood indicates the possibility of arterial bleeding from the
surgery site. The nurse should first stop the heparin, an anticoagulant, infusion. Next, the nurse
should attempt to slow the bleeding by applying either manual pressure or a pressure dressing
directly over the surgical dressing.
Concepts tested

Question 2703
A nurse is caring for a 7-year-old child who is being discharged following a tonsillectomy.
Which instruction is appropriate for the nurse to include during discharge teaching with the
parents?
A The child can return to school after being home for four days
B Report a persistent cough to the health care provider within 24 hours
C Administer chewable aspirin for pain around the clock every six hours
D The child may gargle with saline as necessary for discomfort

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Question Explanation
Correct Answer is B
Rationale: Persistent coughing should be reported to the health care provider as this may
indicate bleeding by a trickling of blood into the back of the throat. The other items are incorrect
information especially the aspirin, which is not to be given to children. The saline may irritate
the wound where the tonsils were removed.
Concepts tested

Question 2704
After surgery, a client who has nasogastric tube placed reports feeling nauseous. What action
should the nurse take?
A Call the health care provider to troubleshoot the problem
B Check the patency of the nasogastric tube
C Administer an antiemetic that is ordered PRN
D Put the head of the bed in a higher position

Question Explanation
Correct Answer is B
Rationale: An initial indication that the nasogastric tube is obstructed is a client's report of
nausea. Nasogastric tubes may become obstructed by being kinked or with mucus or sediment.
Concepts tested

Question 2705
The nurse is caring for a client who is experiencing alcohol withdrawal. The nurse notes the
client has tremors in the upper extremities, hyperactive deep tendon reflexes, and a change in
mental status. The nurse should assess the client for which electrolyte imbalance?
A Hypocalcemia
B Hyponatremia
C Hypokalemia
D Hypomagnesemia

Question Explanation
Correct Answer is D
Rationale: Clients who are experiencing alcohol withdrawal are at risk of developing
hypomagnesemia. The client will exhibit tremors, muscle weakness, changes in mental status,
and hyperactive deep tendon reflexes. The nurse should obtain a serum hypomagnesemia level.
Clients with inadequate calcium intake can develop hypocalcemia. Clients with vomiting or
diarrhea or taking prescribed diuretics can develop hypokalemia. Hyponatremia develops from
an excessive gain of water.
Concepts tested

Question 2706
The nurse is collecting the health history from a client with paraplegia from a spinal cord injury.
Which statement by the client would require immediate follow up by the nurse?
A “I have all the equipment to take a shower, but I prefer a bed bath.”

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B “I spend the majority of the day in my wheelchair.”
C “I am not ready to go out in public.”
D “I am still learning how to use the modified utensils.”

Question Explanation
Correct Answer is B
Rationale: When collecting the health history of a client with spinal cord injury, the nurse will
assess how the client is adapting to the injury and identify any potential complications. Clients
with spinal cord injuries are at increased risk of pressure injuries. Pressure injuries develop from
the client’s inability to move or feel the sensation of pressure. A client who reports spending the
majority of their day in a wheelchair requires follow-up by the nurse to ensure the client has not
developed a pressure injury. A client who prefers a bed bath may need further teaching on how
to use the equipment, but this is not the immediate concern. A client who reports not being ready
to go out in public may be at risk for depression, but this is not the immediate concern.
Concepts tested

Question 2707
The nurse is assessing a client who has a suspected right hip fracture following a fall. Which of
findings would require immediate follow up by the nurse?
A Edema and ecchymosis over the right hip
B Right leg appears shorter than the left leg, and the client reports pain level of 6
C Diminished pedal pulse and capillary refill greater than 3 seconds in the affected extremity
D Adduction of the affected extremity and loss of function

Question Explanation
Correct Answer is C
Rationale: When assessing a client with a suspected right hip fracture, the nurse should expect to
observe the client’s affected extremity will be abducted, appear shorter than the unaffected
extremity, and have edema and ecchymosis. A client with a diminished pedal pulse and capillary
refill greater than 3 seconds would indicate that the client is experiencing a decrease in perfusion
in the affected extremity, which would require immediate follow-up by the nurse.
Concepts tested

Question 2708
The nurse is planning care for a client who is postoperative from an intermaxillary fixation for a
mandibula fracture. Which of the following should be the priority of the nurse place at the
client’s bedside?
A Nasogastric tube
B Wire cutters
C Syringes
D Tongue depressor

Question Explanation
Correct Answer is B

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Rationale: The client who is postoperative intermaxillary fixation will have wires to keep the
jawbone aligned. If a client experiences respiratory distress, the nurse will need to cut the wires
to access the airway. A nasogastric tube is used to decompress the stomach, syringes are used to
irrigate the mouth, and a tongue depressor retracts the cheeks, but these are not a priority.
Concepts tested

Question 2709
The nurse is assessing a client with myasthenia gravis and notes that the client’s respiratory rate
is 10 and there is limited chest wall movement. Which of the following interventions should the
nurse take?
A Prepare the client for mechanical ventilation
B Administer a prescribed anticholinesterase medication
C Instruct the client on pursed-lip breathing
D Position the client in high-Fowler’s

Question Explanation
Correct Answer is A
Rationale: The client with myasthenia gravis has muscle weakness, which can impede the
movement of the chest wall and diaphragm resulting in respiratory failure. A client with a
respiratory rate of 10 and limited chest wall movement is at risk for respiratory failure, and the
nurse should prepare the client for mechanical ventilation. Administration of anticholinesterase
medication, instructing the client on pursed-lip breathing, and positioning the client in high-
Fowler’s will not fix the respiratory failure.
Concepts tested

Question 2710
The nurse is assisting the healthcare provider administer a Tensilon test to a client with suspected
myasthenia gravis. Which finding observed by the nurse would confirm the diagnosis?
A The client develops a pill-rolling tremor.
B The client is able to lift their arm against resistance.
C The client reports diplopia.
D The client will have dilated pupils.

Question Explanation
Correct Answer is B
Rationale: To diagnosis myasthenia gravis, a Tensilon test is administered by the healthcare
provider. During the test, the client will receive an IV injection of edrophonium chloride which
is an anticholinesterase agent. If the test is positive, confirming the diagnosis, the client will have
increased muscle contractions, sweating, excessive salivation, and constricted pupils.
Concepts tested

Question 2711
The nurse is preparing a client for a paracentesis. Which action would be a priority for the nurse
to take before the procedure?
A Auscultate lung sounds

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B Palpate bladder for distention
C Verify last bowel movement
D Administer prescribed analgesia

Question Explanation
Correct Answer is B
Rationale: A paracentesis is a procedure where the healthcare provider uses an ultrasound-guided
needle to drain fluid from the peritoneal cavity. The nurse should assess for bladder distension to
prevent puncture of the bladder during the procedure. Verifying the last bowel movement,
auscultating the lungs, and administering prescribed analgesia are important actions but not the
priority before the procedure.
Concepts tested

Question 2712
A nurse is reviewing the laboratory data of a client who has acute pancreatitis. Which value
should the nurse expect to be elevated?
A Calcium
B Magnesium
C Creatinine
D Amylase

Question Explanation
Correct Answer is D
Rationale: Acute pancreatitis is inflammation of the pancreas due to autodigestion from
pancreatic enzymes of amylase and lipase. Amylase, which is required to convert starchy foods
into simple sugar, will be elevated in acute pancreatitis. Calcium levels will be decreased with
acute pancreatitis. Creatinine and magnesium levels are not affected with acute pancreatitis.
Concepts tested

Question 2713
The nurse is monitoring a client who is 30 minutes post endoscopic retrograde
cholangiopancreatography (ERCP). Which assessment finding would require immediate follow-
up by the nurse?
A Absent gag reflex
B Rigid abdomen
C Drowsiness
D Diminished breath sounds

Question Explanation
Correct Answer is B
Rationale: An ERCP is an endoscopic procedure to remove a gallstone from the common bile
duct. When monitoring a client post ERCP, the nurse should assess for complications, including
perforation, pancreatitis, infection, and bleeding. A rigid abdomen is a manifestation of
perforation which is a medical emergency. An absent gag reflex, drowsiness, and diminished
breath sounds are normal findings following an endoscopic procedure.

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Concepts tested

Question 2714
The nurse is caring for a client with acute appendicitis. Which finding should the nurse
immediately report to the healthcare provider?
A Febrile
B Diarrhea
C Sudden decrease in abdominal pain
D Positive Kernig’s sign

Question Explanation
Correct Answer is C
Rationale: When caring for a client with acute appendicitis, the nurse should monitor the client
for potential complications including rupture of the appendix. A sudden decrease in abdominal
pain is a manifestation of a ruptured appendix and requires immediate surgical intervention.
Diarrhea, febrile, and positive Kernig’s sign are expected manifestations of acute appendicitis.
Concepts tested

Question 2715
The nurse is caring for a client who had a laparoscopic cholecystectomy. The client reports pain
in the shoulder. Which action should the nurse take first?
A Administer prescribed analgesia
B Place client in left lateral Sims' position
C Instruct the client to use the incentive spirometer
D Auscultate bowel sounds

Question Explanation
Correct Answer is B
Rationale: During a laparoscopic cholecystectomy, CO2 is introduced into the abdominal cavity
to allow for visualization. CO2 is irritating to the phrenic nerve and diaphragm resulting in the
client reporting pain in the shoulder. To help expel the CO2 gas, the nurse should place the client
in Sims' position, which will move the gas pocket away from the diaphragm. Then the nurse will
administer prescribed analgesia, encourage deep breathing, and auscultate bowel sounds.
Concepts tested

Question 2716
The nurse has reviewed discharge instructions with a client who is newly diagnosed with irritable
bowel syndrome. Which statement made by the client would indicate that teaching was
effective?
A "I should increase fluids during my meals."
B "I should take a bulk laxative and stool softener every day."
C "I should avoid eating when I have symptoms."
D "I will need to keep a 2-week diary of my food intake and symptoms."

Question Explanation

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Correct Answer is D
Rationale: When teaching clients about IBS, the nurse will instruct the client to keep a diary of
food intake and associated symptoms. The diary will assist the client with identifying potential
triggers that can exacerbate IBS. The client with IBS should avoid taking a bulk laxative or stool
softener daily, which can increase bloating and dehydration. Increasing fluids during meals will
fill the client up and can increase bloating. Clients with IBS should still eat with symptoms to
prevent malnutrition.
Concepts tested

Question 2717
The nurse is reviewing the laboratory results for a client with diabetes type 1. Which finding
would best indicate if treatment has been effective?
A Fasting plasma glucose 130 mg/dL
B Negative urine ketones
C Hemoglobin A1C of 6.0%
D Positive urine glucose

Question Explanation
Correct Answer is C
Rationale: Hemoglobin A1C measures the amount of glucose attached to the total hemoglobin.
The amount of glucose that attaches to the hemoglobin is a correlation to the average blood
glucose levels over a three-month period, which can provide information on the effectiveness of
treatment. The other options are used to diagnose diabetes but not evaluate the effectiveness of
the treatment.
Concepts tested

Question 2718
The nurse is educating a client who is newly diagnosed with Addison’s disease about preventing
complications. Which statement should the nurse include in the teaching?
A “Keep your legs elevated when you are sitting.”
B “Increase your physical activity by 10 minutes every day.”
C “Reduce the amount of sodium in your diet.”
D “Decrease your fluid intake to about 1.5 liters a day.”

Question Explanation
Correct Answer is A
Rationale: Addison’s disease is hypofunction of the adrenal cortex with results in a decrease in
secretion of adrenal corticosteroids (glucocorticoids, mineralocorticoids, and androgens). The
client will have hyponatremia, so the client should increase their sodium intake. Addison’s
disease increases the risk of hypotension, due to hypovolemia, so the nurse should instruct the
client to keep legs elevated when sitting and increase fluid intake. The client with Addison’s is at
risk for decreased glucose levels and activity intolerance and should be instructed to avoid
excessive activity.
Concepts tested

Question 2719
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The nurse is caring for a client who has a prescription for serum cortisol levels. When should the
nurse prepare to obtain the specimen?
A In the middle of the night around midnight
B Before the client goes to sleep
C During the middle of the day after lunch
D First thing in morning before the client is out of bed

Question Explanation
Correct Answer is D
Rationale: Cortisol levels, which evaluate adrenal activity, are the highest in the morning and
then slowly begin to drop through the day with the lowest level around midnight. For accurate
testing, the nurse should obtain the specimen first thing in the morning before the client engages
in activity.
Concepts tested

Question 2720
The nurse is caring for a client who is postoperative a right mastectomy. Which intervention
should the nurse implement to prevent the development of lymphedema?
A Place a cool compress on the affected arm
B Elevated the affected arm on a pillow above the level of the heart
C Maintain a peripheral intravenous site below the antecubital area of the affected arm
D Encourage the client to avoid excessive movements of the affected arm

Question Explanation
Correct Answer is B
Rationale: A client who had a mastectomy is at risk for lymphedema. Lymphedema occurs when
lymph nodes are removed or impaired lymph fluid drainage occurs in the extremity on the side of
the mastectomy. The lymph fluid collects in the tissues of the affected extremity. To prevent
lymphedema, the nurse should encourage the client to perform range of motion exercises and
elevate the extremity above the level of the heart. The nurse will advise the student to avoid any
IVs or blood pressure measurements in the affected arm to prevent fluid collection or increased
pressure. The client should be taught to avoid applying cold compresses, which cause
vasoconstriction.
Concepts tested

Question 2721
A nurse is assessing a client who has end-stage kidney disease. Which findings would indicate
that the client requires hemodialysis treatment?
A A 5 lb weight gain in two days
B Neck veins are flattened
C Oxygen saturation is 93%
D Return of skin to previous position when palpated

Question Explanation
Correct Answer is A

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Rationale: Clients with end-stage kidney disease are at risk for fluid volume overload due to the
kidney’s inability to balance the body’s volume. A client with a 5 lb weight gain in two days
indicates increased fluid volume overload, which is an indication to receive hemodialysis
treatment. Flatten neck veins, oxygen saturation of 93%, and normal skin turgor indicate the
client is not experiencing fluid volume overload.
Concepts tested

Question 2722
The nurse is caring for a client who had plasmapheresis. Which manifestation reported by the
client would indicate a complication of the treatment?
A Vomiting
B Back pain
C Dizziness
D Malaise

Question Explanation
Correct Answer is C
Rationale: Plasmapheresis is the removal of plasma-containing components that can cause
disease, such as autoimmune disorders. The complications of plasmapheresis are hypotension
from a fluid shift and citrate toxicity. Citrate, which is an anticoagulant, can cause hypocalcemia,
resulting in a headache, dizziness, and paresthesia. Back pain is a manifestation of hemolytic
blood transfusion. Malaise and vomiting are manifestations of infection.
Concepts tested

Question 2723
A nurse is caring for a client who has had staples removed from an abdominal wound. The nurse
notes separation of the wound edges with copious light-brown serous drainage. Which action
should the nurse take first?
A Obtain the client’s vital signs
B Assess the client’s pain level
C Obtain a culture of the wound drainage
D Cover the wound with a moist sterile gauze dressing

Question Explanation
Correct Answer is D
Rationale: The client is experiencing dehiscence of the wound, which is when the wound opens
up. The nurse should first cover the wound with a moist sterile gauze dressing to protect the
wound. The nurse would then assess the client’s pain, check vital signs, and obtain a culture of
the wound drainage.
Concepts tested

Question 2725
The nurse is collecting the health history of a client who is scheduled for surgery. Which
statement by the client would be a priority for the nurse to follow up?
A “I got very nauseous the last time I had surgery.”

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B “My father had an infection after surgery.”
C “I am concerned about the pain after the surgery.”
D “My mother had a reaction during a surgery.”

Question Explanation
Correct Answer is D
Rationale: When collecting the health history from a client who is scheduled for surgery, the
nurse will assess the client’s previous experiences and family history related to surgical
procedures. Nausea and pain are expected effects of surgery that the nurse will educate the client
about but is not the priority. A parent that had an infection after surgery is important to document
but not the priority. Malignant hyperthermia, which is an adverse reaction to anesthesia, can be
genetic and would be the priority for the nurse to follow up.
Concepts tested

PHYSIOLOGICAL
ADAPTATIONS
Question 2726
The nurse is assessing a client who has recently been diagnosed with diabetes type II. Which of
the following questions by the nurse is appropriate to determine how the client is adapting to
their new diagnosis?
A “Do you feel like your blood glucose is high today?”
B “Do carbohydrate restrictions change how you feel about food?”
C “Did someone come in to test your blood glucose earlier?”
D “When do you plan to make your follow-up appointment?”

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Question Explanation
Correct Answer is B
Rationale: In order to assess the client’s adaptation, the nurse should ask questions about
feelings, behavioral changes, or the effect that the illness will have on the client’s life. In this
case, asking if the client feels differently about food due to the dietary restrictions allows the
client to discuss their feelings related to this lifestyle change. All other responses do not assess
adaptation.
Concepts tested

Question 2727
The nurse is caring for a client who is 16 weeks pregnant. During the assessment, the client
reports blurred vision and epigastric pain. The nurse should identify these as clinical
manifestations of which gestational complication?
A Placenta previa
B Hypoglycemia
C Hypertension
D Placental abruption

Question Explanation
Correct Answer is C
Rationale: Blurred vision and epigastric pain are indicative of gestational hypertension. The
nurse should further assess the client’s vital signs and accompanying symptoms. Placenta previa
is a condition in which the placenta blocks the cervix during labor. Placental abruption is a
serious complication that occurs due to premature separation of the placenta. Placenta previa and
placental abruption are characterized by vaginal bleeding. Hypoglycemia is not characterized by
the given symptoms. Hypoglycemia results in weakness, lightheadedness, and irritability.
Concepts tested

Question 2728
A nurse is developing a teaching plan for a 60-year-old client with chronic obstructive
pulmonary disease (COPD). The teaching will include ways to reduce the frequency of
exacerbations. Which of the following will the nurse include in the instructions?
A Obtain the pneumococcal polysaccharide 23 vaccine
B Use the prescribed long-acting beta-agonist whenever there is shortness of breath
C Decrease the amount of fluids consumed
D Engage in outdoor activities in the spring and fall when it is not as hot outside

Question Explanation
Correct Answer is A
Rationale: An exacerbation of COPD is defined as an event in the course of the disease
characterized by worsening in the patient’s respiratory symptoms beyond the normal day-to-day
variations. An exacerbation also leads to a change in medication. Primary causes of an acute
exacerbation include tracheobronchial infection and air pollution, including pollen. Clients with
COPD experience thickened mucus and therefore should maintain fluid intake. Studies have
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demonstrated that vaccination against influenza and pneumonia decreases the risk for
exacerbation in patients with COPD. The Centers for Disease Control (CDC) recommends
pneumococcal polysaccharide 23 (PPSV23) for all adults 65 years or older, people 2 through 64
years old with certain medical conditions, and adults 19 through 64 years old who smoke
cigarettes. Long-acting bronchodilator treatment is the cornerstone for the treatment of stable
COPD, and it significantly decreases the risk for exacerbations but is not used for rescue therapy.
Concepts tested

Question 2729
The nurse is caring for a client experiencing diarrhea after radiation therapy. Which of the
following would the nurse include in a teaching plan to help the client manage this side effect?
A “Try to avoid food and drinks that are high in sodium and potassium.”
B “Eat three large meals each day.”
C “Increase the amount of clear liquids consumed each day.”
D "Look for foods that are high in fiber.”

Question Explanation
Correct Answer is C
Rationale: Severe diarrhea can cause fluid and electrolyte imbalances, so clients should increase
fluid intake and look for sources of sodium and potassium as these electrolytes are lost from the
gastrointestinal tract. Often clients will have nausea or decreased appetite when experiencing
diarrhea; therefore, it is best to encourage frequent small meals. Foods that are high in fiber can
make diarrhea worse. The nurse should recommend low-fiber foods, such as bananas, white rice,
or white toast when the client is experiencing diarrhea.
Concepts tested

Question 2730
The nurse is reviewing prescriptions for a client who has a stage 4 pressure injury and is
receiving negative pressure wound therapy (NPWT). Which prescription from the healthcare
provider should the nurse question?
A Perform foam dressing changes every 72 hours
B Administer cefazolin, 1 gram every 6 hours, for a positive wound culture and sensitivity
(C&S)
C Administer enoxaparin, 40mg subcutaneously daily, for venous thromboembolism (VTE)
prophylaxis
D Perform dressing and tubing changes every 24 hours

Question Explanation
Correct Answer is C
Rationale: Anticoagulation therapy is used cautiously in clients with negative pressure wound
therapy as it places the clients at a higher risk for complications of bleeding. The nurse should
follow up with the primary healthcare provider regarding this prescription. The other
prescriptions are standard care and correct for the client.
Concepts tested

Question 2731
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The charge nurse is observing a newly hired nurse perform a wet-to-dry dressing change for a
client’s wound. Which of the following actions by the newly hired nurse requires intervention?
A Squeezing excess moisture out of the gauze prior to packing the wound
B Applying a secondary absorbent dressing over the primary dressing
C Packing the wound tightly to apply pressure against the wound-bed Correct Answer
D Avoiding covering the wound edges with moist gauze

Question Explanation
Correct Answer is C
Rationale: The charge nurse should intervene if the newly hired nurse is observed packing the
wound tightly with gauze. Packing the wound tightly increases pressure on the wound leading to
wound damage. Wounds should be packed gently and loosely to fill the wound. It is the correct
technique to squeeze out excess moisture from the gauze prior to packing the wound. The gauze
should be moist, not dripping wet, to allow the gauze to absorb drainage. A secondary absorbent
dressing should be applied over the primary dressing to absorb excess drainage, promote a more
secure dressing, and better protect the wound. It is the correct technique to avoid covering the
wound edges with moist gauze as this prevents further skin breakdown on otherwise healthy
tissue.
Concepts tested

Question 2732
The nurse is caring for a client who experienced an atonic seizure while in bed. Which action
should the nurse take?
A Reorient the client
B Administer prescribed phenytoin
C Request a CT scan of the head
D Turn the client on their side

Question Explanation
Correct Answer is A
Rationale: An atonic seizure is characterized by loss of muscle tone and a period of confusion
after the seizure occurs. The nurse should reorient the client after the seizure. Administering
phenytoin is indicated for status epilepticus or for the prevention of seizures. This does not
address the effects experienced after the seizure. The client’s seizure occurred while in bed.
Requesting a CT scan of the head to assess for injuries is not indicated. Turning the client on
their side will prevent aspiration. However, an atonic seizure is not characterized by vomiting or
salivation.
Concepts tested

Question 2733
The nurse is caring for a client with increased intracranial pressure who is mechanically
ventilated. Which of the following actions by the nurse is appropriate?
A Hyperventilating the client with 100% oxygen prior to suctioning
B Educating the client to cough to clear respiratory secretions

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C Assessing oxygen saturation every 6 hours
D Increasing the positive end-expiratory pressure

Question Explanation
Correct Answer is A
Rationale: Suctioning can increase intracranial pressure (ICP) but hyperoxygenation prior to
suctioning reduces the increase in pressure. Coughing should be avoided, and positive end-
expiratory pressure (PEEP) should be as low as possible to avoid increasing the ICP further.
Oxygen saturation should be monitored continuously rather than every 6 hours.
Concepts tested

Question 2734
A nurse is caring for an older adult client following knee surgery who received a spinal
anesthetic. What assessment finding requires immediate intervention?
A Pulse oximetry fluctuates between 98% and 96%
B Client reports knee pain increasing from 3/10 to 5/10
C Current blood pressure 100/52 compared to 130/65 in recovery
D Temperature changed from 99.0°F (37.2°C) to 99.4°F (37.5°C)

Question Explanation
Correct Answer is C
Rationale: A drop in systolic blood pressure after surgery and recovery from anesthesia is a sign
of possible hemorrhage. Low-grade fever and moderate pain are expected findings in the
inflammatory stage of wound healing. Pulse oximetry fluctuations that remain in the expected
range are unremarkable.
Concepts tested

Question 2735
The nurse is monitoring a client who is receiving external beam radiation therapy to the upper
chest. The nurse notes the area of radiation has redness and skin breakdown. Which action
should the nurse take?
A Apply lotion to the red areas
B Cover with an occlusive dressing
C Wash the area daily with warm water
D Draw a circle around the area to monitor for changes

Question Explanation
Correct Answer is C
Rationale: Clients who are receiving external beam radiation are at increased risk for skin
breakdown. To prevent complications, the nurse should wash the area daily with warm water.
Lotions should be avoided to prevent irritation or infection. Occlusive dressings can increase the

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risk of moisture causing further breakdown or infection. Marking the area to monitor for changes
is not appropriate as the area will have markings for the radiation beam.
Concepts tested

Question 2736
The charge nurse is observing a newly hired nurse who is caring for a client with
hypomagnesemia and is receiving an intravenous magnesium sulfate infusion. Which of the
following actions by the newly hired nurse requires intervention?
A Requesting to discontinue the client’s prescribed furosemide
B Assessing the client’s deep tendon reflexes every 4 hours
C Requesting a prescription for a stool softener
D Initiating continuous cardiac monitoring

Question Explanation
Correct Answer is B
Rationale: Clients with hypomagnesemia who are receiving intravenous magnesium sulfate
should have deep tendon reflexes monitored hourly to monitor effectiveness and prevent
hypermagnesemia. Clients with hypomagnesemia should be started on continuous cardiac
monitoring to assess for dysrhythmias, have stool softeners ordered due to decreased
gastrointestinal peristalsis, and have high-ceiling diuretics discontinued to prevent further
magnesium losses. These actions all indicate correct management of a client with
hypomagnesemia.
Concepts tested

Question 2737
The nurse is caring for a client who suddenly develops a wide QRS complex. The client's blood
pressure is 82/40 mm Hg and respiratory rate is 22. The client is unarousable, and the nurse
cannot palpate a pulse. Which action would be most appropriate for the nurse to take?
A Administer a prescribed intravenous IV fluid bolus
B Prepare the client for synchronized cardioversion
C Prepare to defibrillate the client
D Administer prescribed metoprolol

Question Explanation
Correct Answer is C
Rationale: The client is experiencing ventricular tachycardia, which is a lethal rhythm. The nurse
should prepare to defibrillate the client. Synchronized cardioversion is indicated for tachycardic
dysrhythmias but will not convert vTach. Metoprolol is a beta-blocker that has anti-dysrhythmic
effects, but for vTach, defibrillation is the priority action.
Concepts tested

Question 2738
The nurse is caring for a client with an arterial line for blood pressure monitoring and frequent
blood gases. To obtain accurate readings, which of the following actions should be taken?
A Level the transducer to the phlebostatic axis

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B Raise the limb with the site of arterial catheter access to the level of the heart
C Turn the stopcock off to the transducer and “zero” it to calibrate the equipment
D Turn the stopcock off to the transducer and perform the square wave test

Question Explanation
Correct Answer is A
Rationale: Arterial line transducers are leveled and calibrated to the phlebostatic axis, which
locates the right atrium. Moving the limb will result in unreliable readings. The stopcock should
be positioned off towards the client for calibrating the equipment to atmospheric pressure. A
square wave test of the transducer system is performed by fast flushing the tubing for 1-2
seconds. A normal (optimally damped) waveform will be a perfect square with 1–2 oscillations.
The stopcock will be closed to the atmosphere for this test.
Concepts tested

Question 2739
The nurse is caring for a client receiving continuous renal replacement therapy (CRRT) for acute
kidney injury of prerenal origin. Which of the following findings indicates that the CRRT is
having the intended effect?
A Serum concentrations of urea are reduced
B Urine output is increased
C Neurological status is improved
D Blood pressure is increased

Question Explanation
Correct Answer is A
Rationale: Prerenal acute kidney injury results from poor perfusion to the kidney. The aim of
CRRT is to gently remove waste and fluid while reducing the burden on the kidney to aid in
recovery. Therefore, BUN/Cr and potassium levels should all decrease after the initiation of
CRRT. While urine output may increase due to a recovery in kidney function, it is not the result
of CRRT. Blood pressure stability is typically the result of vasoactive medication or treatment of
sepsis in clients with prerenal acute kidney injury.
Concepts tested

Question 2740
The nurse is taking care of a client with a viral infection who has an absolute neutrophil count of
900/mm³. Which action will the nurse perform to ensure a protective environment?
A Place the client in a negative pressure room
B Restrict fresh vegetables from the client’s diet order
C Apply an N-95 mask prior to performing client care
D Prohibit the client from receiving visitors

Question Explanation
Correct Answer is B
Rationale: An absolute neutrophil count (ANC) below 1,000/mm³ places the client at significant
risk for infection. Clients with low ANC counts should be placed on neutropenic precautions and

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provided with a protective environment. Fresh vegetables can contain bacteria and should be
avoided in clients who are immunocompromised. Placing the client in a negative pressure room
is not necessary. Negative pressure rooms are used for airborne precautions. An N-95 mask is
not required for neutropenic precautions. N-95 masks are used for airborne precautions. The
client’s visitors should be restricted, not prohibited. Visitors with an active infection should not
be allowed to visit with the client.
Concepts tested

Question 2741
The nurse is preparing to perform a prescribed gastric lavage on a conscious client. How will the
nurse position the client to facilitate the procedure?
A Trendelenburg
B Supine
C High-Fowler’s
D Prone

Question Explanation
Correct Answer is C
Rationale: A gastric lavage includes introducing fluid into the stomach via a nasogastric tube.
Clients should be positioned sitting up (high-Fowler’s) to avoid aspiration of fluid. Placing the
client in a Trendelenburg position, with the head of the bed lower than the foot of the bed,
increases the risk of aspiration. A supine (flat back) and a prone (face down) position increase
the risk of aspiration and do not promote gastric emptying.
Concepts tested

Question 2742
The nurse is monitoring a client with new onset of atrial fibrillation with rapid ventricular
response who is receiving prescribed IV diltiazem. Which finding observed by the nurse would
indicate the treatment is effective?
A The ventricular heart rate is now 110
B The prothrombin time (PTT) is 50
C The client reports improved breathing
D The blood pressure is now 150/62

Question Explanation
Correct Answer is A
Rationale: Treatment for atrial fibrillation is to terminate the rhythm or to control ventricular
rate. This is a priority because it directly affects the cardiac output. Rapid ventricular response
reduces the time for ventricular filling, resulting in a smaller stroke volume. Control of rhythm is
the initial treatment followed by anticoagulation. As the HR slows, the client will likely report
improved rhythm. Diltiazem is a calcium channel blocker and is also used to reduce blood
pressure. This would be a secondary effect and not the intended effect.
Concepts tested

Question 2743

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The charge nurse is observing a newly hired nurse instruct a client who requires endotracheal
intubation for status asthmaticus. Which of the following statements by the newly hired nurse
requires intervention?
A “You will not be able to communicate once the tube is in place.”
B “The mechanical ventilator may alarm, which does not always indicate a problem is
occurring.”
C “The tube will assist with your work of breathing and improve gas exchange.”
D “You will be administered medications to maintain comfort and reduce anxiety as needed.”

Question Explanation
Correct Answer is A
Rationale: Clients who are undergoing endotracheal intubation should be instructed, if possible,
about what to expect during and after the procedure. Clients should be taught that their ability to
talk will be eliminated, however, alternative forms of communication, such as a whiteboard or
pen and paper will be provided to ensure client needs are met. Clients should be educated that
ventilator sounds may occur and reassured that each sound does not always indicate a problem,
which can cause anxiety in clients. Clients should be educated on the purpose of the tube
insertion, which is to reduce the work of breathing and improve gas exchange. Clients should be
assured that their comfort will be managed with medications, such as anxiolytics, as needed.
Concepts tested

Question 2744
The nurse is evaluating a client after initiation of a warm bath to the hands due to frostbite.
Which client response indicates the treatment is effective?
A Erythema is noted to bilateral hands
B Client reports increasing pain to bilateral hands.
C Client’s oral temperature is 37°C (98.6°F)
D Bilateral radial pulses are +1

Question Explanation
Correct Answer is B
Rationale: Frostbite of the extremities leads to numbness and paresthesia. When the tissues
rewarm and thaw, the client will experience burning pain to the extremities, signaling improved
circulation. Erythema is due to vasodilation and is an expected finding for superficial frostbite.
Rewarming results in white or yellow skin tone. The client’s oral temperature is a normal
finding; however, this does not directly evaluate the effectiveness of therapy to the extremities.
Bilateral radial pulses of +1 do not indicate effective treatment. The normal pulse strength is +2.
Concepts tested

Question 2745
The nurse is caring for a client who was admitted for rib fractures and a hemothorax from a
motor vehicle collision. The client currently has an epidural catheter in place and is receiving
continuous epidural analgesia with morphine. Which of the following findings indicates an
adverse response to the client’s therapy?
A Bleeding from IV sites, mottled skin, confusion, and fever

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B Apprehension, anxiety, restlessness, and shortness of breath
C Frequent urination, salivation, excessive tearing, and diaphoresis
D Urinary retention, excessive somnolence, itching, and nausea

Question Explanation
Correct Answer is D
Rationale: Epidural analgesia is given by clinician-given bolus, continuous infusion (basal rate),
and patient-controlled epidural analgesia (PCEA). The most common opioids given intraspinally
are morphine, fentanyl, and hydromorphone. The most common adverse effects of opioids are
constipation, nausea, vomiting, pruritus, hypotension, and sedation. Respiratory depression,
while less common, is the most serious and feared of the opioid adverse effects. Urinary
retention is a complication of epidural analgesia. The other options are concerning but none
reflect adverse reactions to the epidural administration of morphine.

Question 2746
The nurse is caring for a client who has a new colostomy. Which question by the nurse is
appropriate to assess the client’s adaptation to this new change?
A “Can I listen to your bowel sounds?”
B “When was the last time that your colostomy bag was emptied?”
C “Are you experiencing pain at the ostomy site?”
D “Do you feel comfortable completing your own ostomy care?”

Question Explanation
Correct Answer is D
Rationale: In order to assess the client’s adaptation, the nurse should ask questions about
feelings, behavioral changes, or the effect that the illness will have on the client’s life. In this
case, asking if the client feels comfortable with the ostomy care allows the client to discuss their
feelings and express concerns. Asking about pain, the time when the colostomy was emptied,
and listening to bowel sounds assesses the function of the colostomy but not if the client is
adapting to the change.
Concepts tested

Question 2747
The nurse is assessing a client who is 29 weeks pregnant. During the assessment, the client
states, “My baby finally stopped kicking so much throughout the day.” What is an appropriate
nursing response to this statement?
A “How strong are the baby’s kicks?”
B “It must be a relief to not feel pain from so much kicking.”
C “Tell me what else has improved besides the kicking.”
D “When did you notice a decrease in the kicking?”

Question Explanation
Correct Answer is D
Rationale: A decrease in fetal movement may indicate fetal distress. The nurse should ask
follow-up questions to determine the timeline of the possible complication. Asking how strong

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the fetal movements are does not address the decrease in fetal movement. Reassuring the client
that the decrease in fetal movement is a relief is not an appropriate statement. Decreased fetal
movement is not a sign of improvement during the third trimester of pregnancy.
Concepts tested

Question 2748
A nurse is counseling a client on hemodialysis who has chronic constipation about ways to
promote normal bowel function. What should be included in client teaching?
A "Glycerin suppositories are safe and can be used on a regular basis."
B "Magnesium hydroxide can be used for occasional relief from constipation."
C "Use bulk-forming fiber powder to increase regularity."
D "Increase your fluid intake to promote softer stools."

Question Explanation
Correct Answer is C
Rationale: Ensure proper dietary habits, such as eating high-residue and high-fiber foods (e.g.,
fruits, vegetables), adding bran daily (must be introduced gradually), and increasing fluid intake
(unless contraindicated) to help prevent constipation. Avoid overuse or long-term use of
laxatives. Daily dietary intake of 25 to 30 g/day of fiber (soluble and bulk-forming) is
recommended, especially for the treatment of constipation. If laxative use is necessary, one of
the following may be prescribed: bulk-forming agents (fiber laxatives), saline and osmotic
agents, lubricants, stimulants, or fecal softeners. Magnesium is contraindicated in patients with
renal insufficiency.
Concepts tested

Question 2749
A nurse is caring for a client with a traumatic brain injury who has a tympanic temperature of
104°F. Which action would be most appropriate for the nurse to take?
A Administer prescribed acetaminophen
B Apply a cooling blanket
C Place ice packs in the axilla area
D Adjust the environmental temperature

Question Explanation
Correct Answer is A
Rationale: Antipyretics (acetaminophen, aspirin, non-steroidal anti-inflammatory agent) are
given to reset the hypothalamus thermoregulatory mechanism or thermostat for temperatures
greater than 38.5°C. The use of cooling blankets and ice packs are used when antipyretics are not
effective. Caution is used with cooling devices, which can cause shivering and increase
intercranial pressure. Adjusting the environmental temperature will not impact the client’s core
temperature.
Concepts tested

Question 2750
The nurse is caring for a group of assigned clients with closed-chest drainage systems in place.
Which of the following clients should the nurse assess first?
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A The client who has continuous bubbling in the water seal chamber and respirations of 36
B The client who had a chest tube placed 1 hour ago and is reporting moderate pain at the
insertion site
C The client who has tidaling in the water seal chamber and small amounts of crepitus around
the insertion site
D The client who had a thoracotomy 1 day ago and has a chest tube output of 100 mL in the past
2 hours

Question Explanation
Correct Answer is A
Rationale: Continuous bubbling in the water seal chamber indicates an air leak which places the
client at risk for developing a tension pneumothorax. In addition, the client in the key is
tachypneic and should be assessed immediately for airway compromise. It is normal to
experience pain or crepitus at the insertion site and have an output of 100 mL in the past 2 hours.
Concepts tested

Question 2751
The charge nurse is observing a newly hired nurse perform a sterile dressing change. Which of
the following actions by the newly hired nurse requires intervention?
A Opening the dressing supplies and dropping them into the center of the sterile field
B Reaching across the sterile package to open the outer flap
C Using clean gloves to remove the old dressing
D Cleansing the wound from the center toward the edges

Question Explanation
Correct Answer is B
Rationale: The charge nurse should intervene if the newly hired nurse is observed reaching
across the sterile package to open the outer flap. To maintain a sterile field, the outer flap of the
sterile package should be opened by reaching around the package and opening the flap away
from the nurse. It is the correct sterile technique to drop the dressing supplies into the center of
the sterile field, use clean gloves to remove the old dressing, and cleanse the wound from the
center outwards (cleanest to dirtiest).
Concepts tested

Question 2752
The nurse is assessing a client diagnosed with salmonella. The client reports dizziness and dry
mouth for over 48 hours. Which intervention should the nurse implement?
A Provide disposable oral swabs
B Educate on proper hand washing
C Infuse intravenous fluids
D Administer an enema

Question Explanation
Correct Answer is C

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Rationale: Salmonella is a food-borne illness that is transmitted via contaminated food or
animals. Symptoms associated with salmonella include diarrhea, fever, and stomach cramps.
Prolonged diarrhea can lead to dehydration and cause dizziness and dry mouth. The nurse should
expect to administer intravenous (IV) fluids to rehydrate the client. Oral swabs will improve the
client’s dry mouth but will not correct the issue of dehydration. Salmonella can be prevented by
washing hands with soap and water. However, this will not correct the client’s problem.
Administering an enema will worsen the client’s dehydration.
Concepts tested

Question 2753
The nurse is caring for a client who has increased intracranial pressure. Which of the following
medications should the nurse question?
A Propofol 20 mcg/kg/min
B Dobutamine 10 mcg/kg/min
C 0.5% sodium chloride at 125 mL/hour
D Mannitol 135 grams over 60 minutes

Question Explanation
Correct Answer is C
Rationale: The client should question 0.5% sodium chloride, as this would increase fluid volume
and ultimately increase intracranial pressure. Propofol can be used for sedation for the client with
increased ICP, dobutamine is used to improve cardiac output, and mannitol is used to decrease
extracellular fluid volume.
Concepts tested

Question 2754
The nurse is monitoring a client who had a surgical debridement of a pressure injury wound.
Which finding observed by the nurse would indicate the wound is healing by secondary
intention?
A Closed with staples immediately following surgery with the absence of erythema and drainage
B Open with a small amount of yellow slough and a moderate amount of white exudate
C Edges are not approximated, and there is granulation tissue in the wound bed with a scant
amount of serous drainage and no odor
D Closed a week after surgery using sutures with a small amount of erythema and no drainage
present

Question Explanation
Correct Answer is C
Rationale: Closure of a “clean wound” is typically done by primary closure. The wound is
usually closed using sterile techniques with sutures, staples, or synthetic adhesive closure
materials. Secondary intention happens when a wound has a large amount of lost tissue, and the
edges cannot be brought together, such as is the case with a pressure injury. Therefore, healing
must occur from the bottom of the wound upwards. The wound healing process for secondary
intention results in longer repair and healing time, more scarring, and an increased chance of
infection. A tertiary intention, also called delayed or secondary closure, occurs when there is a
need to delay closing a wound, such as when there is poor circulation in the wound area or
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infection. An example would be an abdominal wound that is kept open to allow drainage and
then later closed.
Concepts tested

Question 2755
A nurse is assessing a client who has a calcium level of 8.0 mg/dL. Which finding should the
nurse expect to observe?
A Depressed reflexes
B Polyuria
C Muscle tremors
D Nausea

Question Explanation
Correct Answer is C
Rationale: Hypocalcemia, Ca <9.0 mg/dL, decreases the threshold for activating the sodium
channels, which is required for muscle contraction. This causes nerve excitability and sustained
muscle contraction resulting in muscle tremors. A client with hypercalcemia will experience
depressed reflexes, nausea, and polyuria.
Concepts tested

Question 2756
The nurse is caring for a client who is receiving a 3% hypertonic saline infusion for a serum
sodium level of 120 mEq/L. Which of the following client findings indicates the treatment has
been effective?
A A change in deep tendon reflexes from hyperactive to diminished
B A change in Glasgow Coma Score from 8 to 11
C A change in respirations from 22 to 10
D A change in bowel sounds from hypoactive to hyperactive

Question Explanation
Correct Answer is B
Rationale: Severe hyponatremia can cause changes in the level of consciousness. An increase in
the Glasgow Coma Score from 8 to 11 indicates improvement in the level of consciousness, and
therefore, the effectiveness of treatment of hyponatremia with hypertonic saline. Diminished
deep tendon reflexes, hyperactive bowel sounds, and bradypnea are all symptoms of severe
hyponatremia and do not indicate treatment has been effective.
Concepts tested

Question 2757
The nurse is caring for a client who is postoperative two hours coronary artery bypass graft. The
nurse notes that the client's central venous pressure (CVP) monitoring is 14 mm Hg. Which of
the following actions should the nurse take?
A Auscultate lung sounds
B Check the chest tubes for blockage
C Increase prescribed IV fluids

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D Administer prescribed dopamine

Question Explanation
Correct Answer is A
Rationale: CVP, which has a normal reading of 4-12 mmHg, measures preload in the right side
of the heart. An elevated CVP can indicate fluid volume overload. A client with a CVP of 14
mmHg should be assessed for signs of increased volume and heart failure, including auscultating
lung sounds. A decrease in CVP could indicate bleeding, which would require the nurse to
administer IV fluids, check tubes, and administer vasopressors.
Concepts tested

Question 2758
The nurse is caring for an adult client with septic shock who has a right radial arterial line. The
nurse recognizes an overdamped waveform on the monitor. Which of the following is the likely
cause?
A The pressure on the flush bag is at 300 mmHg.
B The pressure tubing is kinked under the client.
C The client has a 10-point drop in systolic blood pressure.
D The transducer is improperly leveled.

Question Explanation
Correct Answer is B
Rationale: Arterial pressure monitors provide continuous information on a patient's
hemodynamics. This information is invaluable to assist in timely clinical decision-making and
intervention. If the system is overdamped, there will be a falsely low systolic pressure, but the
diastolic pressure is usually accurate. A system that is not optimally damped will be apparent in
waveform analysis. An overdamped trace will show less than 1 1/2 oscillations below the
baseline with an unclear dicrotic notch. Overdamping can be due to a clot or buildup of fibrin in
the catheter tip, loose connections, air in the system, or kinks in the pressure tubing. The pressure
on the flush bag should be set to 300 mmHg. If there is fluid loss or air entry, a damped
waveform could occur. Transducer leveling is essential for accurate readings but does not affect
damping.
Concepts tested

Question 2759
The nurse is admitting a client with a history of end-stage renal disease who was found
unresponsive at home. The client has a history of chronic hemodialysis. The EKG is displaying
bradycardia and peaked t-waves. Which of the following immediate interventions should be
anticipated?
A 50% dextrose and regular insulin administered intravenously
B Insertion of central venous line
C Oral administration of kayexalate
D Initiation of a hemodialysis treatment

Question Explanation

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Correct Answer is A
Rationale: Hyperkalemia is the most life-threatening of the fluid and electrolyte changes that
occur in patients with kidney disorders. Therefore, the patient is monitored for potassium values
greater than 5.0 mEq/L (5 mmol/L), ECG changes (tall, tented, or peaked T waves), and changes
in clinical status. If the patient is hemodynamically unstable (low blood pressure, changes in
mental status, or dysrhythmia), IV dextrose 50%, insulin, and calcium replacement may be given
to shift potassium back into the cells. The shift of potassium into the intracellular space is
temporary, so arrangements for dialysis will then need to be made.
Concepts tested

Question 2760
The nurse is educating a client with a deep vein thrombosis to the right lower extremity about
preventing complications. What should the nurse include in the teaching?
A “Maintain bedrest throughout your therapy.”
B “Massage your right leg if you are feeling pain.”
C “Wear thigh-high compression stockings while in bed.”
D “Apply ice packs to the extremity as needed.”

Question Explanation
Correct Answer is C
Rationale: Deep vein thrombosis (DVT) is a blood clot that impairs circulation. Thigh-high
compression stockings improve circulation and help pump blood back to the heart. Prolonged
bed rest increases the risk of further clot formation. Clients should be encouraged to ambulate
after initiation of anticoagulant therapy. Extremities with a DVT should never be massaged.
Massaging the extremity can dislodge the blood clot and travel to smaller vessels throughout the
body. Ice will constrict blood vessels and further impair circulation. Warm, moist compresses are
recommended.
Concepts tested

Question 2761
The nurse is preparing to perform a prescribed closed system gastric lavage. Which action should
the nurse take before starting the procedure?
A Obtain a 50-ml catheter tip syringe
B Apply sterile gloves to both hands
C Attach a Y-connecter to the nasogastric tube
D Set the regulator to 20 mmHg intermittent suction

Question Explanation
Correct Answer is C
Rationale: A Y-connector is necessary for a closed system gastric lavage. One port is used to
infuse the irrigating solution while the other port is used to suction out stomach contents. A
catheter tip syringe is necessary for an intermittent open system. Sterile gloves are not necessary
for the procedure. Clean technique may be used. The suction canister should be set to continuous
suction and regulated by the nurse by turning it off or clamping when appropriate.
Concepts tested

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Question 2762
A nurse is caring for a client who has a pleural chest tube in place to a closed chest drainage
system. When assessing the water seal, which of the following findings indicate that the client's
lung has re-expanded?
A Continuous bubbling
B Fluctuation during respiration
C Absence of fluctuation or bubbling
D Intermittent bubbling

Question Explanation
Correct Answer is C

Question 2763
The nurse is caring for a client who had a transurethral resection of the prostate (TURP) 1 day
ago and has continuous bladder irrigation infusing. Which of the following findings requires the
nurse to notify the primary health care provider?
A Pink-tinged urine in the urinary drainage bag
B Client report of dizziness and nausea
C Small amounts of blood clots in the client’s drainage bag
D Client report of occasional bladder spasms

Question Explanation
Correct Answer is B
Rationale: Clients who are receiving continuous bladder irrigation following a TURP are at risk
for developing the rare, but potentially life-threatening, complication of TURP syndrome. This
occurs when irrigation fluid is over-absorbed into the body and stress is placed on the heart.
Signs of TURP syndrome include headache, nausea, confusion, shortness of breath, dizziness,
hypertension, and bradycardia. The physician should be notified about these client findings
immediately. Clients may experience occasional bladder spasms, and these are not a concerning
finding, however, severe spasms should be reported as this could indicate catheter obstruction.
The nurse should adjust the flow of the continuous bladder irrigation to maintain clear urine
output and remove clots. The nurse should adjust the flow with these findings; however, the
physician does not need to be notified.
Concepts tested

Question 2764
The nurse is reassessing a client after resuscitative efforts. Which finding indicates the disability
component of the ABCDE approach is intact?
A Client has a GCS score of 15
B Lung sounds are clear bilaterally
C Capillary refill is 2 seconds
D Client is responsive to pain

Question Explanation

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Rationale: The ABCDE approach is a rapid assessment of emergency conditions. The disability
component represents the “D” in ABCDE. Disability determines the client’s level of
consciousness. The Glasgow Coma Scale (GCS) is based on eye-opening, verbal, and motor
responses. The normal finding is a score of 15. Clear lung sounds evaluate breathing, the “B” in
the ABCDE approach. Capillary refill of 2 seconds is a normal finding for circulation, the “C” in
the ABCDE approach. A client who is responsive to pain does not have an intact level of
consciousness.
Concepts tested

Question 2765
The nurse is caring for a client who experienced blunt chest trauma and has been prescribed
oxygen and frequent assessments. Upon assessment, there is a new tracheal shift to the right,
absence of lung sounds on the left side, dullness on percussion of the left chest, and HR 135 and
BP 72/40. The nurse suspects the patient has developed which of the following complications?
A Cardiac tamponade
B Massive hemothorax
C Flail chest
D Pleural effusion

Question Explanation
Correct Answer is B
Rationale: The client is likely experiencing a hemothorax. Tracheal deviation to the right, away
from the side where the lung sounds are absent, indicates that something is filling the space (i.e.
blood). The lack of breath sounds does not help distinguish between hemothorax and
pneumothorax as both would result in absent breath sounds. Dullness on percussion indicates
fluid in the space. Pleural effusions, which is a collection of fluid in the pleural space, result in
muffled breath sounds. Flail chest occurs when sections of ribs are fractured, which causes a
paradoxical chest movement.
Concepts tested

Question 2766
The nurse is caring for a client who has recently been admitted to a skilled nursing facility.
Which question by the nurse is appropriate to assess how the client is adapting to their new
environment?
A “Has your family come to visit you?”
B “Do you think you’ll be discharged soon?”
C “How do you feel about staying here?”
D “Are the nursing staff members treating you well?”

Question Explanation
Correct Answer is C
Rationale: In order to assess the client’s adaptation, the nurse should ask questions about
feelings, behavioral changes, or the effect that the illness will have on the client’s life. In this
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case, asking how the client feels about their admission to the skilled nursing facility allows the
nurse to assess how they are adapting to the new environment. Asking the client how the staff is
treating the client, when the client will be discharged, and if family has visited assesses the
environment, not how the client has adapted to the change.
Concepts tested

Question 2767
The nurse is assessing a client who is 18 weeks pregnant. The client reports mild abdominal
cramping and moderate vaginal bleeding. Further assessment by the healthcare provider reveals a
dilated cervix. The nurse suspects which complication?
A Ectopic pregnancy
B Placenta previa
C Hydatidiform mole
D Spontaneous abortion

Question Explanation
Correct Answer is D
Rationale: Mild abdominal cramping, moderate vaginal bleeding, and a dilated cervix are
characteristic signs of an inevitable abortion. A spontaneous abortion is imminent and cannot be
prevented. An ectopic pregnancy occurs when there is abnormal implantation of the fertilized
ovum outside of the uterus. A dilated cervix is not an expected finding. Placenta previa occurs
when the placenta does not attach to the fundus and implants in the lower segment of the uterus
or over the cervical is. Placenta previa is characterized by painless vaginal bleeding. A
hydatidiform mole is a benign proliferative growth of placental cells. Molar pregnancies are
characterized by severe nausea and vomiting.
Concepts tested

Question 2768
The nurse is assisting with the placement of a central venous catheter into the subclavian vein.
Which action should the nurse take?
A Place the client in Trendelenburg position and turn head away from insertion site
B Obtain full sterile drape and personal protection equipment (PPE)
C Soak sterile cotton in povidone-iodine and place in the sterile field
D Obtain a prescription for an ultrasound to confirm line placement

Question Explanation
Correct Answer is B
Rationale: A central venous catheter/line (CVC or CVL) is a large-bore central venous catheter
that is placed using a sterile technique (unless an urgent clinical scenario prevents sterile
technique placement) in certain clinical scenarios. There are three possible sites for CVL
placement in the adult patient, including the internal jugular (IJ) vein, femoral vein, and
subclavian (SC) vein. The client is placed in reverse Trendelenburg for SC and IJ insertion. The
client is supine for femoral insertion. CVC insertion bundles require that the provider wear head-
to-toe sterile PPE and that the client be maximally draped with a sterile barrier. Chlorhexidine is
the preferred antiseptic for CVC insertion due to its antibacterial efficacy. CVC insertion may be
performed with the aid of ultrasound; however, placement is confirmed with a chest radiograph.
Page | 1092
Concepts tested

Question 2769
The nurse is caring for a client who is experiencing hypothermia following submersion in cold
water. The client is unresponsive with a core body temperature of 25°C (82.5°F) and is
prescribed active rewarming. The nurse should expect to use which rewarming method for this
client?
A Cardiopulmonary bypass
B Warming blankets
C Heating lamps
D Compression heat packs

Question Explanation
Correct Answer is A
Rationale: For a client with hypothermia, rewarming methods used are active and passive
interventions. The client with severe hypothermia (less than 28°C to 32.2°C or 82.5°F to 90°F)
will require active internal rewarming techniques such as cardiopulmonary bypass, infusion of
warm IV fluids, and warmed peritoneal lavage. Clients with mild hypothermia will require
passive external rewarming techniques, such as warming blankets, heat packs, and heating
lamps.
Concepts tested

Question 2770
The nurse is assessing a client who had a closed-chest drainage system placed 6 hours ago for
treatment of a hemothorax. The nurse should notify the primary health care provider (PHCP) of
which of the following findings?
A Drainage from the chest tube has stopped
B Fluid in the water seal chamber rises with inspiration
C Bubbling of water in the water seal chamber with coughing
D Crepitus palpated in the area surrounding the insertion site

Question Explanation
Correct Answer is A
Rationale: No drainage from a chest tube in the first 24 hours after insertion requires immediate
notification to the surgeon; if drainage stops, it can lead to a tension pneumothorax. Bubbling in
the water seal chamber is normal during forceful expiration or coughing because the air in the
chest is being expelled. Crepitus around the insertion site indicates subcutaneous emphysema,
which, unless extensive and extending to the neck, is not a serious complication. Fluid in the
water seal chamber should rise with inspiration and fall with expiration, which is called tidaling.
Concepts tested

Question 2771
The nurse is caring for a client who had a below-the-knee amputation (BKA) 4 weeks ago and is
experiencing phantom limb pain. Which of the following instructions should the nurse provide to
the client?

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A “Avoid massaging your stump for the next 4 weeks.”
B “Apply cold compresses to your stump 4 times daily.”
C “Avoid any physical activity until the pain subsides.”
D “Take your prescribed antiepileptic medication even if pain is not present.”

Question Explanation
Correct Answer is D
Rationale: Clients who are experiencing phantom limb pain are often prescribed antiepileptic
medications to treat nerve pain. These medications should be taken regularly as prescribed to
ensure maximum effectiveness and are not intended to be used for breakthrough pain on an as-
needed basis. Additional interventions for clients experiencing phantom limb pain include
exercise, massage, and heat therapy.
Concepts tested

Question 2772
The nurse is assisting the healthcare provider with a chest tube removal for a client who has a
history of hepatitis B. Which priority intervention will the nurse perform post chest tube
removal?
A Apply sterile gloves before handling the chest tube
B Dispose of the chest tube in the biohazard container
C Document the client’s response to the chest tube removal
D Assess the client’s understanding of the chest tube removal

Question Explanation
Correct Answer is B
Rationale: Chest tubes contain a significant amount of blood product. Nurses should ensure
proper disposal of medical waste to prevent the transmission of infectious diseases. Sterile gloves
are not required to handle the chest tube. Clean gloves may be worn to dispose of the chest tube.
Documenting the client’s response is an important intervention. However, the nurse should
ensure infection control prior to documenting the findings. Assessing the client’s understanding
of the procedure should be performed before and after removal. The nurse should first ensure
infection control before utilizing teach-back methods.
Concepts tested

Question 2773
The nurse is caring for a client with elevated intracranial pressure. Which of the following
actions is appropriate by the nurse?
A Administering osmotic diuretics
B Increasing intravenous fluids
C Placing the client in the Trendelenburg position
D Promoting the Valsalva maneuver

Question Explanation
Correct Answer is A

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Rationale: The nurse should complete interventions that reduce intracranial pressure (ICP), such
as administration of diuretics and implementing fluid restriction. The client’s head should be
placed at a 30-45 degree elevation, and extreme rotation of the neck should be avoided. The
Valsalva maneuver increases ICP and should be avoided.
Concepts tested

Question 2774
The nurse is caring for a client admitted with suspected urosepsis who has tachycardia and
hypotension. The client had a central venous catheter placed for fluid resuscitation and
monitoring of treatment effectiveness. What assessment data indicate that the treatment was
effective?
A Decreased central venous pressure (CVP), increased heart rate (HR), and elevated mean
arterial pressure (MAP)
B Elevated central venous pressure (CVP), decreased heart rate (HR), and elevated mean arterial
pressure (MAP)
C Elevated central venous pressure (CVP), decreased heart rate (HR), and normal mean arterial
pressure (MAP)
D Decreased central venous pressure (CVP), decreased heart rate (HR), and decreased mean
arterial pressure (MAP)

Question Explanation
Correct Answer is C
Rationale: Symptoms of sepsis include fever or hypothermia, tachycardia (e.g., heart rate >90
BPM), hypotension, chills/shaking, confusion, tachypnea (e.g., >20 breaths/minute), decreased
urine output, increased cardiac output, and signs and symptoms that reflect the primary site of
infection dysuria in urinary tract infections. Improved survival from septic shock has been
demonstrated when early goal-directed therapy (e.g., maintaining adequate urine output, MAP at
≥65 mm Hg, and central venous pressure [CVP] at 8–12 mm Hg) is provided. Therefore, a return
to normal CVP, normocardia, and a MAP >65 all indicate successful fluid resuscitation. Elevated
MAP is an indication of increased cardiac workload and possibly fluid volume excess. Clients
with increased HR may be demonstrating signs of inadequate fluid resuscitation or heart failure
from fluid overload.
Concepts tested

Question 2775
The nurse in the emergency department is caring for a client who is confused and disorientated.
The client’s partner states the client was working outside and was sweating profusely. Which
laboratory finding should the nurse expect to observe with this client?
A Serum potassium level of 3.5 mEq/L
B Serum magnesium level of 1.9 mg/dL
C Serum calcium level of 9.5 mg/dL
D Serum sodium level of 125 mEq/L

Question Explanation
Correct Answer is D

Page | 1095
Rationale: The laboratory results show that the client has hyponatremia. Common symptoms
associated with hyponatremia are confusion, disorientation, and poor appetite. Hyponatremia can
occur in extreme temperatures with excessive exercise or working outside. The other laboratory
findings are within normal limits, even though potassium should be closely monitored.
Concepts tested

Question 2776
The nurse is caring for a client who has received intravenous magnesium sulfate for a serum
magnesium level of 1.2 mEq/L. Which of the following client findings indicates that the
treatment has been effective?
A Prolonged QT intervals on the client’s electrocardiogram
B Hyperactive deep tendon reflexes
C Reduction in the client’s abdominal distention
D Numbness and tingling in the toes

Question Explanation
Correct Answer is C
Rationale: Hypomagnesemia can cause cardiovascular, neuromuscular, and intestinal changes in
clients. A reduction in the client’s abdominal distention indicates improvement in the client’s
condition since hypomagnesemia can cause reduced motility, constipation, and possibly paralytic
ileus. Numbness and tingling in the extremities, hyperactive deep tendon reflexes, and prolonged
QT intervals are all symptoms of hypomagnesemia, which indicates that the treatment has not
been effective.
Concepts tested

Question 2777
The emergency room nurse is caring for a client who reports palpitations. When assessing the
client's telemetry strip, the nurse notes a fast rhythm, with a narrow QRS complex, as shown in
the figure below. Which action should the nurse do first?

A Administer prescribed adenosine

B Assess the client's blood pressure and pulse oximetry
C Prepare the client for synchronized cardioversion
D Instruct the client to bear down and hold their breath

Question Explanation
Correct Answer is B

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Rationale: The rhythm in the figure is supraventricular tachycardia (SVT). When a client is
experiencing an abnormal rhythm, the first action the nurse should take is to obtain the client’s
blood pressure and pulse oximetry. Assessing the client’s blood pressure and pulse oximetry will
evaluate if the client is stable or unstable with this abnormal rhythm. Interventions for SVT
include administering prescribed adenosine, synchronized cardioversion, and instructing the
client to perform Valsalva maneuvers, but the first action is to assess the client.
Concepts tested

Question 2778
The nurse is planning discharge teaching for an adult client with a newly inserted permanent
pacemaker. The client plans to return to work in an automobile plant after the recovery period.
What teaching point should be included?
A "Reaching for objects overhead will help maintain range of motion."
B "Avoid lifting anything heavier than 5 pounds for 4 weeks."
C "Strong magnets or motors may affect the pacemaker."
D "Pacemaker insertion will have no impact on the plan to return to work."

Question Explanation
Correct Answer is C
Rationale: In workplaces that contain welding equipment or strong motor-generator systems, it is
recommended that a person with an implanted cardiac device remain at least two feet from
external electrical equipment and leave the immediate locale if lightheadedness or other
symptoms develop. The client needs to avoid lifting anything heavier than 10 pounds or reaching
for objects overhead for 4 weeks after insertion.
Concepts tested

Question 2779
The nurse is caring for a client who is septic shock. Which finding would indicate to the nurse
the client is experiencing acute organ dysfunction?
A Serum creatinine level of 1.5
B Heart rate of 110 on intravenous adrenergic agonists
C Drop in blood pressure of >40mmHg from baseline
D Serum lactate level of <4mmol/L

Question Explanation
Correct Answer is C
Rationale: Prevention of the progression of sepsis to acute organ dysfunction requires prompt
assessment and interventions. The sepsis bundle includes assessment of lactate levels, rapid fluid
resuscitation for hypotension and mean arterial pressure <65mmHg, and initiation of vasoactive
medications for MAP <65 mmHg after infusion of fluids. Persistent hypotension is an indication
of worsening sepsis and progression to organ dysfunction. Serum lactate of <4 indicates the
client’s condition is not deteriorating and is possibly improving. An exaggerated response to
vasoactive medications indicates that the client is responding to the medication.
Concepts tested

Question 2780
Page | 1097
The nurse is educating a client with metabolic syndrome about disease management. Which
client statement indicates the need for further teaching?
A “I should eat less saturated fat to keep my triglyceride levels below 150 mg/dL.”
B “I need to control my sodium intake to keep my systolic blood pressure below 130 mmHg.”
C “I will eat fewer simple carbohydrates, so my fasting blood glucose is below 100 mg/dL.”
D “I will consume more fatty fish to lower my high-density lipoprotein below 40 mg/dL.”

Question Explanation
Correct Answer is D

Question 2781
The nurse is preparing to perform prescribed gastric lavage for a client who ingested a toxic
chemical. Which action should the nurse take first?
A Take the client’s blood pressure
B Connect the client to a cardiac monitor
C Start a secondary intravenous line (IV)
D Set up suction equipment

Question Explanation
Correct Answer is D
Rationale: A gastric lavage irrigates the stomach and removes its contents. The solution is
administered via an oral or nasogastric tube and removed via suction. The nurse should ensure
suction equipment is set up properly before the procedure. Monitoring the client’s blood pressure
is important for assessing circulatory status but is not specific to gastric lavage. Connecting the
client to a cardiac monitor will ensure the client is reacting well to the procedure. However, a
gastric lavage requires suction equipment to function. Starting a secondary intravenous line is not
related to the procedure of gastric lavage.
Concepts tested

Question 2782
The nurse is placing the ventilated client with acute respiratory distress syndrome (ARDS) in
prone position. Which finding indicates that the intervention is having the intended effect?
A Peak airway pressure has increased
B Partial pressure of oxygen has increased
C V/Q ratio declines
D Oxygen saturation remains stable

Question Explanation
Correct Answer is B
Rationale: Proning has become a standard treatment in the management of patients with ARDS
who have difficulty achieving adequate oxygen saturation. Prone positioning is used to improve
V/Q mismatch (increasing the ratio) and oxygenation. Increasing PaO2 is an indication of
improved oxygenation. Proning is usually not implemented in clients with O2 saturations above
92%. Therefore, a goal of prone positioning would be improved oxygen saturation. Increasing
peak airway pressures indicate a worsening of ARDS.

Page | 1098
Concepts tested

Question 2783
The nurse is caring for a client who received fibrinolytic therapy for an acute ischemic stroke 6
hours ago. Which of the following findings requires the nurse to notify the primary health care
provider?
A Client has become drowsy and difficult to arouse
B Bilateral pupils remain 3 mm and sluggish
C Client has continued left-sided weakness
D Client’s blood pressure is 155/70 mmHg

Question Explanation
Correct Answer is A
Rationale: Clients who receive fibrinolytic therapy should be closely monitored for any change
in neurological status due to an increased risk of intracerebral hemorrhage. The first indication of
neurological compromise is the client’s level of consciousness, and the primary health care
provider should be notified immediately if the client has become drowsy and difficult to arouse.
Pupillary reflexes and weakness that have remained unchanged do not need to be reported, and
the blood pressure should be maintained at a systolic of less than 160 mm Hg.
Concepts tested

Question 2784
The nurse is monitoring a client on a high-dose dopamine infusion post-resuscitation for cardiac
arrest. Which finding indicates the client is having a positive response to treatment?
A Blood pressure of 109/64 mmHg
B Pedal pulses +1
C Urine output of 30 mL/hr
D Heart rate of 110 beats/min

Question Explanation
Correct Answer is A
Rationale: Dopamine is an adrenergic vasopressor used to increase blood pressure after cardiac
arrest. The goal of therapy is to maintain the blood pressure within normal limits. A blood
pressure of 109/64 mmHg is a positive finding for a client on dopamine. The normal pulse
strength is +2. A strength of +1 indicates a weak, thready pulse and decreased circulation.
Urinary output of 30 mL/hr is a normal finding. However, high doses of dopamine cause renal
blood vessel constriction and are not intended to treat urinary output. A heart rate of 110
beats/min is not a positive response to treatment. Although vasoconstriction increases the heart
rate, the intended goal is to maintain normal limits. The normal heart rate is 60 to 100 beats/min.
Concepts tested

Question 2785
The nurse is caring for a client recovering from a cardiac catheterization. The introducer sheath
has been removed from the right femoral artery and a pressure dressing is in place. Which of the
following findings indicates a serious complication may be occurring?

Page | 1099
A Creatinine level is increasing
B Ecchymosis is present at the insertion site
C Discomfort at the insertion site
D Extremities are warm bilaterally with trace edema

Question Explanation
Correct Answer is A
Rationale: The risk of contrast-induced kidney injury is increased in clients with underlying
moderate to severe renal disease, people with diabetes, the elderly, females, clients on diuretics,
ACEI, and metformin. Adequate pre-hydration, use of iso-osmolar agents, and techniques to
minimize the amount of dye used will help prevent this complication. Renal emboli can also
cause renal failure. Ecchymosis and discomfort at the site are expected, but the nurse should
monitor for hematomas and retroperitoneal bleeding. The nurse would monitor for signs of
neurovascular impairment in the lower extremities, especially the right leg. Warmth is an
expected finding, and trace edema is not a priority.
Concepts tested

Question 2786
The nurse is caring for a client who has recently undergone an above the knee amputation.
Which of the following questions by the nurse is appropriate to assess the client’s adaptation to
this physical change?
A “Are you currently having any pain in your leg?”
B “Have you been taking your prescribed medications?”
C “What modifications have you made to your daily activities?”
D “Do you plan to go to outpatient physical therapy?”

Question Explanation
Correct Answer is C
Rationale: In order to assess the client’s adaptation, the nurse should ask questions about
feelings, behavioral changes, or the effect that the condition will have on the client’s life. In this
case, asking about modifications to daily activities allows the nurse to assess how they are
adapting to this drastic physical change. Asking if the client has any pain, taking prescribed
medications, and participating in physical therapy assesses the client’s management of the
amputation but does not assess adaption.
Concepts tested

Question 2787
A correctional facility nurse is assessing a 67-year-old client who presents with anorexia, weight
loss, and purulent, blood-tinged sputum. The nurse recognizes these symptoms are indicative of
which disease process?
A Tuberculosis
B Pneumonia
C Influenza
D Sinusitis

Page | 1100
Question Explanation
Correct Answer is A
Rationale: Tuberculosis is an infectious disease that affects the respiratory system. Risk factors
for tuberculosis include poorly ventilated and crowded environments, such as correctional
facilities. Expected findings include blood-tinged, purulent sputum, weight loss, anorexia, and
night sweats. Pneumonia is an inflammatory process that leads to excess fluid in the lungs. The
symptoms displayed in the scenario are not indicative of pneumonia. Influenza is a viral
infection that affects the respiratory system. Blood-tinged sputum is not an expected finding.
Sinusitis is an inflammation of the mucous membranes in the nasal airway. Anorexia and weight
loss are not associated with sinusitis.
Concepts tested

Question 2788
The nurse is assisting with endotracheal intubation for a client with respiratory failure. Which of
the following findings provides the best confirmation of tube placement?
A Presence of symmetrical lung sounds
B Absence of breath sounds over the stomach
C Color change from purple to yellow on the end-tidal carbon dioxide monitor
D Chest X-ray indicating distal tip is proximal to the carina

Question Explanation
Correct Answer is D
Rationale: After placing the endotracheal tube, it is essential to confirm its placement in the
trachea and position proximal to the carina. End-tidal carbon dioxide monitoring provides gold-
standard bedside confirmation of tube placement. However, post-intubation chest X-ray confirms
that the endotracheal tube’s tip is 2 to 4 cm proximal to the carina and rules out mainstem
bronchus intubation. The nurse should also auscultate for symmetric bilateral breath sounds and
the absence of breath sounds over the stomach.
Concepts tested

Question 2789
The nurse is caring for an older adult client with heatstroke. Upon admission, the client appears
confused and has a temperature of 104°F. Which is the priority action for the nurse to take first?
A Apply cooling blanket
B Initiate seizure precautions
C Position a fan towards the client
D Administer prescribed IV fluids

Question Explanation
Correct Answer is A
Rationale: Homeostatic regulatory mechanisms fail to function during an episode of heatstroke
and result in a critical elevation in body temperature usually greater than 104°F. If the emergent
condition is not treated quickly, or there is a lack of a positive response to acute treatment,
multiorgan system failure and death can potentially result. Priority actions include cooling down
the client with cooling blankets, ice, and providing adequate hydration with cooled intravenous
Page | 1101
saline. Once the cooling blanket is applied, the nurse will then position a fan towards the client to
decrease any dissipating heat.
Concepts tested

Question 2790
The nurse has received report on a group of assigned clients who are receiving prescribed
peritoneal dialysis. Which client should the nurse see first?
A The client who is scheduled for peritoneal dialysis in 1 hour and has a serum potassium level
of 5.5 mEq/L
B The client who is receiving continuous ambulatory peritoneal dialysis (CAPD) who has
become restless and has a respiratory rate of 36
C The client who had a peritoneal dialysis catheter placed 1 day ago and is reporting pink-tinged
dialysate outflow
D The client who is reporting redness, warmth, and purulent drainage at the peritoneal dialysis
catheter site

Question Explanation
Correct Answer is B
Rationale: Clients with chronic kidney disease are at high risk for complications related to fluid
and electrolyte imbalances. The client in the key is exhibiting manifestations of acute pulmonary
edema, which is life-threatening and should be assessed first. The client with hyperkalemia is
scheduled for peritoneal dialysis, which will treat the client’s laboratory abnormalities. Pink-
tinged dialysate outflow is expected for the first week following the new placement of a
peritoneal dialysis catheter. The client with redness and purulent drainage at the catheter site is
exhibiting signs of possible peritoneal dialysis catheter infection but can be seen after the client
in the key.
Concepts tested

Question 2791
The nurse is developing the plan of care for a client with chronic obstructive pulmonary disease
(COPD). Which of the following should the nurse include?
A Encourage the client to consume a low calorie, low-protein diet
B Assist the client to identify strategies for managing anxiety
C Restrict the client’s fluid intake to less than 2 L/day
D Encourage the client to perform most activities of daily living at 1 time in the morning

Question Explanation
Correct Answer is B
Rationale: Clients with COPD often experience anxiety during episodes of dyspnea. Anxiety can
also cause dyspnea; therefore, clients should identify strategies to manage these episodes. The
work of breathing with COPD raises calorie and protein needs, which can lead to protein-calorie
malnutrition. Clients should be encouraged to eat a high-calorie, high-protein diet. Clients should
be encouraged to drink more than 2 L of water per day to loosen any thick, tenacious secretions
that occur with COPD. Clients should be encouraged to space out their activities of daily living
throughout the day to conserve energy.
Concepts tested
Page | 1102
Question 2792
The nurse is planning care for a client with tuberculosis. Which intervention will the nurse
implement to prevent transmission of the disease?
A Infuse prescribed antibiotics to the client
B Ensure the client wears an N95 mask when transported
C Administer humidified oxygen to the client
D Place the client in a negative-airflow room

Question Explanation
Correct Answer is D
Rationale: Tuberculosis is an infectious disease transmitted via the airborne route. Airborne
particles must be contained in the client’s room using negative airflow. Infusing antibiotics will
treat the disease but will not prevent transmission. The N95 mask should be worn by healthcare
providers. The client should wear a surgical mask if transportation to another unit is required.
Administering oxygen to the client will assist with oxygenation but will not prevent disease
transmission.
Concepts tested

Question 2793
The nurse is caring for a client who is three hours postoperative after abdominal surgery. Which
of the following actions should the nurse take to prevent respiratory complications?
A Teaching the client to avoid coughing
B Encouraging incentive spirometer use every two hours
C Assessing the client’s incision site every eight hours
D Holding the administration of pain medications

Question Explanation
Correct Answer is B
Rationale: In order to prevent postoperative respiratory complications, the nurse should
encourage the client to turn, cough, and deep breathe as well as use an incentive spirometer every
two hours. Pain medications should be administered as needed. If the client is experiencing acute
pain, they are less likely to ambulate, turn, cough, or deep breathe. While the nurse should assess
the incision site, this does not prevent respiratory complications.
Concepts tested

Question 2794
The nurse is caring for a symptomatic client diagnosed with a 2nd degree, Mobitz Type II heart
block. Transcutaneous pacing has been initiated. Which of the following findings indicates that
the intervention is having the intended effect?
A Normal sinus rhythm shows on the electrocardiogram (EKG)
B Ventricular pacing is evident on EKG with a HR of 65
C Pacemaker spikes are present after the QRS complex on the EKG
D Accelerated ventricular rhythm is present on the EKG with a HR of 68

Page | 1103
Question Explanation
Correct Answer is B
Rationale: Treatment for a Mobitz Type II involves initiating pacing as soon as this rhythm is
identified. Type II blocks imply structural damage to the AV conduction system. This rhythm
often deteriorates into a complete heart block. These patients require transvenous pacing until a
permanent pacemaker is placed. The line that represents pacing is called a pacemaker spike. The
appropriate ECG complex should immediately follow the pacing spike; therefore, a P wave
should follow an atrial pacing spike, and a QRS complex should follow a ventricular pacing
spike. Capture is a term used to denote that the appropriate complex followed the pacing spike.
Pacing does not result in normal sinus rhythm or accelerated ventricular rhythms.
Concepts tested

Question 2795
The nurse is caring for a client who is experiencing alcohol withdrawal. The nurse notes the
client has tremors in the upper extremities, hyperactive deep tendon reflexes, and a change in
mental status. For which of the following electrolyte imbalances would the nurse consider a
priority for assessment?
A Hypomagnesemia
B Hypokalemia
C Hyponatremia
D Hypocalcemia

Question Explanation
Correct Answer is A
Rationale: Clients who are experiencing alcohol withdrawal are at risk for developing
hypomagnesemia. The client will exhibit tremors, muscle weakness, changes in mental status,
and hyperactive deep tendon reflexes. The nurse should obtain a serum hypomagnesemia level.
Clients with inadequate calcium intake can develop hypocalcemia. Clients with vomiting or
diarrhea or taking prescribed diuretics can develop hypokalemia. Hyponatremia develops from
an excessive gain of water.
Concepts tested

Question 2796
The nurse is caring for a client who received intravenous furosemide for a serum potassium level
of 6.0 mEq/L. Which of the following findings on the client’s electrocardiogram indicates that
the treatment has been effective?
A Tall, peaked T waves
B PR interval of 0.18 seconds
C Absent P waves
D QRS duration of 0.20 seconds

Question Explanation
Correct Answer is B
Rationale: Hyperkalemia can cause several electrocardiogram abnormalities, such as tall, peaked
T waves, prolonged PR intervals, flat or absent P waves, and wide QRS complexes. A normal PR
interval is 0.12 – 0.20 seconds; therefore, a PR interval of 0.18 seconds on the client’s
Page | 1104
electrocardiogram indicates the effective resolution of the client’s hyperkalemia. Tall, peaked T
waves, absent P waves, and a prolonged QRS of 0.20 seconds indicate treatment for
hyperkalemia has not been effective.
Concepts tested

Question 2797
The nurse is developing the plan of care for a client who was admitted with newly diagnosed
pericarditis. Which intervention should the nurse include in the plan of care?
A Strict bed rest
B Fluid restriction
C Supine position
D Decrease stimuli

Question Explanation
Correct Answer is A
Rationale: Pericarditis is inflammation of the pericardial sac around the heart. The nurse should
implement bed rest to decrease the activity demand on the heart. Supine position increases pain,
so clients should be positioned side-lying. The client should be encouraged to drink fluids or may
require IV fluid infusion. Decreasing stimuli does not impact pericarditis.
Concepts tested

Question 2798
The clinic nurse is caring for a client with a cardiac history who has a pacemaker. The client has
intractable upper back pain and cancer is suspected. Which of the prescriptions should the nurse
clarify?
A Administration of oxycontin on a routine schedule
B Complete metabolic panel
C MRI of the spine with contrast
D Cardiac enzymes

Question Explanation
Correct Answer is C
Rationale: With the introduction of “MRI safe” pacemakers, many clients can have MRIs done.
However, this needs to be clarified with the provider. The client has intractable pain, so
oxycontin around the clock is a reasonable therapy. A CMP and cardiac enzymes will tell the
provider additional information to make an appropriate diagnosis.
Concepts tested

Question 2799
The nurse is caring for a client who is receiving treatment for neurogenic shock. The client's
mean arterial pressure (MAP) has fallen to 55 mm Hg. When assessing the impact on the client's
kidney function, which data would indicate potential kidney injury?
A Glomerular filtration rate of 90
B Blood Urea Nitrogen 10
C Urine output of 0.6 ml/kg/hr

Page | 1105
D Creatinine 1.9

Question Explanation
Correct Answer is D
Rationale: Rising creatinine levels are indicative of potential kidney injury. BUN is a less
reliable indicator because it is influenced by fluid volume. The client’s urine output is above 0.5
ml/kg/hr, which is considered normal. Glomerular filtration less than 90 would be an indication
of worsening kidney function. It is important to monitor trends in all labs to identify deterioration
or improvement.
Concepts tested

Question 2800
The nurse is providing education to a client with exertional angina about treatment options. What
should the nurse include in the teaching?
A “A thrombolytic agent will be added to your medication regimen.”
B “You will require a coronary angioplasty to correct this condition.”
C “It is important to find healthy coping mechanisms to handle stress.”
D “You should perform high intensity exercises to maximize endurance.”

Question Explanation
Correct Answer is C
Rationale: Exertional angina (stable angina) occurs after strenuous exercise or emotional stress.
Exertional chest pain is relieved with rest or nitroglycerin. Increased stress with ineffective
coping skills is a risk factor. Clients should be encouraged to utilize healthy coping mechanisms
to manage emotional stress. A thrombolytic agent is prescribed when there is a blood clot present
during a myocardial infarction. A coronary angioplasty is indicated for clients with
atherosclerosis and worsening (unstable) angina. High-intensity exercises should be avoided to
decrease the incidence of angina.
Concepts tested

Question 2801
The nurse is performing prescribed gastric lavage for a client with gastrointestinal bleeding.
Which action should the nurse take?
A "Administer oral activated charcoal.”
B “Irrigate the NG tube with normal saline.”
C “Infuse water through the NJ tube.”
D “Provide syrup of ipecac for ingestion.”

Question Explanation
Correct Answer is B
Rationale: A gastric lavage requires the solution to be infused via a nasogastric (NG) tube.
Irrigation with normal saline will stop an active gastric bleed. Activated charcoal is given to
clients who ingest toxic agents. A nasojejunal (NJ) tube is used primarily for feeding. Gastric
lavages are administered into the stomach. Syrup of ipecac is an expectorant that induces

Page | 1106
vomiting. This drug was used in clients who ingested toxic agents but is no longer administered
in clinical practice.
Concepts tested

Question 2802
The nurse is caring for a client diagnosed with septic shock. The client has received fluid
resuscitation and has been started on IV norepinephrine. Which of the following is the intended
effect of the intervention?
A Improved tissue perfusion
B Anticoagulation
C Improved stress response
D Target the invading organism

Question Explanation
Correct Answer is A
Rationale: Fluids and vasopressors (norepinephrine) are the first-line treatments of the
hypotension and fluid shifts that occur in septic shock. Bacterial (endo)toxins are released into
the bloodstream, which trigger vasodilation. Activation of the coagulation system occurs in
sepsis and puts the client at risk of thrombus & eventually bleeding due to consumption of
platelets. However, fluids and vasopressors are not the treatment of hypercoagulability. Cortisol
is released as a physiologic response to stress from sepsis, but depletion is treated with
corticosteroid therapy. Anti-infectives are used to kill the invading pathogen.
Concepts tested

Question 2803
The nurse is caring for a client who has a closed-chest drainage system in place. Which of the
following findings is a priority for the nurse to notify the primary health care provider?
A No drainage from the tube
B Crepitus palpated around the insertion site
C Bubbling in the water seal chamber with coughing
D Tidaling in the water-seal chamber with inspiration and expiration

Question Explanation
Correct Answer is A
Rationale: Clients with closed-chest drainage systems should be closely monitored for
complications that could lead to airway compromise, such as pneumothorax. No drainage from
the tube may indicate a blockage and requires notification of the primary health care provider. If
drainage is blocked, this can lead to a tension pneumothorax. A small amount of crepitus around
the insertion site is usually not problematic and is monitored to ensure it does not extend further
to the anterior chest and neck. Tidaling in the water-seal chamber is an expected finding.
Bubbling in the water-seal chamber with forceful coughing or sneezing is expected, however,
continuous bubbling in the water-seal chamber could indicate an air leak, in which the primary
health care provider should be notified.
Concepts tested

Question 2804
Page | 1107
The nurse is assessing a client on positive-pressure ventilation for a flail chest. Which finding
indicates the client is responsive to treatment?
A Respiratory rate of 20 breaths/min
B Symmetrical chest expansion
C Oxygen saturation of 94%
D Absence of pain

Question Explanation
Correct Answer is C
Rationale: Positive-pressure ventilation (PPV) forces air into the lungs to assist with oxygenation
and perfusion. A flail chest results from fractured, detached ribs that prevent the lung from
expanding properly. The expected response is adequate oxygenation and perfusion as indicated
by a normal oxygen saturation (>92%). Symmetrical chest expansion would not be an expected
finding on a client with a flail chest. A respiratory rate of 20 breaths/min is normal. However, the
respiratory rate is not a direct reflection of the effectiveness of PPV. The absence of pain does
not evaluate adequate oxygenation.
Concepts tested

Question 2805
The emergency department nurse is receiving a report on a client with insulin-dependent diabetes
mellitus being brought in by ambulance. The client reports extreme thirst, vomiting, and frequent
urination. Ketones are present in the urine. Based on these findings, which of the following
prescriptions will be implemented?
A Dextrose 50% IV push
B Regular insulin via continuous infusion
C Humulin N subcutaneous injection on a sliding scale
D Dextrose 5% with lactated Ringer's (D5LR) infusion at 50 mL/hour

Question Explanation
Correct Answer is B
Rationale: The client is likely experiencing diabetic ketoacidosis, which is treated with isotonic
fluid resuscitation, electrolyte replacement, and a continuous infusion of regular insulin via
protocol. Administering dextrose will worsen hyperglycemia. Lactated Ringer's will worsen the
acidosis.
Concepts tested

Question 2806
The nurse is caring for a client who has a Jackson-Pratt drain. Which of the following actions
should the nurse take when emptying the drain reservoir?
A Measure the amount of drainage in a graduated cylinder
B Remove the drain before assessing output
C Flush the drain with normal saline after emptying
D Hang the drain reservoir above the wound site

Question Explanation

Page | 1108
Correct Answer is A
Rationale: When emptying the client’s Jackson-Pratt (JP) drain, it is important to assess drainage
(amount, color, etc.). The JP drain should not be removed by the nurse. Flushing the drain may
contaminate the wound site, and the drain should be secured to the client’s gown below the level
of the wound site.
Concepts tested

Question 2807
A client presents to the clinic experiencing fatigue, nausea, and a recent unintentional weight loss
of 6 pounds. The client tells the nurse they had unprotected sexual intercourse 2 weeks prior. The
nurse identifies these manifestations as symptoms of which disease?
A Hepatitis A
B Syphilis
C Viral meningitis
D Human immunodeficiency virus

Question Explanation
Correct Answer is D
Rationale: Unintentional weight loss, nausea, and fatigue are characteristic of a human
immunodeficiency (HIV) viral infection. Symptoms occur between 2 to 4 weeks after initial
exposure. Hepatitis A is a viral infection transmitted through the fecal-oral route. Unintentional
weight loss is not an expected finding. The average incubation period for hepatitis A is 28 days.
Syphilis is a sexually transmitted infection (STI) with an average incubation period of 21 days.
Syphilis is characterized by a chancre sore at the site of viral entry. Viral meningitis is a viral
illness caused by conditions, such as herpes, measles, and influenza. Sexual transmission is not a
source of infection.
Concepts tested

Question 2808
The nurse is assisting with an endoscopy. The client is receiving moderate sedation. What
finding during an endoscopy indicates an expected response?
A Responds to verbal commands with depressed level of consciousness. Airway protection and
ventilation require no intervention.
B Requires repeated verbal stimuli for purposeful response. Airway protection and ventilation
require increased monitoring.
C No response to repeated verbal or painful stimuli. Airway protection and ventilation support
are required.
D Responds to verbal commands with minimally reduced consciousness. Airway protection and
ventilation require no intervention.

Question Explanation
Correct Answer is A
Rationale: Moderate conscious sedation (MCS) is a medication-induced depression of
consciousness used to prevent or minimize the patient’s anxiety and discomfort while
maintaining protective reflexes and the ability to respond appropriately to verbal and tactile
stimuli. MCS is used to produce sedation, analgesia, and retrograde amnesia during invasive
Page | 1109
treatments and diagnostic procedures (such as endoscopy). Under some circumstances, MCS is
also used during patient care in critical care settings. MCS is considerably safer than general
anesthesia and allows patients to return to baseline physical and neurologic status rapidly The
desired outcome of caring for and monitoring the adult patient receiving MCS is that the
procedure will be performed safely and efficiently and cause minimal or no complications or
discomfort to the patient as evidenced by stable vital signs and EKG rhythm, adequate
ventilation, and other clinical findings (e.g., skin color, respiratory effort, response to verbal
commands).
Concepts tested

Question 2809
The nurse is caring for a client who is undergoing an initial peritoneal dialysis treatment. Which
finding should the nurse report immediately to the healthcare provider?
A Client reports discomfort during dialysate inflow.
B The dialysate outflow is blood tinged.
C There is leakage of dialysate during inflow.
D The dialysate outflow is cloudy.

Question Explanation
Correct Answer is D
Rationale: Peritoneal dialysis is a type of dialysis that uses a catheter through the peritoneal
cavity to instill dialysate to remove toxins. When caring for a client who is undergoing initial
peritoneal dialysis treatment, the nurse should expect to observe blood-tinged outflow and client
report of discomfort which occurs with initial treatment. Leakage can occur if the catheter is not
secure. Cloudy dialysate outflow could indicate an infection and should be reported to the
healthcare provider.
Concepts tested

Question 2810
The nurse has received report on a group of assigned clients who are receiving prescribed
peritoneal dialysis. Which client should the nurse see first?
A The client who is reporting abdominal pain and has a rigid, board-like abdomen
B The client who has a serum creatinine level of 1.8 mg/dL and is reporting the inability to void
C The client who had a peritoneal dialysis catheter placed 1 day ago and is reporting pink-tinged
dialysate outflow
D The client who has a peritoneal dialysis catheter infection and has a temperature of 102.1°F

Question Explanation
Correct Answer is A
Rationale: The client in the key is exhibiting signs and symptoms of peritonitis, which is a life-
threatening complication in the client undergoing peritoneal dialysis and should be assessed first.
The client with a creatinine level of 1.8 mg/dL is exhibiting expected manifestations of chronic
kidney disease. The client who has pink-tinged dialysate outflow is exhibiting expected findings
following the placement of a catheter 1 day ago. Clients can expect pink-tinged and bloody
dialysate outflow for 1 week following catheter placement. The client with a peritoneal dialysis
catheter infection is exhibiting expected fever and can be seen after the client in the key.
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Concepts tested

Question 2811
The nurse is caring for a middle-aged client who sustained multiple fractures after a motor
vehicle accident. The client refuses to participate in physical therapy and states, “All of those
exercises cause me too much discomfort.” Which action should the nurse take?
A Educate the client on the importance of participating in physical therapy sessions
B Collaborate with the physical therapist to modify exercises
C Consult with the healthcare provider to decrease the frequency of physical therapy sessions
D Administer prescribed pain medication prior to physical therapy sessions

Question Explanation
Correct Answer is D
Rationale: Client participation in physical therapy sessions will promote recovery and prevent
complications of immobility. The nurse should ensure adequate pain management, so the client
is able to participate in the sessions. Modifying the exercises may not be conducive to the
client’s recovery. Decreasing the frequency of physical therapy sessions does not promote
recovery and increases the risk of immobility. Educating the client on the benefits of physical
therapy will not alleviate the physical discomfort.
Concepts tested

Question 2812
The nurse is teaching a client with atelectasis about how to use an incentive spirometer. Which
statement should the nurse include in the teaching?
A “Hold your breath for 3 seconds after inhaling through the mouthpiece.”
B “You should perform this exercise every 2 hours.”
C “This device measures the amount of fluid in your lungs.”
D “Place your lips tightly over the mouthpiece before exhaling.”

Question Explanation
Correct Answer is A
Rationale: An incentive spirometer helps clients improve their deep breathing and prevent lung
collapse after medical procedures or long episodes of immobility. Holding the breath for 3
seconds maximizes lung expansion and prevents further alveolar collapse. Incentive spirometry
should be performed 10 times every hour while the client is awake. The incentive spirometer
does not have the capability to measure the amount of fluid in the lungs. The client should be
told to inhale slowly after placing their lips around the mouthpiece.
Concepts tested

Question 2813
The nurse is caring for a client who has a surgical drain and is one day postoperative. Which of
the following interventions should be included in the client’s care for today?
A Avoid the use of antiembolism stockings
B Flush the surgical drain with normal saline

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C Remove the client’s sutures
D Assist the client with ambulation

Question Explanation
Correct Answer is D
Rationale: Early mobility reduces the risk of many postoperative complications. The nurse
should assist the client with ambulation to ensure safety (especially due to the presence of a
surgical drain). Antiembolism stockings are encouraged to prevent thrombi formation, and
sutures should not be removed the day following surgery; they are typically removed about one
week after the procedure.
Concepts tested

Question 2814
The nurse is reviewing the laboratory data for a client who is taking newly prescribed lovastatin.
Which results would indicate to the nurse that the medication has had a therapeutic effect?
A Lactic acid levels are elevated
B Total cholesterol is normal
C WBC is normal
D LDL levels are elevated

Question Explanation
Correct Answer is B
Rationale: Statin medications reduce the formation of cholesterol precursors which causes LDL
to lower, HDL to increase, and total cholesterol to decrease.
Concepts tested

Question 2815
The nurse is assessing a client who has a potassium level of 3.2 mEq/L. Which finding should
the nurse expect to observe?
A Shallow respirations
B Hypoglycemia
C Tetany
D Abdominal pain

Question Explanation
Correct Answer is A
Rationale: Hypokalemia, or a decreased level of potassium, occurs with gastrointestinal or renal
losses. For clients at risk for developing hypokalemia, the nurse should monitor for signs such as
shallow respirations, constipation, hyperglycemia, and irregular pulse. Assessment findings
associated with hyperkalemia include irritability, muscle weakness, paresthesia, abdominal pain,
diarrhea, vomiting, and confusion.
Concepts tested

Question 2816

Page | 1112
The nurse is assessing a client who is experiencing decreased cardiac output due to a left-sided
heart failure exacerbation. Which of the following findings should the nurse expect to observe?
A Jugular venous distention
B Serum hematocrit of 55%
C Dependent edema in the legs
D Serum creatinine level of 2.1 mg/dL

Question Explanation
Correct Answer is D
Rationale: The nurse who is caring for a client with decreased cardiac output due to a left-sided
heart failure exacerbation should expect possible organ dysfunction, particularly renal, due to
decreased blood flow. A serum creatinine level of 2.1 mg/dL indicates possible acute kidney
injury due to reduced blood flow to the kidneys. Jugular venous distention and dependent edema
in the legs would be observed in a right-sided heart failure exacerbation. A serum hematocrit of
55% is elevated, which is not an expected finding.
Concepts tested

Question 2817
The nurse is reviewing discharge instructions with a client who is newly diagnosed with
cardiomyopathy. The client asks the nurse "How will I know if I am overdoing an activity?"
Which of the following is the best response by the nurse?
A “Stop the activity if you begin to feel fatigue.”
B “Avoid activities that you know will increase your fatigue.”
C “You will experience chest pain if the activity is too strenuous.”
D “The activity will need to be modified if you develop a cough.”

Question Explanation
Correct Answer is A
Rationale: Clients with cardiomyopathy experience decreased cardiac output from the inability
of the ventricular to adequately pump. Clients with decreased cardiac output should be
encouraged to engage in activity but can develop activity intolerance. The nurse should instruct
the client to stop the activity if they become fatigued. Developing a cough or chest pain indicates
execration of the decreased cardiac output. The client should stop the activity before they
develop symptoms of exacerbation.
Concepts tested

Question 2818
A nurse is caring for a client with a ventricular pacemaker who is on electrocardiogram (ECG)
monitoring. When interpreting the ECG strip, proper pacemaker functioning is based on which
of the following findings?
A Pacemaker spikes after each QRS complex
B Pacemaker spikes before each P wave
C Pacemaker spikes before each QRS complex
D Pacemaker spikes after each P wave

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Question Explanation
Correct Answer is C
Rationale: The pacemaker fires, which stimulates the ventricle to depolarize, and the QRS
complex appears. Pacemaker firing is indicated by the spike on the ECG. If the spike occurs
before each P wave, it indicates atrial pacing. Undersensing occurs when the pacemaker fails to
detect spontaneous myocardial depolarization, which results in asynchronous pacing. Atrial or
ventricular pacing spikes arise regardless of P waves or QRS complex.
Concepts tested

Question 2819
The nurse is caring for a client with neurogenic shock. The client’s temp is 97.9°F, blood
pressure is 85/54, heart rate is 53 beats per minute, and skin is warm and dry. What intervention
will be implemented?
A Apply warming blankets
B Administer intravenous fluid resuscitation
C Remove the stimuli that is causing the client’s symptoms
D Prepare for transcutaneous pacing

Question Explanation
Correct Answer is B
Rationale: Neurogenic shock is a form of distributive shock that leads to hypotension. However,
the overriding parasympathetic stimulation that occurs with neurogenic shock causes bradycardia
unlike other forms of shock. The first-line intervention for distributive shock is fluid
resuscitation. The client’s heart rate is slow but does not require transcutaneous pacing at this
point because the skin is warm. Warming the client may result in worsening hypotension, so this
should be avoided unless the client is hypothermic.
Concepts tested

Question 2820
The nurse is providing education to a client with chronic cystitis on the prevention of recurring
urinary tract infections. Which statement by the client indicates a need for further teaching?
A “I will avoid scented hygiene products.”
B “I will drink at least 3 liters of water daily.”
C “I will empty my bladder every 4 hours.”
D “I will include cranberry juice in my diet.”

Question Explanation
Correct Answer is D
Rationale: Cranberry juice should be avoided in clients with chronic cystitis. Cranberry juice
irritates the bladder and can lead to further inflammation. Scented hygiene products, such as
tampons, pads, and toilet paper can irritate the urethra and increase bacterial growth. Clients
should be instructed to drink at least 3 liters of fluid daily. Drinking at least 3 liters of water daily
flushes out bacteria from the urinary tract. The bladder should be emptied at least every 4 hours
to avoid stagnant urine and bacterial growth in the bladder.
Concepts tested

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Question 2821
The nurse is planning the discharge for a client diagnosed with a hip fracture who is homeless.
The client has a prescription for outpatient physical therapy. Which action by the nurse would be
most appropriate for this client?
A Make a follow-up appointment for the client
B Educate the client on the importance of attending the sessions
C Collaborate with the social worker for transportation
D Teach mobility exercises that can be performed independently

Question Explanation
Correct Answer is C
Rationale: Collaboration with social workers is an important intervention for vulnerable clients.
Arranging transportation for the homeless client will ensure they are able to attend their physical
therapy sessions. Making a follow-up appointment does not guarantee the client will be able to
attend the session. Educating the client on the importance of attending physical therapy is a
valuable intervention. However, the client may not have the means to remain compliant.
Teaching mobility exercises to the client does not fulfill the discharge prescription.
Concepts tested

Question 2822
The nurse is caring for a client with altered mental status, hypotension, and decreasing urine
output. Urosepsis is suspected. Which of the following urinalysis findings would support this
diagnosis?
A Specific gravity of 1.021
B Positive for nitrites
C WBC <5
D Negative for leukocyte esterase

Question Explanation
Correct Answer is B
Rationale: Normal urine contains nitrates, which are converted to nitrites by bacteria. Therefore,
when nitrites are present, it is indicative of a urinary tract infection. Normal specific gravity
values range from 1.010 to 1.030, therefore, this is a normal finding. WBCs less than 5 is normal
as well as a negative leukocyte esterase.
Concepts tested

Question 2823
The nurse is caring for a client who had a cardiac catheterization via the left femoral artery 1
hour ago. Which of the following findings is a priority for the nurse to report to the primary
health care provider?
A Left dorsalis pedal pulse +2
B Scant amount of blood at the insertion site
C Left upper extremity weakness
D Sinus tachycardia at a rate of 102

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Question Explanation
Correct Answer is C
Rationale: Clients who have undergone a cardiac catheterization should be closely monitored for
complications such as dysrhythmias, bleeding, hematoma formation, and thromboembolism,
which can cause stroke, cardiac ischemia, or pulmonary embolism. A client who has left upper
extremity weakness may be experiencing signs of stroke, and the nurse should notify the primary
care provider immediately. The client’s pedal pulse of +2 indicates adequate circulation to the
affected extremity. Scant amounts of blood at the insertion site may be present following the
procedure and should be marked and monitored closely for signs of hemorrhage. Mild sinus
tachycardia does not warrant immediate notification of the primary health care provider;
however, any dysrhythmias should be reported immediately.
Concepts tested

Question 2824
The nurse is taking care of a client with severe Alzheimer’s. The nurse expects to perform which
action to promote safety?
A Raising the head of the bed
B Placing seizure pads on the client’s bed
C Activating the bed alarm
D Assembling an overhead trapeze on the bed

Question Explanation
Correct Answer is A
Rationale: Severe Alzheimer’s is characterized by severe cognitive decline. Clients may
experience the inability to swallow or clear their own secretions. Raising the head of the bed will
prevent aspiration. Placing seizure pads on the client’s bed is not indicated for a client with
Alzheimer’s. Seizures are not expected findings of the disease. Activating the bed alarm is useful
for earlier stages of the disease. Late stages result in ataxia, or the inability to move extremities.
Assembling an overhead trapeze will not promote safety related to cognitive decline.
Concepts tested

Question 2825
The nurse is caring for a client receiving a continuous infusion of isotonic fluid. When assessing
the site, the nurse notes that the skin is cool and pale and there is edema. The IV therapy is
discontinued. Which action would be appropriate for the nurse to make?
A Elevate the extremity
B Massage the extremity
C Prepare to administer phentolamine
D Prepare to administer hyaluronidase

Question Explanation
Correct Answer is A
Rationale: Iatrogenic complications of IVT include infection, phlebitis, infiltration,
extravasation, soft-tissue necrosis, and compartment syndrome. Infiltration refers to leakage of
nonvesicant (nonirritating) solution into the extravascular space while extravasation involves a
vesicant (irritating) solution. Maneuvers to reduce edema, such as limb elevation, should be
Page | 1116
instituted, but massage is not recommended. Phentolamine is the antidote to vasoactive
medications. Hyaluronidase is the antidote to many other hypertonic extravasations.
Concepts tested

Question 2826
The nurse is assessing a client’s Hemovac drainage system. Which of the following assessment
findings should the nurse report to the provider immediately?
A Serosanguineous drainage is present in the collection chamber.
B The drain is secured to the client’s gown with a safety pin.
C An obstruction is present in the drainage tube.
D The collection chamber does not expand quickly after being compressed.

Question Explanation
Correct Answer is C
Rationale: When assessing the client’s Hemovac drain, it is important to assess the insertion site,
the drainage, and the drain tubing. Significant increases/decreases in the amount of drainage,
insertion site abnormalities, or obstructions of the tube should be reported to the provider
immediately. Serosanguineous drainage and securing the drain to the client’s gown are normal
findings. The collection chamber should not expand quickly after compressing it; this indicates
negative pressure is not being maintained.
Concepts tested

Question 2827
The nurse is taking care of a client with muscle aches, headache, and a rash with a “bull’s-eye”
appearance on the upper back. Which statement made by the client is consistent with the physical
findings?
A “I scraped myself with a piece of metal while working in my garage yesterday.”
B “I just returned from a weekend trip to the beach.”
C “My family and I went camping last week in the woods.” Correct Answer
D <span style="font-weight: 400;">&ldquo;I ate potatoes that I canned at home last
month.&rdquo;</span>
“I ate potatoes that I canned at home last month.”

Question Explanation
Rationale: Muscle aches, headache, and a distinctive rash with a bull’s-eye pattern are indicative
of Lyme disease. Lyme disease is transmitted via ticks. Ticks live in wooded, grassy areas. The
incubation period is 3-30 days. An injury from a piece of scrap metal can potentially lead to
tetanus. The symptoms are not consistent with a tetanus infection. Lyme disease is caused by
ticks. A sand and water environment is not conducive to ticks. Home-canning vegetables or food
can lead to botulism. The symptoms presented are not indicative of botulism.
Concepts tested

Question 2828
An ICU nurse is caring for a client with a suspected foreign body in the airway. The client is
scheduled for a bedside bronchoscopy. How should the nurse prepare this client?

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A Place the client in a supine position
B Apply local anesthetic to the back of the client's throat as prescribed
C Administer the prescribed oral anxiolytic
D Obtain consent from the client

Question Explanation
Correct Answer is B
Rationale: Bronchoscopy is the direct inspection and examination of the larynx, trachea, and
bronchi through either a flexible fiberoptic bronchoscope or a rigid bronchoscope. Before the
procedure, the nurse should verify that informed consent has been obtained, but it is not the role
of the nurse to obtain consent. The patient must remove dentures and other oral prostheses. The
client is placed in a semi-recumbent or lateral position to prevent aspiration. The examination is
usually performed under local anesthesia or moderate sedation, which is administered
intravenously not orally. General anesthesia may be used for rigid bronchoscopy. A topical
anesthetic such as lidocaine is normally sprayed on the pharynx or dropped on the epiglottis and
vocal cords and into the trachea to suppress the cough reflex and minimize discomfort.
Concepts tested

Question 2829
The nurse is responding to a low-pressure alarm for a client with acute respiratory distress
syndrome (ARDS) and is being mechanically ventilated. The nurse should understand that which
finding would indicate the reason for the alarm?
A Inadequate inflation of the tube cuff
B Kink in the tube
C Pulmonary congestion and secretions
D Bronchospasm

Question Explanation
Correct Answer is A
Rationale: A low-pressure alarm indicates that pressure within the ventilator circuit has
decreased. Low-pressure alarms are usually caused by a leak or disconnect in the circuit.
Secretions, water in the tubing, bronchospasm, or kinks in the tubing can cause a high-pressure
alarm.
Concepts tested

Question 2830
The nurse has provided discharge teaching to a client with chronic kidney disease (CKD) who is
starting peritoneal dialysis. Which of the following statements by the client indicates the need for
further teaching?
A “I should avoid the use of magnesium oxide antacids if I experience an upset stomach.”
B “I will monitor my peritoneal dialysis catheter site daily and report any signs of infection.”
C “I should expect my dialysate outflow to be cloudy or opaque in appearance.”
D “I will avoid using my microwave to warm my dialysate.”

Question Explanation

Page | 1118
Correct Answer is C
Rationale: Dialysate outflow that is cloudy or opaque in appearance indicates possible infection
and peritonitis, which needs to be reported. Clients with renal failure should avoid magnesium
oxide antacids due to the potential for magnesium toxicity. It is the correct understanding of the
teaching to monitor the peritoneal dialysis catheter site for infection and to avoid using the
microwave to warm dialysate.
Concepts tested

Question 2831
The nurse is caring for a 22- year-old female client who experienced a spontaneous abortion at
17 weeks gestation. The client appears to be crying and avoids eye contact with the nurse. Which
statement by the nurse would be appropriate?
A “It’s a tragic event, and you need to move on.”
B “This happens to a lot of women, so you are not alone.”
C “You are young and will be able to get pregnant again.”
D “Talk to me about what this loss means to you.”

Question Explanation
Correct Answer is D
Rationale: A spontaneous abortion can cause intense feelings of grief and loss. The nurse should
acknowledge the client’s condition and encourage communicating her feelings. Telling the client
that they need to move on does not allow the client to experience the stages of grief and loss.
Telling the client that a spontaneous abortion is common does not promote patient-centered care.
The nurse should acknowledge the client’s own feelings. Telling the client that they are young
and will get pregnant again does not promote empathy and does not allow the client to
experience grief.
Concepts tested

Question 2832
The nurse is caring of a client with chronic obstructive pulmonary disease (COPD) who has a
prescription for chest physiotherapy (CPT). Which action should the nurse take?
A Question the healthcare provider’s prescription
B Prepare suctioning equipment
C Perform the maneuver in short time segments
D Educate the client on coughing and deep breathing

Question Explanation
Correct Answer is C
Rationale: Chest physiotherapy (CPT) is used to loosen secretions in the airways. CPT can be
performed via percussion, vibration, or postural drainage. Clients with chronic obstructive
pulmonary disease (COPD) have decreased activity tolerance and may not tolerate a full session
of CPT. The procedures should be done in short intervals followed by rest periods. CPT can be
performed in clients with COPD if secretions are retained in the airways. Suctioning equipment
should be prepared for all clients receiving CPT in case they are unable to remove their own
Page | 1119
secretions. Coughing and deep breathing should be taught to all clients to assist in clearing their
own secretions.
Concepts tested

Question 2833
The nurse is completing a surgical incision dressing change for a client that is two days
postoperative. Which of the following actions is appropriate?
A Administering prescribed pain medication after the dressing change
B Applying tape over the dressing with moderate tension
C Applying the new dressing using sterile technique
D Disposing of the soiled dressing in the sharps container

Question Explanation
Correct Answer is C
Rationale: Wound care of the surgical incision is sterile to prevent the introduction of pathogens
to the fresh incision. Pain medication should be given prior to wound care, especially if the client
is experiencing incisional pain. Soiled wound dressings should be discarded in a biohazard waste
container, and tape should not be applied with tension. Pressure or tension from a dressing can
cause skin shearing and breakdown.
Concepts tested

Question 2834
A nurse is monitoring a client with a head injury who is receiving prescribed mannitol. Which
finding would indicate that the treatment is effective?
A Client is more responsive.
B Pupils are 8mm and non-reactive.
C Urine output decreases.
D Systolic BP remains around 140 mmHg.

Question Explanation
Correct Answer is A
Rationale: Mannitol is an osmotic diuretic that raises plasma and extracellular osmolality, which
moves fluid out of the brain and into the circulating blood volume. This leads to an increase in
stroke volume, cardiac output, urine output, and increased blood pressure.
Concepts tested

Question 2835
The nurse is reviewing the arterial blood gas (ABG) for a client. The nurse notes the results are
pH 7.49, CO2 32 mm/Hg, and HCO3 24 mEq/L. Which of the following interventions should the
nurse implement?
A Administer prescribed bronchodilator
B Teach the client how to use the incentive spirometer
C Apply prescribed oxygen via nasal cannula
D Instruct the client to breathe into a paper bag

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Question Explanation
Correct Answer is D
Rationale: An ABG result of pH 7.49 indicates the client has alkalosis, and a CO2 of 32 mm/Hg
indicates he is losing carbon dioxide, which is documented as respiratory alkalosis. The nurse
should implement interventions to promote the client to retain CO2, such as breathing in a paper
bag. After breathing in a paper bag, the client will re-breathe in a higher concentration of CO2.
For a client who is experiencing respiratory acidosis, the nurse will teach the client to use the
incentive spirometer, administer a prescribed bronchodilator, or apply oxygen.
Concepts tested

Question 2836
The nurse is assessing a client with decreased cardiac output. Which of the following findings
should the nurse expect to observe?
A Oliguria
B Bradycardia
C Bounding pulses
D Metabolic alkalosis

Question Explanation
Correct Answer is A
Rationale: Client’s with decreased cardiac output are at risk for developing organ dysfunction,
particularly renal, due to decreased perfusion to the kidneys and other organs. Oliguria is a
finding that may indicate reduced kidney function in clients with decreased cardiac output.
Tachycardia is often seen as a compensatory mechanism due to hypotension from the decreased
cardiac output. Weak, thready pulses are often seen due to reduced blood pressure and perfusion.
Clients may have metabolic acidosis, not alkalosis, due to lactic acid buildup causing lactic
acidosis.
Concepts tested

Question 2837
The nurse is teaching a client with heart failure strategies to manage activity intolerance. Which
statement should the nurse include in the teaching?
A “Complete all your activities in the beginning of your day.”
B “Finish one task before moving on to the next activity.”
C “Adapt tasks to allow for minimizing effort.”
D “Focus on activities that require more energy first.”

Question Explanation
Correct Answer is C
Rationale: Clients with decreased cardiac output should be taught strategies to manage activity
intolerance that promote energy conservation. Clients should be taught to take frequent rest
periods during activity. Clients should be encouraged to adapt tasks to minimize effort, such as
sitting when preparing meals. Clients should perform tasks that require little energy first.
Activities should be completed at peak periods of energy, which can be at different times of the
day.
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Concepts tested

Question 2838
The nurse is initiating transcutaneous pacing. After turning on the pacemaker and setting the rate
to 60, the nurse notes pacer spikes with failure to capture on the electrocardiogram. Which
intervention is appropriate?
A Increase the current output by 10%
B Change the rate from 60 to 65
C Change the pacemaker batteries
D Increase the sensing threshold

Question Explanation
Correct Answer is A
Rationale: Capture failure occurs when the generated pacing stimulus does not initiate
myocardial depolarization. Pacing spikes are present, but they are not followed by a QRS
complex in the event of ventricular non-capture or by the lack of P waves in the event of atrial
non-capture. The most common reason for not obtaining capture is not adequately increasing the
current. Increasing the rate will not affect capture, and because the nurse is able to see pacemaker
spikes, the pacemaker is functioning properly. Increasing the sensing threshold would be done to
manage undersensing, which is not occurring here.
Concepts tested

Question 2839
The emergency room nurse is caring for a client who has 25% total body surface area burns and
is in the initial burn stage. Which intervention should be the priority for the nurse to implement?
A Administer a unit of packed red blood cells
B Administer potassium chloride IVPB
C Administer a broad-spectrum antibiotic
D Administer IV crystalloids

Question Explanation
Correct Answer is D
Rationale: Pathophysiologic changes resulting from major burns during the initial burn-shock
period include massive fluid losses. Addressing these losses is a major priority in the initial
phase of treatment. Antibiotics and PRBCs are not normally given during this phase. Potassium
chloride would exacerbate the client's hyperkalemia, which is common due to electrolyte shifts
outside of the cells.
Concepts tested

Question 2840
The nurse is educating a client with heart failure on therapeutic nutrition. What should the nurse
include in the teaching?
A “Avoid adding extra condiments to your food.”
B “Drink plenty of fluids to stay hydrated.”
C “Decrease the percentage of protein in your diet.”

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D “Eat large, high-calorie meals to increase your energy.”

Question Explanation
Correct Answer is A
Rationale: Heart failure is the inability of the heart to effectively pump blood throughout the
body. Inadequate blood flow leads to fluid retention and edema. Condiments contain large
amounts of sodium. Sodium attracts fluid, increasing retention and edema throughout the body.
Clients should be advised to monitor their fluid intake and possibly restrict it to 2 liters/day.
Excess fluid will cause the workload of the heart to increase. Protein is necessary for muscle
building. Clients with heart failure should increase their protein intake to 1.12 g/kg. Large, high-
calorie meals can lead to obesity, which increases the risk of complications from heart disease.
Clients should be encouraged to eat smaller, low-calorie foods.
Concepts tested

Question 2841
The nurse is planning the discharge for a client with a poor prognosis. The client requires pain
management and assistance with activities of daily living. Which action does the nurse take to
ensure continuity of care?
A Educate the client on the importance of mobility
B Collaborate with the case manager for palliative care
C Request a prescription for home health services
D Provide the client with a list of support groups

Question Explanation
Correct Answer is B
Rationale: Palliative care is a resource that aggressively treats the symptoms of a chronic illness
and provides social, emotional, and practical support. The nurse should ensure the client receives
follow-up care prior to discharge. Educating the client on the importance of mobility is
important. However, it does not address pain management. Requesting a prescription for home
health services is not indicated at this time. Home health services provide intermittent care for an
acute illness. The client has a poor prognosis and requires specialized care. Providing the client
with a list of support groups does not address the physiological needs.
Concepts tested

Question 2842
The nurse is caring for a client with chronic obstructive pulmonary disease who is receiving
prescribed oxygen. The client reports an increase in drowsiness, and the nurse notes that the
client is alert and oriented to name and time. Which intervention should the nurse implement?
A Obtain a prescription for an arterial blood gas (ABG)
B Obtain a prescription for a chest X-ray
C Encourage incentive spirometry
D Increase the oxygen flow rate to achieve an increased oxygen saturation

Question Explanation
Correct Answer is A

Page | 1123
Rationale: Hypercapnia is a common complication of COPD. Signs of hypercapnia include
confusion and drowsiness. Increasing the oxygen flow rate can worsen the retention of carbon
dioxide. The partial pressures of both oxygen and carbon dioxide are measured through ABGs. A
chest radiograph can assist with the diagnosis of COPD and pneumonia but does not provide
information on gas exchange. Incentive spirometry can worsen CO2 retention in clients with
COPD.
Concepts tested

Question 2843
The nurse is performing a primary assessment on an unconscious client who arrived at the
emergency department after a motor vehicle accident. Which action will the nurse
perform prior to assessing obstruction of the airway?
A Perform in-line stabilization of the neck
B Place the client in a sitting position
C Extend the client’s head using a chin lift maneuver
D Insert a nasopharyngeal airway

Question Explanation
Correct Answer is A
Rationale: Unconscious clients are unable to verbalize pain or neurovascular deficits. Trauma
clients have a potential for cervical spine injuries. The cervical spine must be protected prior to
performing all assessments. In-line stabilization of the neck provides cervical spine alignment.
Placing the client in a sitting position may injure the cervical spine. Clients should be kept supine
with the cervical spine protected. The chin lift maneuver can hyperextend the neck and cause
injury to the cervical spine. The neck must be stabilized prior to clearing the airway. Inserting a
nasopharyngeal airway can help maintain the client’s airway. However, the cervical spine should
be protected prior to this intervention.
Concepts tested

Question 2844
The nurse is reviewing the medical record of a client diagnosed with breast cancer. The nurse
notes M1 as part of the TNM staging system. How should the nurse interpret this information?
A The tumor is 1 mm in size.
B The cancer has spread to other parts of the body.
C The primary tumor cannot be evaluated.
D The cancer has affected 1 axillary lymph node.

Question Explanation
Correct Answer is B
Rationale: The tumor-node-metastasis (TNM) system is used to stage cancer. The “M” signifies
evidence of cancer spreading to other parts of the body. M1 represents distant metastasis. The
tumor size and evaluation are characterized by the letter “T” in the TNM system. Lymph node
involvement is characterized by the letter “N” in the TNM system.
Concepts tested
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Question 2845
A nurse is assessing a client who is receiving one unit of packed RBCs to treat blood loss from a
duodenal ulcer. The client reports chest tightness, dyspnea, and low back pain. Which action
should the nurse take?
A Slow the rate of infusion, and medicate the client for pain as prescribed
B Stop the blood transfusion, and begin an infusion of normal saline
C Stop the blood transfusion, and obtain a prescription for an antihistamine
D Slow the rate of the transfusion, and obtain a prescription for a diuretic

Question Explanation
Correct Answer is B
Rationale: An acute hemolytic transfusion reaction is an immune-mediated reaction that is the
result of recipient antibodies present to blood donor antigens. Antibodies already present in the
recipient’s plasma rapidly combine with antigens on donor erythrocytes, and hemolysis occurs.
Symptoms include fever, chills, low back pain, nausea, chest tightness, dyspnea, and anxiety.
Hypotension, bronchospasm, and vascular collapse may result. When a transfusion reaction is
suspected, the transfusion should be immediately stopped, and the intravenous line should be
kept open using appropriate fluids (usually 0.9% saline). In this type of reaction, slowing the
infusion is of no benefit.
Concepts tested

Question 2846
The nurse is assessing a client who has a closed chest drainage system. Which action by the
nurse is appropriate?
A Manually squeezing the tube to remove additional drainage
B Marking the level of drainage on the output chamber with date and time
C Emptying the drainage from the collection chamber into a biohazard container
D Clamping the drainage tube while the comprehensive assessment is completed

Question Explanation
Correct Answer is B
Rationale: When assessing the client’s closed chest drainage system, it is important to assess the
drainage in the collection chamber for color and amount. Significant increases/decreases in the
amount of drainage or obstructions of the tube should be reported to the provider immediately.
The collection chamber should not be emptied to measure output. Instead, the level of drainage
should be marked on the chamber with the date and time to determine the volume change from
the previous assessment. The tube should not be squeezed, milked, or stripped. Clamping the
tube should only be done for very short periods of time such as changing the drainage unit.
Concepts tested

Question 2847
The nurse is caring for a client with a history of drug abuse. The client informs the nurse their
last drug use was 6 weeks ago and are now experiencing abdominal pain and clay-colored stools.
Which statement would be appropriate for the nurse to make?

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A “Have you noticed dark urine since you took the drugs?”
B “Did you experience any headaches after you took the drugs?”
C “What kind of medications are you taking for your abdominal pain?”
D “Do you take any medications that change the color of your stool?”

Question Explanation
Correct Answer is A
Rationale: The client’s symptoms are indicative of viral hepatitis infection. Drug use is a primary
risk factor for hepatitis C. Hepatitis C is transmitted via injection-drug use and has an incubation
period of 2-12 weeks. Dark urine is a symptom of a newly acquired hepatitis C infection.
Headache is a non-specific symptom unrelated to an acute hepatitis C infection. Asking what
medications are being taken for the abdominal pain does not help identify the diagnosis.
Obtaining information regarding medications that change stool color is not enough to identify the
client’s problem. The nurse should focus on the timeframe of drug use and possible viral
exposure.
Concepts tested

Question 2848
The nurse is monitoring a client with psoriasis who is receiving prescribed localized
phototherapy. Which findings should the nurse expect to observe after phototherapy?
A Redness and a burning sensation at the site
B Fever less than 101⁰F and chills
C Headache, fatigue, and nausea
D New growths or patches near the site

Question Explanation
Correct Answer is A
Rationale: For patients who do not respond well to topical treatments, phototherapy using
narrow-band ultraviolet-B (UVB) therapy may be effective as a single-therapy modality.
Maintenance of mild skin erythema is desired for optimal results; however, burning should be
avoided. Signs and symptoms of burning post-phototherapy include moderate-to-severe redness,
tenderness, pain, tightness, itching, and rarely, blistering of the skin. Phototherapy may trigger a
recurrence of herpes simplex infections and increase the risk of skin cancer. Therefore, all new
lesions need to be evaluated.
Concepts tested

Question 2849
The nurse is responding to a low-pressure alarm for a client who has acute respiratory distress
syndrome and is on mechanical ventilation. Which action should the nurse take?
A Check if there is a disconnection in the system
B Suction the endotracheal tube
C Evaluate if the client is biting the tube
D Prepare the client for chest tube insertion

Question Explanation

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Correct Answer is A
Rationale: The low-pressure alarm on the mechanical ventilator indicates that there is a decrease
in pressure or loss in volume. When responding to a low-pressure alarm, the nurse should check
for disconnection in the system causing a leak. A high-pressure alarm indicates a peak in airway
pressure, often causes by kinked tubing from biting, increased secretions blocking the tube, and a
pneumothorax.
Concepts tested

Question 2850
The nurse is teaching a client with chronic kidney disease (CKD) about home management for
peritoneal dialysis (PD). Which of the following statements by the client indicates a need for
further teaching?
A “If my dialysate outflow is cloudy in appearance, it could mean that I have an infection.”
B “If my dialysate outflow is brown, it indicates that I am dehydrated.”
C “My dialysate outflow should typically be clear to light-yellow in appearance.”
D “My dialysate outflow may be bloody or pink-tinged for the first week.”

Question Explanation
Correct Answer is A
Rationale: Dialysate outflow should typically be clear to light-yellow in appearance. Dialysate
that is brown in appearance occurs with a bowel perforation and should be reported immediately.
It is common for dialysate outflow to be bloody or pink-tinged the first week after insertion of a
PD catheter; however, pink-tinged urine is not expected after this time frame. Cloudy appearance
of dialysate indicates possible infection and should be reported immediately to reduce the risk of
peritonitis.
Concepts tested

Question 2851
The nurse is teaching a client with a new colostomy about self-care management. Which
statement by the client would indicate to the nurse teaching was effective?
A “I should expect my stool to look watery.”
B “I will eat dark leafy vegetables daily to decrease the odor.”
C “The stoma should look beefy red and moist.”
D “I should empty the bag when it is two-thirds full.”

Question Explanation
Correct Answer is C
Rationale: The stoma should appear beefy red or pink and be well hydrated. A discolored stoma
can be an indication of anemia, and a dark purple or black stoma is a sign of impaired
circulation. A colostomy is created in the area of the large intestine. The majority of the water
has been absorbed. Therefore, the stool should be formed. Dark leafy vegetables increase the
odor of the stool. The colostomy bag should be emptied when it is one-third to one-half full to
prevent it from being dislodged from the appliance.
Concepts tested

Question 2852
Page | 1127
The nurse is taking care of a client experiencing dyspnea. The client becomes visibly anxious
and begins to hyperventilate. Which intervention will best promote airway clearance?
A Voluntary coughing
B Deep breathing exercises
C Incentive spirometry
D Pursed-lip breathing

Question Explanation
Correct Answer is D
Rationale: Pursed-lip breathing helps to prolong expiration and decrease airway collapse. Clients
should be instructed to purse their lips to create a narrow opening for air to flow through. This
will improve air exchange and decrease the shortness of breath. Voluntary coughing helps to
clear secretions but will not correct the existing dyspnea. Deep breathing exercises are beneficial
for clients experiencing hypoventilation. Incentive spirometry helps clients practice deep
breathing and expand their lungs. This intervention is not indicated for clients who are presently
experiencing shortness of breath.
Concepts tested

Question 2853
The nurse is caring for a client who is in the post-anesthesia care unit 30 minutes after a major
surgical procedure. The client states that they are experiencing nausea. Which of the following
actions by the nurse is appropriate to minimize additional gastrointestinal upset?
A Provide the client with a regular diet
B Administer an antiemetic medication
C Tell the client to walk to the bathroom
D Increase intravenous fluid intake

Question Explanation
Correct Answer is B
Rationale: If a client complains of nausea, they should be given an antiemetic medication to
avoid worsening of nausea or vomiting. The client should not be given a regular diet until they
have been able to tolerate clear liquids. While a client might be physically able to walk to the
bathroom 30 minutes after a surgical procedure, this is most likely a safety risk. Increasing
intravenous fluids does not minimize gastrointestinal discomfort.
Concepts tested

Question 2854
The nurse is preparing to give a dose of prescribed gentamycin IV to a client who has been
admitted with meningitis. Which lab results should be reported to the doctor before beginning
the medication?
A Creatinine level of 2.5 mg/dL
B Hematocrit of 45%
C White blood cell count of 20,000 mm3
D Erythrocyte count of 4.7 million/mm3

Page | 1128
Question Explanation
Correct Answer is A
Rationale: Gentamycin is used to treat meningitis but is nephrotoxic. The labs for kidney
function need to be monitored along with the WBCs. Creatinine is high and would indicate some
concerns related to the gentamycin.
Concepts tested

Question 2856
The nurse is caring for a group of assigned clients. The nurse should understand that which of the
following clients has the highest risk for developing metabolic acidosis?
A The client with diabetes who has had nausea for a week
B The client with pneumonia who reports shortness of breath
C The client with an ileus who has a prescription for nasogastric suctioning
D The client with an infection who has a documented temperature of 102°F

Question Explanation
Correct Answer is A
Rationale: Metabolic acidosis has a pH greater than 7.45 and HCO3 less than 22 and occurs
when the client loses bicarbonate through excessive diarrhea or with renal failure and diabetes. A
client with pneumonia is at risk for developing respiratory acidosis. A client with an infection
who has a fever is at risk of developing respiratory alkalosis. The client with an ileus who has a
prescription for nasogastric suctioning is at risk for developing metabolic alkalosis.
Concepts tested

Question 2857
The nurse is assessing a client with heart failure. Which finding observed by the nurse would
indicate a decrease in cardiac output?
A Crackles in bilateral lung bases
B Hypoactive bowel sounds
C Jugular vein distension
D Lower extremity edema

Question Explanation
Correct Answer is B
Rationale: Heart failure, which is the impairment of the ventricles to adequately fill and contract,
can lead to a decrease in cardiac output. A decrease in cardiac output will lead to a decrease in
perfusion to organs. Decreased perfusion will impair the function of the organs, such as
decreased peristalsis in the intestines, cool skin, confusion, and pain. When the heart is unable to
adequately pump the blood, vascular pressure will back up into the lungs and the systemic
circulation, leading to crackles in the lungs, edema, and vein distention.
Concepts tested

Question 2858
The nurse is caring for a client who is in a second-degree heart block and reports dizziness and
shortness of breath. The nurse notes the client's blood pressure is 90/40 mmHg. Which action
should the nurse take?
Page | 1129
A Prepare for transcutaneous pacing
B Perform synchronized cardioversion
C Administer prescribed atropine
D Administer prescribed vasopressin

Question Explanation
Correct Answer is A
Rationale: A second-degree block occurs when the electrical conduction is interrupted, usually at
the AV node, and does conduct through the Purkinje fibers. This results in the failure of the
ventricles to contract, which decreases cardiac output. To treat a second-degree block, the nurse
should prepare the client for transcutaneous pacing, which will increase cardiac output.
Synchronized cardioversion is used to treat tachycardia dysrhythmias, such as SVT or atrial
fibrillation. Atropine contraindicating in treating a second-degree block. Vasopressin causes
vasoconstriction, which increases blood pressure but will not treat second-degree block.
Concepts tested

Question 2859
The nurse on the telemetry unit is caring for a client who has a history of uncontrolled atrial
fibrillation. The nurse notes the client's heart rate has suddenly increased from 90 to 150 on the
central monitor. What action should the nurse take?
A Monitor the client at the bedside with the code cart defibrillator
B Have the telemetry technician notify the nurse of any changes
C Prepare to transfer the client to the intensive care unit
D Review the monitor history for the rhythm change

Question Explanation
Correct Answer is A
Rationale: Telemetry monitoring should be used for clients at high risk for life-threatening
dysrhythmias. However, when a change is detected, the client should be transitioned to a bedside
monitor. The code cart defibrillator provides monitoring and intervention as needed. Monitoring
of the client should not be delegated in an unstable client situation. The client has a history of
atrial fibrillation and may not require transfer to a higher level of care. Even so, other
interventions take priority. Reviewing the cardiac history in the monitor is not the priority for
this patient.
Concepts tested

Question 2860
The nurse is caring for a client with a history of advanced peripheral vascular disease. Which of
the following findings should be reported to the healthcare provider immediately?
A Dull pain in both calves
B Pedal edema 3+ by the end of the day
C Redness of a unilateral extremity
D Diminished sensation in the lower extremities

Question Explanation

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Correct Answer is C
Rationale: Increased redness in one extremity is a sign of impaired venous return and possibly
venous thromboembolism. This is a reportable assessment finding. All other findings are
expected in the client with PVD.
Concepts tested

Question 2861
The nurse is providing education on medication resistance to a client with tuberculosis. Which
statement made by the client indicates further teaching is needed?
A “I will need to take a combination of medications to eliminate the bacteria.”
B “I will need to take these medications until I feel better.”
C “Some of these medications may change the color of my urine.”
D “I will need to have liver function tests before and after treatment.”

Question Explanation
Correct Answer is B
Rationale: Medications prescribed for tuberculosis should be taken for the entire course of
treatment (between 6-12 months) to decrease the risk of resistant strains. Two or more
medications are recommended to decrease the risk of resistance. Rifampin, a bacteriostatic and
bactericidal antibiotic used to treat tuberculosis changes the color of urine and other bodily
secretions to orange. Isoniazid, rifampin, and pyrazinamide are three primary medications used
to treat tuberculosis. All medications can cause hepatotoxicity, so liver function studies should
be performed before and after treatment.
Concepts tested

Question 2862
The nurse is receiving a report from a skilled nursing facility (SNF) for a client being admitted to
an inpatient unit. The client has a worsening wound infection that requires treatment. Which
statement from the SNF nurse will require further follow-up by the nurse?
A “The client is able to ambulate 50 feet independently.”
B “The last oral temperature was 37.5°C (99.6°F).”
C “The latest white blood cell count (WBC) was 7,500/mm³.”
D “There is a stage 3 pressure ulcer to the coccyx.”

Question Explanation
Correct Answer is D
Rationale: Handoff report should follow the situation-background-assessment-recommendation
(SBAR) strategy. A detailed report should include a focused physical assessment and a current
treatment plan. The nurse reporting a stage 3 ulcer should include accompanying symptoms,
drainage, and treatment. The statement regarding the client’s independent ambulation does not
require further details. The latest temperature and laboratory values are expected findings for
someone with an infection.
Concepts tested
Page | 1131
Question 2863
The nurse has received reports on a group of assigned clients with neurological disorders. Which
client should the nurse see first?
A The client who had a lumbar laminectomy, equal strength in bilateral lower extremities, lower
back pain 4/10, and denies numbness/tingling
B The client who had an ischemic stroke, received thrombolytic therapy in the ER, a BP of
160/90, and a stable neurological assessment
C The client who reports uncontrolled headaches, was diagnosed with glioblastoma, and is
vomiting for the second time in 3 hours
D The client who has kyphoplasty of a spinal compression fracture, back pain 3/10, and
persistent bilateral tingling and weakness in the lower extremities

Question Explanation
Correct Answer is C

Question 2864
The emergency department nurse is caring for a client with a laceration to the right leg that is
bleeding profusely. The client has a heart rate of 115 beats/min and a capillary refill of 4 seconds
to the right toes. Which action does the nurse perform to promote circulation in the client?
A Place the client in a prone position
B Infuse prescribed isotonic intravenous fluids
C Apply a gauze dressing to the right leg
D Administer prescribed opioid analgesics

Question Explanation
Correct Answer is B
Rationale: A primary survey for trauma clients consists of the ABCDE criteria. “C” stands for
circulation, and interventions are aimed at restoring effective blood flow. Isotonic intravenous
fluids maintain fluid volume and prevent shock. Placing the client in a prone position will not
promote circulation. In clients with impending shock, the lower extremities should be elevated to
shunt blood towards vital organs. Applying a wound dressing to the right leg will not promote
circulation. Hemorrhage control includes applying direct pressure to the wound. Administering
prescribed analgesics will help the client with pain management but will not promote circulation.
Concepts tested

Question 2865
The nurse is caring for a client with rheumatoid arthritis experiencing epigastric pain and
dyspepsia. Which question will provide the nurse with further details about the client’s
symptoms?
A “How long have you had rheumatoid arthritis?”
B “Do you exercise regularly?”
C “Which medication do you take for the inflammation?”
D “How much fiber do you consume daily?”

Page | 1132
Question Explanation
Correct Answer is C
Rationale: The treatment for rheumatoid arthritis (RA) begins with nonsteroidal anti-
inflammatory drugs (NSAIDs). NSAIDs reduce the inflammation associated with rheumatoid
arthritis. NSAIDs can damage the gastric mucosa and cause ulcerations, heartburn, and
indigestion. Asking the client how long they have had RA will not provide specific information
related to the epigastric pain and dyspepsia. Asking the client if they exercise regularly is
unrelated to the client’s concern. The amount of fiber consumed daily is unrelated to the client’s
medical history.
Concepts tested

Question 2866
A nurse is caring for a client who experienced head trauma from a motor vehicle collision. While
assessing the client, the nurse notes a serosanguinous fluid leaking from the client’s ear. Which
is the priority action for the nurse to take?
A Obtain a culture of the drainage
B Observe the drainage for a halo sign
C Document the drainage
D Cleanse the area to remove the drainage

Question Explanation
Correct Answer is B
Rationale: Basal skull fractures are suspected when CSF escapes from the ears (CSF otorrhea)
and the nose (CSF rhinorrhea). Drainage of CSF is a serious problem because meningeal
infection can occur if organisms gain access to the cranial contents via the nose, ear, or sinus
through a tear in the dura. The “halo” or “double-ring” sign is a method for determining whether
bloody discharge from the ears or nose contains cerebrospinal fluid (CSF). Culture,
documentation, and hygiene are all important components of care, but identifying a CSF leak is
the priority intervention.
Concepts tested

Question 2867
The nurse is caring for a client who has a wound with a closed drainage system in place. Which
of the following assessments findings should be documented each time the collection chamber is
emptied?
A Color of drainage
B Urine output amount
C Auscultation of bowel sounds
D Size of wound measurement

Question Explanation
Correct Answer is A
Rationale: When a drain is emptied, the nurse should assess and document the drainage color and
amount as well as if there are clots or sediment present in the drainage. Urine output, bowel
sounds, and wound measurements are assessed frequently but are not necessary to be assessed
each time the collection chamber is emptied.
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Concepts tested

Question 2868
The nurse is caring for a client with a chronic ankle wound. There is limited hair growth on the
leg, the skin is pale, non-edematous, and the patient reports pain with ambulation. Which
prescription would require collaboration with the healthcare provider?
A Obtain an ankle brachial index
B Apply a compression bandage
C Schedule a doppler ultrasound
D Perform neurovascular checks

Question Explanation
Correct Answer is B
Rationale: Knowing the etiology of a wound directly impacts decisions related to assessment and
treatment of the wound. The client is demonstrating signs and symptoms of arterial disease.
Compression therapy is used in the treatment of venous insufficiency and would not be used in
the management of arterial disease. All other options are appropriate for the diagnosis and
management of peripheral artery disease.
Concepts tested

Question 2869
A nurse is developing the plan of care for a neonate diagnosed with hyperbilirubinemia with a
new prescription for phototherapy. What intervention should the nurse include in the plan of
care?
A Keep in the fetal position
B Ensure the neonate is covered
C Apply opaque eye covers
D Transition the neonate to formula feedings

Question Explanation
Correct Answer is C
Rationale: Absorption of light through the skin converts unconjugated bilirubin into bilirubin
photoproducts that are excreted in the stool and urine. During phototherapy, the newborn's eyes
are covered to protect from the lights. The newborn is turned every 2 hours to expose all areas of
the body to the lights and is kept undressed, except for the diaper area, to provide maximum
body exposure to the lights. Fluid intake is increased to allow for added fluid, protein, and
calories but transitioning to formula is not required.
Concepts tested

Question 2870
The nurse is caring for a client who has a tracheostomy to a bedside ventilator. The nurse notes
the client attempting to speak through the tracheostomy. Which action should the nurse take?
A Assess cuff pressure
B Provide tracheostomy care
C Suction the client

Page | 1134
D Assess lung compliance

Question Explanation
Correct Answer is A
Rationale: Assessment of the tracheostomy cuff should be completed to assure the ventilatory
processes are being achieved to the maximum potential. Tracheostomy tube cuff pressures
should be routinely monitored. Cuff pressure should be maintained between 15-30 cm H2O (up
to 22 mm Hg). When cuff pressures are low, it can be due to inadequate cuff inflation,
positioning, damaged cuff, or tracheomalacia.
Concepts tested

Question 2871
The nurse is performing suctioning of a client’s endotracheal (ET) tube. Which of the following
actions is appropriate for the nurse to make?
A Apply suctioning for at least 30 seconds
B Hyperoxygenate the client prior to inserting the suction catheter
C Apply suction while inserting and removing the suction catheter
D Instill 2-3 drops of saline into the ET tube prior to suctioning

Question Explanation
Correct Answer is B
Rationale: The nurse should hyperoxygenate the client with 100% oxygen for 30 seconds to 3
minutes prior to suctioning the endotracheal tube to prevent hypoxemia. The nurse should
suction no longer than 15 seconds at a time. Suctioning should only be applied while removing
the catheter, never during insertion. Instillation of normal saline during suctioning is not
supported by evidence; this action may impair gas exchange and increase the risk of pulmonary
infection.
Concepts tested

Question 2872
The nurse is caring for a client who is scheduled for a jejunostomy tube placement. The client
states “Why is the tube not being placed in my stomach?” Which statement by the nurse would
be appropriate to make?
A “The jejunum can tolerate more feedings than the stomach.”
B “It is safer to place the tube in the jejunum as opposed to the stomach.”
C “The tube is more secure in the jejunum than in the stomach.”
D “The jejunum absorbs nutrients better than the stomach.”

Question Explanation
Correct Answer is D
Rationale: The jejunum is part of the small intestine and is the site of maximum nutrient
absorption. The stomach prepares food for absorption. The jejunum is the largest part of the
small intestine. Jejunostomies are placed to enhance absorption, not because of size. Insertion of
both feeding tubes carries the same risks. Jejunostomies and gastrostomies can be done via

Page | 1135
percutaneous endoscopy or a surgical procedure. Enteral tubes are not easily dislodged. They are
secured with internal and external crossbars.
Concepts tested

Question 2873
The nurse is preparing to implement prescribed postural drainage (PD) for a client with cystic
fibrosis. The nurse notes that the client has an accumulation of mucous secretions in the left
lower lateral bronchus. The nurse should position the client in which position?
A High-Fowler’s
B Low-Fowler’s
C Left Sims'
D Right Trendelenburg

Question Explanation
Correct Answer is D
Rationale: Postural drainage (PD) requires client positioning that promotes drainage of secretions
into the trachea for easier removal. Secretions in the left lower lateral bronchus require the client
to be on their right side with the head of the bed lowered to facilitate the movement of secretions
via gravity. High- and low-Fowler’s positions will cause further accumulation of secretions at the
bases of the lungs. Left Sims' will not promote movement of the secretions into the trachea. The
movement needs to flow opposite the area of concern.
Concepts tested

Question 2874
A nurse is preparing to remove staples from a client's surgical incision who had a total knee
arthroplasty. Which of the following actions should the nurse take?
A Instruct the client that this is a painless procedure
B Squeeze the handle while simultaneously lifting the staple remover
C Scrub the surgical site prior to removing the staples
D Remove every other staple first

Question Explanation
Correct Answer is D
Rationale: Every other staple should be removed first to monitor the wound edges for
approximation. Surgical sites with sutures and staples should not be scrubbed but should be
cleansed prior to removal to allow for assessment. Removal of staples requires a staple
extractor. Do not pull up while depressing the handle on the staple remover. The closed handle
depresses the middle of the staple causing the two ends to bend outward and out of the top layer
of skin. Removal of the metal skin staples after total knee arthroplasty is associated with
moderate-to-severe pain, and therefore, the nurse needs to premedicate the client as prescribed.
Concepts tested

Question 2875
The nurse is reviewing lab results for a client that has been taking anti-tuberculosis medication.
Which diagnostic result would indicate that the treatment is having the desired effect?

Page | 1136
A Sputum culture
B Chest X-ray
C Tuberculin skin test
D Gold test

Question Explanation
Correct Answer is A
Rationale: Sputum culture results are monitored for acid-fast bacilli to evaluate the effectiveness
of the treatment regimen and adherence to therapy. The other tests will not indicate the
effectiveness of treatment.
Concepts tested

Question 2876
The nurse is caring for a client with hypotension who has a prescription to administer an infusion
of isotonic IV fluids. Which of the following fluids should the nurse anticipate administering to
the client?
A 0.33% normal saline
B 0.9% normal saline
C 5% dextrose in normal saline
D 0.45% normal saline

Question Explanation
Correct Answer is B
Rationale: A client with hypotension requires fluid volume replacement in the vascular space.
Isotonic solution, such as 0.9 normal saline and lactated Ringer’s, is used to increase vascular
volume. Isotonic solutions do not create a fluid shift, which will keep the volume in the vascular
space increasing the blood pressure. Hypertonic solutions, such as 5% dextrose in 0.9% normal
saline, will shift fluid from the intracellular space into intravascular space. Hypotonic solutions,
such as 0.33% normal saline and 0.45% normal saline, shift fluid from the vascular space to the
intracellular space.
Concepts tested

Question 2877
The nurse is caring for a client with aortic valve stenosis who reports dizziness and shortness of
breath with ambulation. Which would be the priority for the nurse to assess?
A Heart rate
B Pulse oximetry
C Blood pressure
D Respiratory rate

Question Explanation
Correct Answer is C
Rationale: Aortic stenosis is a hardening of the aortic valve leaflets resulting in an impairment of
the aortic valve to open and close. The left ventricle has to work harder to push blood through
the stenotic valve, which can result in a decreased cardiac output. A client who is engaging in

Page | 1137
activity and reports dizziness and shortness of breath could be experiencing a decrease in cardiac
output. The nurse should assess the client’s blood pressure to evaluate decreased cardiac output.
Heart rate, pulse oximetry, and respiratory rate can assess an alteration in cardiac and respiratory
function but does not directly assess cardiac output.
Concepts tested

Question 2878
The nurse is assessing a client who is 16 hours post CABG. The nurse notes that the client's
pulmonary artery wedge pressure is elevated at 14 mmHg. Which of the following would be the
best action for the nurse to take?
A Auscultate lung sounds
B Increase the prescribed intravenous fluids (IVF)
C Position the client in modified Trendelenburg
D Administer prescribed dopamine

Question Explanation
Correct Answer is A
Rationale: The pulmonary artery wedge pressure assesses left ventricular function. Normal
wedge pressures are between 4-12 mmHg. A pulmonary wedge pressure of 14 mm/Hg indicates
a high pressure in the left ventricular. High pressures usually occur with increased volume in the
left ventricular, associated with left ventricular failure. The nurse should assess for the
development of left ventricular failure and fluid volume overload by auscultating lung sounds.
The nurse would increase IVF, administer prescribed dopamine, and position in modified
Trendelenburg if the client had a low pulmonary artery wedge pressure, which would indicate
decrease volume.
Concepts tested

Question 2879
The nurse is caring for a client with acute coronary syndrome when the client’s cardiac monitor
indicates artifact. What action should the nurse take?
A Provide skin care to electrode sites
B Request that the family members encourage the client to rest
C Remove the client’s blankets from over the leads
D Assist the client to take deep breaths and cough

Question Explanation
Correct Answer is A
Rationale: Artifact is a common finding in patients requiring an electrocardiogram (ECG).
Muscle twitching is a prominent cause (i.e., shivering, tremors); however, improper lead
placement and lead displacement from sweating can also be causes. Artifact can also be caused
by hiccups and internal medical devices. Removing the blankets will cause the client to lose heat
and possibly lead to shivering. Blankets rarely cause artifact. Cough can lead to temporary
artifact but is not a common cause.
Concepts tested

Question 2880
Page | 1138
The nurse is caring for a client with a history of unstable angina who reports chest pain. What
accompanying assessment finding would be the priority to include when reported to the
healthcare provider?
A Elevated blood pressure
B ST-segment elevation
C Jaw pain
D Dizziness

Question Explanation
Correct Answer is B
Rationale: Angina pectoris refers to chest pain that is brought about by myocardial ischemia.
Unstable angina is characterized by attacks that increase in frequency and severity and are not
relieved by rest and administering nitroglycerin. Patients with myocardial ischemia may present
with a variety of symptoms other than chest pain. Pain can cause a transient elevation in blood
pressure. Some complain of epigastric distress and pain that radiates to the jaw or left arm.
Patients who are older or have a history of diabetes or heart failure may report shortness of
breath. Many women have been found to have atypical symptoms, including indigestion, nausea,
palpitations, and numbness. Patients presenting with acute coronary syndrome without ST-
segment elevation on the electrocardiogram are classified as having unstable angina. Once ST-
segment elevation occurs, this indicates a potential progression to myocardial infarction and
should be reported immediately.
Concepts tested

Question 2881
The nurse is providing education on self-care to a client with diabetes type 2. Which statement
made by the client indicates an understanding of the teaching?
A “I should eat a carbohydrate snack after intense exercise.”
B “I need to test the temperature of the water before I wash my feet.”
C “I will buy a soft toothbrush to brush my teeth.”
D “I should avoid taking my hypoglycemic medication if I’m sick.”

Question Explanation
Correct Answer is B
Rationale: One of the complications of diabetes is diabetic neuropathy. Damage to the sensory
nerve fibers causes numbness, tingling, and pain in the lower extremities. Clients with diabetes
are at a higher risk for injury due to a lack of sensation on the feet. Water should be tested prior
to use to avoid burns. Carbohydrates should be eaten prior to exercising to avoid hypoglycemia.
A soft toothbrush is indicated for clients on anticoagulants to prevent bleeding gums. Clients
should continue taking their medication even if ill to prevent hyperglycemia and complications
from diabetes.
Concepts tested

Question 2882
The nurse is caring for a client with multiple fractures. After the client’s physical therapy
session, the client’s caregiver verbalizes to the nurse, “I don’t know if I can manage all of this at
home.” What is the nurse’s response?
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A “I will speak with the case manager regarding outpatient options.”
B “It is difficult, but the fractures will heal soon.”
C “Who else will be helping you at home?”
D “Why do you think you will have trouble performing the therapy?”

Question Explanation
Correct Answer is A
Rationale: Continuity of care ensures that the client and their caregivers feel comfortable
performing mobility exercises at home. Concerns regarding the ability to continue treatment
should be referred to a case manager for follow-up. The client may benefit from outpatient
therapy or home health services. Telling the caregiver that the fractures will heal soon does not
address the concern. Asking who else will be helping the caregiver assumes that the client has
additional social support and does not address the caregiver’s concerns. “Why” questions have
an accusatory tone and do not promote empathy towards the client or caregiver.
Concepts tested

Question 2883
The nurse is caring for a client with a central venous line who has a prescription for intravenous
potassium chloride to treat severe hypokalemia. When attempting to administer the medication,
the nurse encounters significant resistance to flushing. What is the appropriate procedure in this
situation?
A Forcefully flush the line and begin the infusion
B Aspirate and reattempt flushing
C Clamp and remove the line
D Insert a peripheral access, and administer the infusion

Question Explanation
Correct Answer is B
Rationale: Assessing for blood return is important in determining the patency of a central line. If
blood return is present, flush the line, and begin the infusion. Forceful flushing of a line may
dislodge a thrombus attached to the end of the line leading to embolization. If a blockage is
identified, the line may be cleared with tPA; therefore, it is not appropriate to immediately
remove the line. Administration of IV potassium via peripheral IV is discouraged due to
phlebitis.
Concepts tested

Question 2884
The nurse is assessing a child with bacterial epiglottitis. The nurse notes inspiratory stridor and
substernal retractions. After placing the child on oxygen, which action should the nurse perform
next?
A Place the client on airborne precautions
B Obtain a throat culture
C Prepare an intubation tray
D Administer prescribed corticosteroids

Page | 1140
Question Explanation
Correct Answer is C
Rationale: Bacterial epiglottitis is an inflammation of the epiglottis and is considered a medical
emergency. Swelling of the epiglottis blocks airflow as indicated by stridor and substernal
retractions. The nurse should prepare an intubation tray and be prepared to assist in the
procedure. Clients should be placed on droplet precautions after initiation of antibiotic therapy.
Throat cultures should be avoided with epiglottitis to prevent further obstruction of the airway.
Administration of corticosteroids is an expected treatment. However, the airway must first be
secured.
Concepts tested

Question 2885
A nurse is reviewing laboratory data for a client with diabetes mellitus type 2. Which finding
indicates disease progression?
A Serum glucose level of 110 mg/dL
B Hemoglobin level of 11 g/dL
C HbA1C level of 5.8%
D Creatinine level of 2.1 mg/dL

Question Explanation
Correct Answer is D
Rationale: Creatinine level measures kidney function. One of the complications of diabetes
mellitus is diabetic nephropathy. The normal creatinine level is 0.5 to 1.0 mg/dL. Elevated levels
indicate kidney damage. A serum glucose level of 110 mg/dL is slightly elevated but not
uncommon for a client with a history of diabetes mellitus. The normal serum glucose level is 65
to 99 mg/dL. A hemoglobin level of 11 g/dL is below normal but is unrelated to diabetes
mellitus. Hemoglobin levels evaluate the amount of oxygenated red blood cells. An HbA1C level
of 5.8% is slightly above normal (5.7%). However, this does not indicate disease progression.
Concepts tested

Question 2886
The nurse is caring for a client who is postoperative and is unable to void 6 hours after removal
of the indwelling urinary catheter. Which of the following actions is appropriate?
A Obtain a prescription to reinsert the indwelling catheter.
B Perform a bladder scan.
C Monitor the client for discomfort.
D Provide the bedpan more frequently.

Question Explanation
Correct Answer is B
Rationale: Postoperative urinary retention is the inability to urinate after a surgical procedure
despite having a full bladder. It is a relatively common complication. Anesthesia, medications,
and pain can all affect the client’s ability to void. Measures to encourage normal voiding include
providing privacy and assisting the patient with the use of the bathroom or bedside commode,
rather than a bedpan, to provide a more natural setting. When the patient cannot void, bladder
scanning is used to assess for distension, then straight catheterization (as prescribed) is used to
Page | 1141
prevent overdistention of the bladder. Continuing to monitor the client is not ideal as retained
urine increase the risk for infection.
Concepts tested

Question 2887
The nurse is caring for a client who is undergoing radiation therapy. Which of the following
assessment findings would indicate that the client is experiencing an adverse effect of this
treatment?
A Mild fatigue after treatment.
B Desquamation of the treatment area.
C Reduction of urine output.
D Increase in white blood cell count.

Question Explanation
Correct Answer is B
Rationale: Desquamation is an alteration of the skin that indicates radiation dermatitis. This
should be monitored closely, and if severe, may necessitate interruption or cessation of radiation
therapy. Fatigue is an expected finding and is not considered an adverse effect. White blood cell
count may remain the same or decrease but does not increase with radiation therapy. Urine
output is not affected by radiation therapy.
Concepts tested

Question 2888
The nurse is transporting a client with an indwelling urinary catheter to the radiology
department. What intervention should be implemented to reduce the risk of catheter-associated
urinary tract infection (CAUTI)?
A Empty the drainage bag and keep it below the level of the bladder during transport.
B Break the red seal and disconnect the drainage bag for transport.
C Remove the catheter and reinsert when the client returns to the room.
D Remove the catheter and reinsert when the client returns to the room.

Question Explanation
Correct Answer is A
Rationale: Hospital-acquired infections (HAI) can often be linked to invasive devices, such as a
urinary catheter. For example, CAUTIs are the most common type of HAIs. Infection control
measures include adherence to recommended best practices or bundles. The CAUTI bundle
includes core prevention strategies, such as using aseptic technique and sterile equipment during
insertions, maintaining a closed drainage system, and maintaining unobstructed urine flow.
Therefore, it is important to keep the tubing and bag below the level of the bladder. Changing
indwelling catheters or drainage bags is not recommended unless based on clinical indications
such as infection, obstruction, or when the closed system is compromised.
Concepts tested

Question 2889
The nurse is monitoring a neonate with jaundice who is receiving prescribed phototherapy. What
finding would indicate to the nurse the treatment is effective?
Page | 1142
A Urine specific gravity level is decreasing.
B Hemoglobin level is decreasing.
C Albumin level is decreasing.
D Bilirubin level is decreasing.

Question Explanation
Correct Answer is D
Rationale: Phototherapy reduces bilirubin levels in the blood by breaking down unconjugated
bilirubin to be excreted in the bile and stool. Phototherapy aims to prevent kernicterus, a
condition in which unconjugated bilirubin enters the brain. If untreated, kernicterus can lead to
brain damage and death. Side effects of phototherapy include frequent loose stools and increased
insensible water loss. Therefore, when caring for newborns receiving phototherapy for jaundice,
nurses should monitor fluid and electrolyte balance, weight, urine output, and urine specific
gravity. However, changes to specific gravity do not indicate treatment effect. Serum protein is
unaffected by phototherapy. Hemoglobin levels may decline due to hemolysis or hydration status
but do not indicate treatment effectiveness.
Concepts tested

Question 2890
The nurse is caring for a client who has just been intubated in preparation for mechanical
ventilation. Which action should the nurse do next?
A Obtain a STAT chest x-ray.
B Collect arterial blood gas specimen.
C Verify end-tidal CO2.
D Auscultate bilateral breath sounds.

Question Explanation
Correct Answer is A
Rationale: During intubation, an endotracheal tube is inserted through the client’s mouth, into the
airway. Before the endotracheal tube can be connected to the mechanical ventilation, the tube
placement must be confirmed. The nurse will auscultate bilateral breath sounds. A chest x-ray,
arterial blood gas specimens, and verifying end-tidal CO2 are performed but after the placement
has been confirmed.
Concepts tested

Question 2891
The nurse is performing suctioning of a client’s tracheostomy. Which of the following actions is
appropriate for the nurse to make?
A Apply suction with the pressure dial at 80–120 mm Hg.
B Instill 2–3 drops of saline into the tracheostomy prior to suctioning.
C Apply suction for less than 30 seconds.
D Hyperoxygenate the client for 15 seconds after suctioning.

Question Explanation
Correct Answer is A

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Rationale: The pressure dial for suctioning should never exceed 120 mm Hg to prevent
hypoxemia and trauma to the respiratory mucosa. Instillation of normal saline during suctioning
is not supported by evidence; this action may impair gas exchange and increase the risk of
pulmonary infection. The nurse should suction no longer than 15 seconds at a time.
Hyperoxygenation after suctioning should be performed for 1 to 5 minutes after suctioning or
until the client’s baseline heart rate and oxygen saturation are within normal limits.
Concepts tested

Question 2892
The nurse is teaching the partner of a client with a newly placed tracheostomy tube about home
care. Which statement by the client’s partner indicates understanding of tracheostomy care?
A “I will make sure my partner is lying flat while I perform the care.”
B “A cotton filled gauze dressing should be applied around the tube.”
C “I will throw away left over saline solution at the end of the day.”
D “This procedure must always be performed in a sterile environment at home.”

Question Explanation
Correct Answer is C
Rationale: Saline solution can harbor bacteria and enter the respiratory system if used. Caregiver
education should include instructions on infection control. The client should be placed in a semi-
Fowler’s position as tolerated. This position facilitates breathing and coughing. Gauze dressings
should not be filled with cotton as they can cause the aspiration of foreign bodies into the lungs.
Sterile technique is not necessary in a home setting. Clean technique may be used.
Concepts tested

Question 2893
A client in the emergency department reports severe abdominal pain, referred shoulder pain, and
vaginal bleeding. An ultrasound confirms an ectopic pregnancy. Which intervention does the
nurse expect to perform next?
A Prepare the client for surgery.
B Educate the client on maintaining bedrest.
C Provide emotional care and support.
D Administer prescribed analgesic.

Question Explanation
Correct Answer is A
Rationale: The client’s signs and symptoms are indicative of ectopic pregnancy with tubal
rupture. Medical management includes surgery to remove the fallopian tube and control the
bleeding. The nurse should prepare the client for surgery. Educating the client on maintaining
bedrest is not indicated at this time. Providing emotional care and support is an important
intervention after the client has been stabilized. Administering an analgesic will relieve the pain
but is not a priority intervention at this time.
Concepts tested

Question 2894
Page | 1144
The nurse is removing staples from a wound. During the process, the nurse notes that the edges
of the wound begin to separate, and the client reports increased pain. What is the appropriate
action?
A Allow the client to have time to deep breath and relax and then continue to remove the
staples.
B Stop removing the staples and apply steri-strips to the open area.
C Pause to medicate the patient for pain before continuing to remove the remainder of the
staples.
D Decrease the rate at which each staple is removed.

Question Explanation
Correct Answer is B
Rationale: Dehiscence is a complication of suture/staple removal, especially with abdominal
wounds. If the nurse notices that the wound edges are separating, it is essential to stop removing
the staples, apply steri-strips to the open areas, and notify the healthcare provider. Pain is a
symptom of dehiscence and therefore it is more important to focus on the cause at this time.
Decreasing the rate of staple removal will not reduce the risk of dehiscence.
Concepts tested

Question 2895
The nurse in the clinic is caring for a client who is taking newly prescribed HARRT. Which
diagnostic test should the nurse review to determine the effectiveness of this treatment?
A Complete blood count
B Viral load
C Total lymphocyte count
D CD4 level

Question Explanation
Correct Answer is B
Rationale: Viral load measures the amount of HIV genetic material that is in the blood, A
decrease in the viral load would show that HAART is effective. CD4 levels, total lymphocytes,
and blood count will show the impact of HIV on the immune system but not the effectiveness of
antiviral treatment.
Concepts tested

Question 2896
The nurse is monitoring a client with fluid volume excess (FVE). Which of the following would
provide the nurse with the most accurate evaluation of the client’s fluid balance?
A Strict intake documentation
B Daily weights
C Weekly hemoglobin testing
D Lower extremity edema measurements
Lower extremity edema measurements

Question Explanation

Page | 1145
Correct Answer is B
Rationale: When monitoring clients with fluid volume excess (FVE), the nurse should evaluate
the client’s fluid balance for any increase or decrease in the balance. Physical assessments, such
as measuring edema and auscultating lungs, provide information to the nurse if the client has an
excess fluid, but does not indicate if the client has an increase in the balance. Laboratory results,
such as hemoglobin and hematocrit or electrolytes, can determine if there is an excess in fluid
volume but does not indicate if there is a change in the balance. Strict intake documentation is
appropriate for a client with FVE but is not accurate. Daily weights are the most accurate way to
evaluate fluid volume balance.
Concepts tested

Question 2897
The nurse is reviewing the cardiac rhythm strip of a client who reports the sudden onset of
palpitations. The nurse should understand the client is experiencing which abnormal cardiac
rhythm?

A Ventricular fibrillation
B Sinus tachycardia
C Atrial fibrillation
D Supraventricular tachycardia

Question Explanation
Correct Answer is D
Rationale: Supraventricular tachycardia (SVT) is an abnormal cardiac rhythm that occurs when
the cardiac impulse reenters from the AV node, resulting in a fast, regular rate. SVT will have a
narrow QRS and no identifiable P waves on the rhythm strip. Sinus tachycardia will have a fast
regular rate but identifiable P waves. Atrial fibrillation will have a fast, irregular rate with no
identifiable P waves. Ventricular fibrillation will have no rate, no P waves, and no QRS.
Concepts tested

Question 2898
A nurse is reviewing the telemetry strip for a client with a newly placed pacemaker set for
ventricular pacing. Which finding would indicate to the nurse the pacemaker is functioning
properly?
A Pacemaker spikes after each ST segment.
B Pacemaker spikes before each P wave.
C Pacemaker spike before each QRS complex.
D Pacemaker spike after the R wave.

Page | 1146
Question Explanation
Correct Answer is C
Rationale: A pacemaker is inserted when a client has dysrhythmias that cause slow or fast heart
rates. The pacemaker provides electrical stimulation that will control the client’s heart rate.
Pacemakers are designed to provide electrical stimulation in the atria, ventricles, or both. For a
ventricular pacemaker, the pacemaker spike will appear before the QRS, which represents
ventricular contraction. A pacemaker spike will appear before the P wave for atria pacing. A
pacemaker spike after the R wave or ST-segment indicates a malfunction of the pacemaker.
Concepts tested

Question 2899
The nurse is caring for a client whose cardiac monitoring has been complicated by frequent
artifact. While at the nurses’ station, the central monitor alarms indicate that the heart rate is
outside of the alarm parameters. What is the correct action by the nurse?
A Call the telemetry technician to verify the rhythm.
B Go to the client’s room to collect additional assessment data.
C Ask a second nurse to review the rhythm on the monitor.
D Silence the central monitor alarm.

Question Explanation
Correct Answer is B
Rationale: Telemetry monitoring comes with various alarms, some signaling critical events that
require clinical intervention. Telemetry can also trigger nuisance alarms, such as low battery,
artifact, and improperly set limits, contributing to alarm fatigue in nurses. Alarm fatigue
increases the risk of adverse patient outcomes. Alarms should be set appropriately, and artifacts
mitigated to protect patient safety. The patient should be assessed first to determine if there is an
actual cardiac event, then additional interventions can be implemented.
Concepts tested

Question 2900
The nurse is assessing a client with an abdominal wound who had surgery 5 days ago. Which
finding would the nurse report immediately to the healthcare provider?
A Serosanguinous fluid draining from the incision.
B Tissue swelling along the incisional line.
C Tenderness on the incision upon palpation.
D Dryness noted around the skin of the incision.

Question Explanation
Correct Answer is A
Rationale: Serosanguinous fluid draining from an incision that is 5 days post-operatively is an
indication of impending dehiscence. The nurse should report this drainage to the healthcare
provider promptly. Tissue swelling along the incisional line can be indicative of collagen
synthesis, a normal response to wound healing. Tenderness upon palpation of the incision is an
expected finding within the post-operative timeframe. Dryness noted around the skin of the
incision requires education to the client. The wound and surrounding skin should be kept well
hydrated to promote healing.
Page | 1147
Concepts tested

Question 2901
The nurse is providing education on illness management to a client with rheumatoid arthritis.
What instructions should the nurse provide to the client?
A “Take over the counter medications if you have a fever.”
B “Apply an ice pack to your painful joints.”
C “Take a cold shower in the mornings.”
D “Space out activities throughout the day.”

Question Explanation
Correct Answer is D
Rationale: Expected findings in a client with rheumatoid arthritis (RA) include fatigue. Clients
should be encouraged to space out activities throughout the day to conserve energy. Fever is an
early or late manifestation of a RA exacerbation and should be reported immediately to the
healthcare provider. Pain in the joints benefits from heat, not cold. Morning stiffness of the joints
benefits from a hot, not cold shower.
Concepts tested

Question 2902
The nurse is preparing to perform nasotracheal suctioning for a client with secretions. Which
action should the nurse take first?
A Set the suction pressure to 160 mmHg.
B Apply clean gloves.
C Raise the head of the bed to 30 degrees.
D Preoxygenate the client.

Question Explanation
Correct Answer is D
Rationale: Suctioning of the airway can irritate the mucosa and remove oxygen from the airways.
The nurse should administer supplemental oxygen before the procedure to avoid hypoxemia. The
suction pressure should be set to no more than 150 mmHg for adults. The tube used to suction
the airway can introduce organisms into the lungs. The procedure should be sterile. The head of
the bed should be elevated to at least 45 degrees to promote coughing and lung expansion.
Concepts tested

Question 2903
The nurse is assisting with an emergency endotracheal intubation who has a prescription for soft,
bilateral wrist restraints. Which of the following is an appropriate action for the nurse to take?
A Secure the restraint to the bed using a quick release knot.
B Ensure four fingers fit under the restraint cuff.
C Time periods without restraints are attempted.
D Assess circulation every 4 hours.

Question Explanation

Page | 1148
Correct Answer is A
Rationale: Self-extubating poses a serious risk to a client with respiratory failure. Restraints are
implemented to protect the patient from harm, but also pose their own risks. Two fingers should
fit between the cuff and the client’s wrist. Restraints should be tied to the bed frame using a
quick-release knot (i.e., slipknot). Assess the patient at least every hour or according to facility
policy. Assessment should include the placement of the restraint, neurovascular assessment of
the affected extremity, and skin integrity. In addition, assess for signs of sensory deprivation,
such as increased sleeping, daydreaming, anxiety, panic, and hallucinations. Monitor the
patient’s vital signs. Restraints should be removed to assess the skin and then replaced. Trialing a
restraint-free period is not performed.
Concepts tested

Question 2904
The emergency department nurse is taking care of a client with suspected opioid toxicity. The
client is difficult to arouse and has shallow breathing. Which intervention does the nurse expect
to perform first?
A Place the client on prescribed supplemental oxygen.
B Prepare to perform prescribed gastric lavage.
C Assess bilateral pupils.
D Administer prescribed naloxone.

Question Explanation
Correct Answer is A
Rationale: Clients with suspected opioid toxicity are at high risk for respiratory depression and
death. Airway and breathing should be secured before performing other interventions. The nurse
should administer supplemental oxygen. A gastric lavage is used for the ingestion of toxic
agents. Clients with opioid toxicity will benefit from a reversal agent. Assessing bilateral pupils
can help confirm the diagnosis but will not correct the problem. Naloxone is the reversal agent
for opioids and should be administered to prevent further complications. However, the client’s
airway and breathing should be secured first.
Concepts tested

Question 2905
The nurse is assessing a client’s healing wound to the coccyx area. The nurse notes moist, light
red tissue surrounding the wound. The nurse knows the wound is in which phase of healing?
A Inflammatory
B Maturation
C Proliferation
D Hemostasis

Question Explanation
Correct Answer is C
Rationale: Wound healing occurs in four phases. The proliferation phase is characterized by new
tissue formation that appears red in color. Granulation tissue should be protected to promote
healing. The inflammatory phase is the second phase and lasts 2 to 3 days. It is characterized by
swelling and erythema around the wound. The maturation phase is the last phase of wound
Page | 1149
healing and is characterized by collagen deposits that result in wound closure and scar formation.
Hemostasis is the initial phase of wound healing and is characterized by liquid exudate
containing blood and plasma.
Concepts tested

Question 2906
The nurse is caring for the client who had a cesarean birth 6 hours ago. The client has silent
bowel sounds and has not passed flatus. Which of the following interventions is appropriate?
A Assist the client with ambulation.
B Provide clear liquids
C Encourage a bland diet
D Obtain a prescription for a laxative

Question Explanation
Correct Answer is A
Rationale: Manipulation of the abdominal organs during surgery may produce a loss of normal
peristalsis for 24 to 48 hours, depending on the type and extent of surgery. Even though nothing
is given by mouth, swallowed air and GI tract secretions enter the stomach and intestines
producing distention and causing the patient to complain of fullness or pain in the abdomen.
Distention may be avoided by having the patient turn frequently, exercise, and ambulate as early
as possible. Chewing gum has also been shown to improve peristalsis and reduce the risk of
paralytic ileus. Food and liquid should not be encouraged until bowel sounds are auscultated or
flatus is passed. Laxatives are for the treatment of constipation.
Concepts tested

Question 2907
The nurse is caring for a client who is receiving radiation therapy in the head and neck region.
Which of the following questions by the nurse would be appropriate to assess for symptoms of
adverse effects?
A “Have you experienced any incontinence?”
B “How long have you been receiving radiation?”
C “Have you noticed a reduction in your mobility?”
D “Are you finding that your mouth is dry?”

Question Explanation
Correct Answer is D
Rationale: Radiation of the head and neck region may produce xerostomia (dryness of the
mouth), stomatitis (inflammation of the oral tissues), loss of taste, etc. Asking the client about
these symptoms is necessary to determine if treatment needs to be modified. The length of
treatment does not directly affect the likelihood of these adverse effects. Incontinence and
mobility are not directly affected by head and neck radiation therapy.
Concepts tested

Question 2908

Page | 1150
The nurse is conducting medication administration with the client. When given an intravenous
(IV) medication, the client says to the nurse, "I usually take pills. Why does this medication have
to be given in my arm?" Which nursing response is appropriate?
A “The medication will cause fewer adverse effects if given intravenously.”
B “The intravenous medication will be absorbed into the bodies' tissues more slowly.”
C “The medication will begin to work sooner when given intravenously.”
D “There is a lower chance of allergic reaction when medications are given intravenously.”

Question Explanation
Correct Answer is C
Rationale: Numerous factors affect the rate and extent of drug absorption, including dosage
form, route of administration, blood flow to the site of administration, gastrointestinal function,
the presence of food or other drugs, etc. For rapid drug action and response, the IV route is most
effective because the drug is injected directly into the bloodstream. The risk for adverse effects is
potentially increased with the IV route. The risk of allergic reaction remains the same.
Concepts tested

Question 2909
The nurse is reviewing the medical record for a client who is receiving prescribed phototherapy
for psoriasis. Which information noted by the nurse would require further intervention?
A The client started taking ciprofloxacin 5 days ago.
B No skin care products were applied to the site prior to arrival.
C It has been 48 hours since the last session.
D The client reports using an emollient cream after showering yesterday.

Question Explanation
Correct Answer is A
Rationale: Patients must bring a list of all current medications, including herbs and supplements,
to the first appointment for review with the phototherapy nurse and be taught to report any
medication changes as they arise. Fluoroquinolone antibiotics, such as ciprofloxacin, increase
photosensitivity and may result in a canceled treatment or reduced dosing. It is important for
clients to moisturize the skin at least twice daily while receiving phototherapy. The best time to
moisturize is after bathing. Skincare products should not be applied on the morning of the
treatment but will be applied afterward. Emollients may be prescribed for application
immediately prior to the treatment to help promote the effectiveness of the UVB light. There
should be a minimum of 24 hours between treatments.
Concepts tested

Question 2910
The nurse is reviewing the laboratory data for a client who is postoperative abdominal surgery
with an incision that is edematous and erythemic. Which data indicates to the nurse the client is
experiencing a complication?
A White blood count (WBC): 3,500 cells/mcL
B Hemoglobin (HgB): 14.5 grams/dL
C Platelets: 140,000/mcL

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D White blood count (WBC): 10,500 cells/mcL

Question Explanation
Correct Answer is A
Rationale: Signs and symptoms of infection include localized swelling, redness, pain or
tenderness, loss of function in the affected area, palpable heat. White blood count (WBC)
increasing identifies the body’s ability to fight off infection. Low: below 4,500, Normal: 4,500-
11,000, High: Greater than 11,000. Significantly low WBC can indicate a risk for infection
particularly with the older adult population. An infection may be present without any change in
WBC count.
Concepts tested

Question 2911
The charge nurse is observing a newly hired nurse who is caring for a client with a nasogastric
(NG) tube to continuous suction. Which of the following actions by the newly hired nurse
requires the charge nurse to intervene?
A Adjusting the suction pressure dial between 150 - 200 mm Hg
B Maintaining the air vent of the NG tube above the level of the stomach
C Instilling 50 mL of irrigating solution into the NG tube to remove a blockage
D Maintaining the client in a semi-Fowlers position

Question Explanation
Correct Answer is A
Rationale: The suction pressure dial should never be set above 120 mm Hg for gastrointestinal
suctioning to reduce trauma to the gastrointestinal mucosa. The air vent of an NG tube should be
maintained above the level of the stomach to prevent reflux of gastric contents into the air lumen
of the tube. NG tubes may be irrigated per the healthcare provider’s orders to remove blockages
and ensure patency of the tube. Maintaining the client in a semi-Fowlers position prevents the
likelihood that the NG tube lies against the wall of the stomach, which ensures adequate
suctioning and prevents reflux of gastric contents that could lead to aspiration.
Concepts tested

Question 2912
A nurse is providing education to a client with an ileostomy about self-care management. Which
statement made by the client indicates to the nurse further teaching is required?
A “I will make sure to leave enough space between the appliance and the stoma."
B “I will drink plenty of water to avoid dehydration.”
C “Eating crackers and toast can decrease the amount of gas.”
D “The stoma should appear round, pink, and hydrated.”

Question Explanation
Correct Answer is A
Rationale: There should be none-to-minimal skin visible between the stoma and the appliance.
Exposed skin increases the risk of leakage and can disrupt skin integrity. Ileostomies can have a
large output due to the watery consistency of the stool. Clients should be encouraged to drink

Page | 1152
plenty of water. Foods with high fiber content will reduce the amount of intestinal gas produced.
A stoma should be pink and moist. Variations in color can signal decreased oxygen or
circulation.
Concepts tested

Question 2913
The nurse is assessing a client who is in active labor. The nurse notes the protrusion of the
umbilical cord from the introitus. Which action should the nurse take first?
A Initiate intravenous (IV) access and administer a bolus of IV fluids.
B Apply an oxygen face mask on the client and set the rate at 8 L/min.
C Insert a gloved hand into the vagina and elevate the fetal presenting part.
D Leave the room and immediately notify the healthcare provider.

Question Explanation
Correct Answer is C
Rationale: A prolapsed umbilical cord can result in compression and decreased circulation to the
fetus. The nurse should relieve cord compression by elevating the fetal presenting part.
Administering IV fluids is an important intervention. However, the priority is to maintain fetal
circulation. Applying an oxygen mask to the client will improve oxygenation to the fetus.
However, relieving cord compression is the priority intervention. The nurse should not leave the
client unattended. The nurse should call for immediate assistance while in the room.
Concepts tested

Question 2914
The nurse is caring for a client who had bariatric surgery. When removing the staples from the
abdominal wound, which of the following techniques should the nurse use?
A Remove every other staple first and monitor wound edges.
B Start from the top and move downward to remove all staples.
C Begin at the bottom of the incision and move upward to remove all staples.
D Remove several staples from the top and bottom of the incision and monitor wound edges.

Question Explanation
Correct Answer is A
Rationale: Removing alternative staples provides strength to the incision line during removal and
prevents accidental separation of the incision. If the wound edges remain approximated, remove
remaining staples. This may occur on a different day based on the prescription.
Concepts tested

Question 2915
The nurse is reviewing the laboratory data for a client with hepatitis who is taking prescribed
lactulose. Which finding indicates the treatment is effective?
A Ammonia 18 mcg/dL
B AST 12 U/L
C Bilirubin 2 mg/Dl
D ALT 10 U/

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Question Explanation
Correct Answer is A
Rationale: Hepatitis causes a build-up of ammonia in the circulation. Lactulose decreases the pH
in the colon which causes ammonia to leave the circulatory system and move into the colon to be
expelled. This causes ammonia blood levels to return to normal.
Concepts tested

Question 2916
The nurse is reviewing the laboratory data for a client who is receiving prescribed intravenous
(IV) fluids to treat fluid volume deficit. Which result would indicate the fluid therapy has been
effective?
A Serum sodium 138 mEq/L
B Blood urea nitrogen (BUN) 26 mg/dL
C Hematocrit (Hct) 56%
D Urine specific gravity 1.038

Question Explanation
Correct Answer is A
Rationale: For clients who are receiving prescribed IV fluids to treat fluid volume deficits,
laboratory data can be used to determine if the fluid therapy is effective. In fluid volume deficit,
the client will have low sodium, increased BUN, increased hematocrit, and increased urine
osmolarity. A serum sodium of 138mEq/L is within the normal range (135-145), indicating that
the fluid therapy has been effective. Normal BUN is 6-20, normal hematocrit is 35%-47% for
females and 39%-50% for males, and normal specific gravity is 1.010-1.025. The elevated BUN,
Hct, and urine specific gravity indicate the client is still experiencing fluid volume deficit.
Concepts tested

Question 2917
The nurse is reviewing the cardiac rhythm strip of a client who has a history of heart failure. The
nurse notes an irregular rhythm with no identifiable P waves and a rate of 130. The nurse should
understand the client is experiencing which abnormal cardiac rhythm?

A Sinus tachycardia
B Atrial fibrillation
C Supraventricular tachycardia
D Ventricular fibrillation

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Question Explanation
Correct Answer is B
Rationale: Atrial fibrillation is an abnormal cardiac rhythm that occurs when multiple areas of
cells in the atria initiate electrical conductions. Atrial fibrillation will have a fast, irregular rate
with no identifiable P waves. Supraventricular tachycardia will have a regular rhythm with a rate
over 150 and no identifiable P waves on the rhythm strip. Sinus tachycardia will have a fast
regular rate, but identifiable P waves. Ventricular fibrillation will have no rate, no P waves, and
no QRS.
Concepts tested

Question 2918
The nurse is caring for a client who reports the sudden onset of palpitations. The nurse reviews
the client's electrocardiogram strip. Which prescribed medication should the nurse anticipate
administering to the client?

A Metoprolol
B Digoxin
C Lisinopril
D Adenosine

Question Explanation
Correct Answer is D
Rationale: Supraventricular tachycardia occurs when there is a reentry pathway in the cardiac
conduction resulting in a rhythm that is regular, without clear p-wave, and heart rate greater than
150. For SVT, the nurse should prepare to administer adenosine. Beta-blockers, calcium channel
blockers, and digoxin are preferred medications for atrial fibrillation.
Concepts tested

Question 2919
The nurse is caring for a client admitted to the telemetry unit. The client has been in sinus
rhythm, but the monitor is showing what appears to be new onset atrial fibrillation. What action
should the nurse take first?
A Obtain a 12-lead electrocardiogram.
B Attempt to reposition the leads.
C Measure the client’s blood pressure.
D Print a strip for interpretation.

Question Explanation

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Correct Answer is C
Rationale: Atrial fibrillation can lead to hypotension and poor client outcomes, so measuring the
blood pressure is the nurse’s priority intervention. All other interventions are important and part
of the nurse’s responsibilities, but the blood pressure is first.
Concepts tested

Question 2920
The nurse is assessing a client with diverticulitis. Which finding would the nurse report
immediately?
A Abdomen appears distended upon inspection.
B Bowel sounds are hypoactive upon auscultation.
C Abdomen is rigid upon light palpation.
D Pain is felt in the left lower quadrant upon deep palpation.

Question Explanation
Correct Answer is C
Rationale: A rigid abdomen upon light palpation is a hallmark indication of peritonitis. The nurse
should report this finding immediately to prevent sepsis. Diverticulitis is an infection and
inflammation of the bowel mucosa. A distended abdomen is an expected finding in clients with
diverticulitis. Constipation and hypoactive bowel sounds are expected findings with diverticulitis
due to the inflammatory response. Diverticulitis occurs in the colon. Pain in the left lower
quadrant of the abdomen is an expected response due to the anatomical location of the colon.
Concepts tested

Question 2921
The nurse is caring for a client with a pneumothorax. Which intervention will the nurse perform
to improve gas exchange?
A Request a prescription for analgesics.
B Educate the client on incentive spirometry.
C Place the client in a protective lateral position.
D Monitor arterial blood gases.

Question Explanation
Correct Answer is B
Rationale: An incentive spirometer improves airflow and encourages deep breathing and lung
expansion. The nurse should educate the client on performing incentive spirometry 10 times an
hour while awake to improve gas exchange. Analgesics are helpful in controlling pain. However,
these medications do not improve gas exchange. Clients should be placed in high Fowler’s to
maximize lung expansion and improve gas exchange in the lungs. Monitoring arterial blood
gases is an important assessment for clients with a pneumothorax. However, it does not help with
improving gas exchange.
Concepts tested

Question 2922
The nurse is initiating prescribed oxygen therapy at 5 L/min via nasal cannula for a client with
pneumonia. After verifying the flow rate, which action should the nurse take next?
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A Educate the client on safe oxygen delivery.
B Connect a humidifier to the regulator.
C Change the delivery method to a simple mask.
D Document the client’s response to oxygen therapy.

Question Explanation
Correct Answer is B
Rationale: Oxygen delivered via a nasal cannula at rates above 4 L/min can dry out mucous
membranes. A humidifier prevents drying of the membranes. Providing education to the client
regarding oxygen delivery is an important intervention. However, the nurse should ensure client
comfort before educating. Nasal cannulas can deliver up to 6L/min. The delivery method does
not need to be changed. Documentation of the client’s response should be completed until
actions that promote safety and comfort are performed.
Concepts tested

Question 2923
The nurse is caring for a client who is experiencing a cardiac arrest due to ventricular fibrillation.
The client is currently receiving high-quality cardiopulmonary resuscitation. Which of the
following actions should the nurse take?
A Administer Atropine, 6mg IV
B Prepare the client for transcutaneous pacing.
C Administer Epinephrine, 1mg IV.
D Perform carotid massage to stimulate a vagal response.

Question Explanation
Correct Answer is C
Rationale: Clients experiencing a cardiac arrest due to ventricular fibrillation should have high-
quality CPR initiated as soon as possible, followed by rapid defibrillation. The client should have
Epinephrine administered per CPR guidelines and possibly amiodarone if indicated. Atropine
and transcutaneous pacing are indicated for clients who are experiencing symptomatic
bradycardia or heart block, not ventricular fibrillation. Carotid massage is occasionally
performed for clients experiencing supraventricular tachycardia in order to stimulate a vagal
response; however, this practice is controversial.
Concepts tested

Question 2924
The nurse is removing staples from a client’s abdominal incision. Upon removal of a few staples,
the nurse notes the incision begins to separate. Which intervention does the nurse perform next?
A Clean the incision with saline solution and continue the procedure.
B Remove the remaining staples and apply an adhesive wound-closure strips.
C Apply adhesive wound-closure strips along the incision after staples are removed.
D Cover the area with moistened sterile towels and notify the healthcare provider.

Question Explanation
Correct Answer is D

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Rationale: Separation of wound edges is known as dehiscence. Dehiscence can lead to
evisceration if not assessed and treated. The nurse should cover the incision with sterile towels
moistened with saline and notify the healthcare provider. Continuing the procedure can lead to
evisceration despite cleaning the wound. Removing the remaining staples can lead to
evisceration. A pressure dressing secured with an abdominal binder can increase pressure on the
area of dehiscence and further separate the wound. Adhesive wound-closure strips are not
enough to keep the wound from complete dehiscence.
Concepts tested

Question 2925
A client arrives at the clinic verbalizing fatigue, chills, and a headache after attending a large
gathering 3 days ago. The nurse suspects influenza. Which stage of infection is consistent with
the client’s condition?
A Incubation
B Prodromal
C Chronic
D Convalescent

Question Explanation
Correct Answer is B
Rationale: The prodromal stage of infection is the second stage and is characterized by vague
and nonspecific symptoms. Influenza has an incubation period of 1-2 days before progressing
into the prodromal stage. The client’s time frame of exposure is consistent with the prodromal
stage. Influenza symptoms are not yet present in the incubation stage. Chronic is not a stage of
infection. The convalescent stage of infection is characterized by the recovery from the illness.
Signs and symptoms are no longer present in the convalescent stage.
Concepts tested

Question 2926
The nurse is reviewing the urine culture results for a client with incontinence who has an
indwelling urinary catheter in place. The results indicate the presence of Klebsiella. Which
action should the nurse take?
A Insert a new catheter
B Change the catheter tubing and bag at the seal
C Flush the catheter using the luer lock port
D Obtain a prescription for a condom catheter

Question Explanation
Correct Answer is D
Rationale: Catheter-associated urinary tract infections (CAUTIs) are the most frequently reported
hospital-acquired infection. The Centers for Medicare and Medicaid Services named hospital-
acquired UTI as one of the original “never events”. CDC guidelines recommend external
catheters as an alternative to indwelling catheters in clients without urinary retention or
obstruction. If a CAUTI is diagnosed, the indwelling catheter should be discontinued, if possible.
While it may be necessary to insert a new catheter, based on guidelines an alternative should be

Page | 1158
attempted. Catheters are not disconnected at the seal and flushing the catheter is not
recommended as both actions increase the risk of bacterial contamination.
Concepts tested

Question 2927
The nurse is reviewing the serum laboratory findings for a client who has hypertension and is
prescribed hydrochlorothiazide. Which finding should the nurse report to the health care
provider?
A Sodium 134 mEq/L
B Potassium 2.3 mEq/L
C Phosphorus 4.3 mg/dL
D Calcium 8.6 mg/dL

Question Explanation
Correct Answer is B
Rationale: Hydrochlorothiazide is a diuretic that can cause an increased loss of potassium from
the kidneys, leading to hypokalemia. Normal potassium levels are 3.5 to 5.0 mEq/L. The nurse
should report a potassium level of 2.3 to the provider. The other lab values are within normal
range or just barely out of range that would not require notifying the provider.
Concepts tested

Question 2928
The nurse is caring for a client who is receiving continuous tube feedings and medication
administration through a nasogastric tube. The nurse will include which of the following in the
plan of care?
A Verify tube placement every shift.
B Flush the tube with sterile saline after administering medications.
C Assess the skin around the patient’s nares.
D Discard the gastric aspirate.

Question Explanation
Correct Answer is C
Rationale: Discarding gastric contents may lead to an electrolyte imbalance. Gastric aspirate
should be emptied into a clean container and re-instilled once the volume is measured. Tube
placement should be verified every 4 hours or per hospital policy. Gastric tubes are flushed with
water, sterile or tap, based on hospital policy. The skin around the nares should be assessed for
breakdown.
Concepts tested

Question 2929
The nurse is providing education on radiation therapy to a client receiving treatment for cancer.
Which of the following statements indicates that teaching has been effective?
A “I can use petroleum jelly if my skin becomes reddened.”
B “I need to apply an SPF 15 sunscreen when I am outside for the day.”
C “I can apply an ice pack to the site if it becomes sore.”

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D “I should not wash off the markings.”

Question Explanation
Correct Answer is D
Rationale: Radiation causes damage to both normal and cancerous cells in a localized area. The
area to be treated is marked carefully to minimize damage to normal cells. Therefore, it is
important for the client to avoid soaping the area. Clients should apply unscented aqueous
creams or moisturizers that are not petroleum-based. Avoid the use of heat or ice packs at the
site. During the treatment, and for 8 weeks after, the skin will be photosensitive. Protecting the
skin with a high-SPF (30 or above) sunscreen is advised.
Concepts tested

Question 2930
The nurse is performing wound care for a client with an abdominal wound. Which action would
prevent infection?
A Obtaining a new sterile gauze for each stroke of the wound during cleansing
B Cleansing the wound from the outer edges to the inner bed with each stroke
C Using wet-dry technique with sterile water for dressing application
D Reapplying sterile gloves before applying the new sterile dressing

Question Explanation
Correct Answer is A
Rationale: Aseptic technique decreases the chances of transmitting pathogens and interrupts the
chain of infection. In order to minimize cross-contamination of the wound, a new sterile gauze is
utilized to not reintroduce contaminants into other areas of the wound bed. Wounds should be
cleansed from the inner bed to the outer to avoid contamination. Normal saline is used for the
wet-dry dressing technique. Sterile gloves minimize the introduction of pathogens but not the
cross-contamination of pathogens pre-existing.
Concepts tested

Question 2931
The nurse is observing an unlicensed assistive personnel (UAP) perform oral suctioning for a
client. Which of the following actions by the UAP would require the nurse to intervene?
A Raising the head of bed to 30 degrees prior to suctioning
B Applying continuous suction down the side of the client’s cheek towards the back of the
throat
C Hyperextending the neck as tolerated prior to inserting the suction catheter
D Adjusting the suction pressure to the level of 120 mm Hg

Question Explanation
Correct Answer is B
Rationale: The nurse should only apply suction once the catheter has reached the back of the oral
cavity. Applying suction prior may cause oral mucosal damage and invoke gagging in the client.
The nurse should position the client in a semi-Fowlers position at 30 degrees and hyperextend

Page | 1160
the neck as tolerated to promote comfort, prevent aspiration and reduce the incidence of gagging
in the client. Suction dials should be set at 120 mm Hg for oral suctioning.
Concepts tested

Question 2932
The nurse is caring for a client who experienced a tonic-clonic seizure. The client had autonomic
manifestations during the seizure. Which intervention should the nurse implement to ensure the
safety of the client post-seizure activity?
A Restrain the client’s lower extremities.
B Raise the siderails of the client’s bed.
C Check the client’s vital signs.
D Place the client in a lateral recumbent position.

Question Explanation
Correct Answer is D
Rationale: Autonomic symptoms include vomiting, salivation, and incontinence. The nurse
should place the client in a side-lying position to avoid aspiration of oral secretions. Clients
should not be restrained during or after a seizure. Restraining the limbs during a seizure can
cause injury. Raising the side rails of the bed is considered a restraint if all of them are raised.
The side rails should be padded to ensure safety and prevent injury. Checking the vital signs is an
appropriate intervention after a seizure. However, this assessment does not promote safety in this
situation.
Concepts tested

Question 2933
The nurse is caring for a client who just delivered a term neonate vaginally. Upon assessment,
the nurse notes a saturated perineal pad, hypotension, and tachycardia. Which action by the nurse
is appropriate?
A Massaging the uterine fundus
B Removing the infant from the room
C Assessing deep tendon reflexes
D Assisting the client with ambulation

Question Explanation
Correct Answer is A
Rationale: Based on the assessment findings of hypotension and excessive vaginal bleeding, this
client is likely experiencing a hemorrhage. Interventions that would be appropriate for the
hemorrhaging client include massaging the uterine fundus, emptying the client’s bladder, and
administration of uterotonic drugs. The infant should be kept with the mother unless the mother
is unable to care for the baby, deep tendon reflexes are not directly related to hemorrhage, and
ambulation would be unsafe until the client’s bleeding is controlled.
Concepts tested

Question 2934
The nurse has removed the sutures from a client with an abdominal wound and applied steri-
strips. What education should be provided to the client after suture removal?
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A Instruct patient to take showers rather than bathe.
B Tell the client to remove the steri-strips in one week.
C Inform the client that the skin is fully healed.
D Advise the client that clear drainage is expected.

Question Explanation
Correct Answer is A
Rationale: Instruct patient to take showers rather than bathe to reduce the risk of infection.
Instruct patients not to pull off the Steri-Strips and to allow them to fall off naturally and
gradually (usually takes one to three weeks). Wound healing time can be diverse, but the
maturation phase begins at day 21 and may take up to a year or more to heal completely. Sutures
are usually removed around day 7 to 10 after insertion. Therefore, the skin would not be fully
healed. Once a wound is beyond the inflammatory phase, serous drainage can indicate infection
and should be reported.
Concepts tested

Question 2935
A client with cancer is scheduled for radiation therapy. The nurse is providing teaching about
generalized adverse effects. Which adverse effect should the nurse prepare the client to expect?
A Fatigue
B Vomiting
C Stomatitis
D Alopecia

Question Explanation
Correct Answer is A
Rationale: Radiation may cause generalized effects such as fatigue and anorexia. Hair loss,
vomiting, and stomatitis are related to the systemic effects of chemotherapy toxicity.
Concepts tested

Question 2936
The nurse is caring for a client who has a serum sodium level of 117 mEq/L. Which of the
following actions is a priority for the nurse to take?
A Place the client on continuous cardiac monitoring.
B Restrict the client’s oral fluid intake.
C Implement seizure precautions.
D Provide a high-sodium diet.

Question Explanation
Correct Answer is C
Rationale: Clients with severe hyponatremia are at high risk for developing seizures, which could
result in coma and death. The priority action for this client is to implement seizure precautions to
protect the client’s safety. Cardiac dysrhythmias are common with other electrolyte
abnormalities, and therefore, is not the priority intervention for a client with hyponatremia. The
nurse should implement restricting the oral fluid intake and replacing dietary sodium; however,

Page | 1162
the response to these interventions is gradual, as sodium should not be replaced too rapidly, and
therefore, is not the priority action over initiating seizure precautions.
Concepts tested

Question 2937
The nurse is reviewing the cardiac rhythm strip of a client with a history of chronic obstructive
pulmonary disease. The nurse should understand the client is experiencing which abnormal
cardiac rhythm?

A Premature ventricular contraction

B AV nodal reentry
C Atrial flutter
D Sinus bradycardia

Question Explanation
Correct Answer is A
Rationale: Premature ventricular contraction (PVC) is an electrical impulse conducted from an
ectopic area of the ventricles. A PVC will be a wide complex that occurs before a normal
complex on a cardiac rhythm strip. Atrial fibrillation will have a fast, irregular rate with no
identifiable P waves. Supraventricular tachycardia, which is an AV nodal reentry, will have a
regular rhythm with a rate over 150 and no identifiable P waves on the rhythm strip. Sinus
bradycardia will have a slow regular rate, but identifiable P waves.
Concepts tested

Question 2938
A nurse in the emergency department is caring for a client with left-sided heart failure who
reports the sudden onset of dyspnea. The client's blood pressure is 108/79, the apical pulse is
112, and the nurse notes the client has blood-tinged, frothy sputum. After administering high-
flow oxygen to the client, which intervention should the nurse do next?
A Obtain a prescription for a chest x-ray.
B Place the client in high-Fowler's position with legs dependent.
C Administer prescribed furosemide IV.
D Initiate bedside cardiac monitoring.

Question Explanation
Correct Answer is B
Rationale: Clients with heart failure are at increased risk for pulmonary edema. Pulmonary
edema develops when the left ventricular function is impaired resulting in a backup of pressure
in the pulmonary vasculature system. After administering high flow oxygen, the next action is to
place the client in high-Fowler’s position with legs dependent. This position decreases preload,

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with decreases the volume of blood in the heart and pulmonary vasculature. Then, the nurse will
administer prescribed furosemide. Cardiac monitoring should be initiated once the client has
interventions to decrease preload.
Concepts tested

Question 2939
The charge nurse is observing a newly hired nurse caring for a client experiencing a seizure.
Which of the following actions by the newly hired nurse requires intervention?
A Turning the client’s head to the side
B Recording the time of seizure onset
C Loosening clothing around the client’s chest
D Placing a tongue depressor in the client’s mouth

Question Explanation
Correct Answer is D
Rationale: Clients experiencing a seizure should be protected from injury, including loosening
any restrictive clothing and turning the client's head to the side to prevent aspiration. The time of
onset of seizure should always be noted by the nurse. Objects should never be inserted into the
client’s mouth during a seizure. Inserting a tongue depressor to prevent the client from biting the
tongue during a seizure is contraindicated and this action requires intervention, as this can
obstruct the airway and possibly break the client’s teeth.
Concepts tested

Question 2940
The nurse is planning care for a client with pulmonary edema due to severe fluid overload.
Which independent nursing action will assist in managing this condition?
A Applying a low-flow nasal cannula at 2 L/min
B Administering a loop diuretic
C Positioning the head of the bed at 90 degrees
D Obtaining the client’s oxygen saturation

Question Explanation
Correct Answer is C
Rationale: Independent nursing actions can be initiated without a prescription from the
healthcare provider. Pulmonary edema is fluid accumulation in the alveoli that prevents adequate
gas exchange in the lungs. Positioning the head of the bed at 90 degrees will help to maximize
ventilation. Applying a low-flow nasal cannula at 2 L/min will not help manage this condition.
High-flow oxygen is recommended and is a dependent nursing action if the oxygen is
administered continuously. Administration of a loop diuretic is a dependent nursing action.
Obtaining the client’s oxygen saturation level is important. However, this assessment does not
directly manage the condition.
Concepts tested

Question 2941
The nurse is taking care of a client with a spinal cord injury at the level of L3. Which
intervention will the nurse perform to promote muscle tone?
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A Administer prescribed anti-spasticity medications.
B Transfer the client to a chair.
C Apply heel protectors to bilateral feet.
D Assist the client with passive range of motion.

Question Explanation
Correct Answer is D
Rationale: Clients with spinal cord injuries will experience loss of sensation below the level of
injury. A lumber injury at the level of L3 will result in flaccid paralysis. Assisting the client with
passive range of motion will help muscles maintain their tone. Anti-spasticity medications, or
muscle relaxants, relieve spasms associated with injuries above the level of L1 and L2 but do not
promote muscle tone. Transferring the client to a chair is beneficial for mobility but does not
increase muscle tone. Applying heel protectors to bilateral feet prevents pressure ulcers and
maintains skin integrity. However, it does not promote muscle tone.
Concepts tested

Question 2942
The nurse is educating a client with chronic obstructive pulmonary disorder (COPD) on
diaphragmatic breathing. What will the nurse include in the teaching?
A “Take a deep breath and hold it for a few seconds.”
B “Put both hands on your chest and breathe in deeply.”
C “Purse your lips and take in a deep breath."
D “Breathe in through your nose and let your abdomen rise.”

Question Explanation
Correct Answer is D
Rationale: Diaphragmatic breathing focuses on using the abdominal muscles to guide the breath.
The abdomen should rise upon inhalation through the nose and contract upon exhalation through
the mouth. Holding the breath for a few seconds upon inhalation is a technique used with
incentive spirometry. One hand should be placed on the middle of the chest and the other on the
abdomen. The client should be instructed to purse their lips upon exhalation.
Concepts tested

Question 2943
The nurse is caring for a client who is undergoing synchronized cardioversion for stable
ventricular tachycardia. Which of the following instructions should the nurse provide to the
client?
A “Pacing electrodes will be applied to your chest and you will feel muscle contractions with
each heartbeat.”
B “You will receive a transdermal analgesic patch to ensure comfort during the procedure.”
C “The procedure will start with the lowest energy and may be increased as needed to restore a
normal cardiac rhythm.”
D “This procedure will eliminate the possibility of future dysrhythmias from occurring.”

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Question Explanation
Correct Answer is C
Rationale: Synchronized cardioversion for ventricular tachydysrhythmias involves a
synchronized energy delivery to the client on the R wave of the QRS complex on the ECG. This
energy is typically started at the lowest energy of 50 – 100 Joules and increased as needed with
further energy delivery if a normal sinus rhythm is not restored. Clients are typically given
intravenous sedation for comfort, and all transdermal patches should be removed prior to the
procedure. The procedure may temporarily restore a normal sinus rhythm, however, future and
recurrent dysrhythmias may occur, requiring a permanent implantable cardioverter/defibrillator.
Concepts tested

Question 2944
A postoperative client returns to bed after ambulation and tells the nurse, “I feel something
popping out of my abdomen.” The nurse notes protruding bowel from the abdominal incision.
Which action does the nurse perform next?
A Leaves the room to immediately call the healthcare provider.
B Pushes the bowel back into the abdomen.
C Places the client in a low Fowler’s position.
D Covers the wound with an abdominal binder.

Question Explanation
Correct Answer is C
Rationale: Wound evisceration is a medical emergency. The nurse should place the client in a
low Fowler’s position to avoid further straining of the abdominal muscles. Clients should not be
left unattended during a medical emergency. The nurse should call for assistance. The protruding
bowel should not be pushed back into the abdomen. Surgical repair is required to correct the
problem. The protruding bowel should be kept moist using sterile towels moistened with sterile
saline.
Concepts tested

Question 2945
A nurse is assessing a client with chronic pulmonary disease. The chest x-ray reveals
hyperinflation of the alveoli. Which clinical manifestation does the nurse expect to assess?
A Anterior to posterior ratio of 1:2
B Dullness upon percussion of the chest
C Clubbing of the fingernails
D PaO2 level of 85 mmHg

Question Explanation
Correct Answer is C
Rationale: Hyperinflation of the alveoli prevents adequate gas exchange in the lungs. Impaired
oxygenation leads to chronic hypoxia and clubbing; an increased angle of the nail of more than
160 degrees. Clients with chronic pulmonary disease will develop a barrel chest with an AP:lat
ratio of 1:1. Hyperinflation of the alveoli results in air trapping. Hyperresonance is expected with
percussion. Decreased gas exchange in the alveoli results in hypoxemia and partial pressure of
oxygen (PaO2) levels below 80 mmHg.
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Concepts tested

Question 2946
A nurse is caring for a client who has been on bed rest after a partial gastrectomy. On
assessment, the nurse notes diminished breath sounds in the bases of the lungs and oxygen
saturation of 92% on 2 L. The client reports pain 2 out of 10 and that “it doesn’t hurt if I don’t
move”. Which action would be a priority for the nurse to take?
A Administer the prescribed pain medication
B Assist the client to use the incentive spirometer
C Reposition the client for comfort
D Obtain a prescription for an arterial blood gas (ABG)

Question Explanation
Correct Answer is B
Rationale: Atelectasis and pneumonia are prevalent postoperative pulmonary complications.
When a mucus plug obstructs one of the bronchi entirely, the pulmonary tissue beyond the plug
collapses, resulting in atelectasis. To clear secretions, the nurse encourages the patient to turn
frequently, take deep breaths, cough, and use the incentive spirometer at least every 2 hours. If
the oxygenation does not improve after ICS, it is appropriate to request a prescription for an
ABG or CXR. Pain medication may worsen respiratory status at this point and should be delayed
until pulmonary hygiene is performed.
Concepts tested

Question 2947
A client is receiving external radiation therapy for a neck tumor. The nurse assesses the client
after the therapy is completed. Which finding requires prompt intervention from the nurse?
A Dysgeusia
B White blood cell (WBC) count of 9,000/mm³
C Platelet count of 350,000/mm³
D Dysphagia

Question Explanation
Correct Answer is D
Rationale: Dysphagia, or trouble swallowing, is an injury that can occur after radiation. The
nurse should assess the airway to prevent aspiration. Dysgeusia (altered taste) is a common
finding after external radiation. The nurse should encourage a diet without red meat as it can be
unpalatable. Decreased white blood cell (WBC) and platelet counts are common effects after
radiation. The normal range of WBCs is 5,000 to 10,000/mm³. The normal platelet count is
150,000 to 400,000/mm³.
Concepts tested

Question 2948
The nurse is providing individualized nutrition counseling with a client who has chronic
obstructive pulmonary disease (COPD). The client is experiencing unintended weight loss. What
instructions should the nurse include in the teaching?

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A “Buy products that contain whole grains.”
B “Increase your intake of fruits and fruit juices.”
C “Eat high- protein snacks between meals and at bedtime.”
D “Choose a variety of vegetables throughout the day.”

Question Explanation
Correct Answer is C
Rationale: For a client with COPD, nutrition is part of the therapeutic regimen. Cachexia and
muscle-wasting is a frequent, but partly reversible, complication in patients with COPD and
affects the disease progression and prognosis. Weight loss in COPD is a consequence of
increased energy requirements unbalanced by dietary intake. Metabolism of carbohydrates
produces the most carbon dioxide for the amount of oxygen used; metabolism of fat produces the
least. For some people with COPD, eating a diet with fewer carbohydrates and more protein
helps them breathe easier and maintain muscle mass.
Concepts tested

Question 2949
The nurse is planning care for a client with prostate cancer who has a high-dose brachytherapy
implant. Which intervention should the nurse implement to prevent adverse effects of the
brachytherapy?
A Place the client in a negative pressure room.
B Limit visitors to 10 to 30 minutes.
C Stand 3 feet away from the client.
D Increase nursing interaction with the client.

Question Explanation
Correct Answer is B
Rationale: During the time the implant is in place, staff entering the room are exposed to gamma
rays. Once the treatment is completed and the implant is removed, the patient is no longer
radioactive and presents no hazard. The client should be in a private room, but negative pressure
is unnecessary. Nurses should work quickly, but effectively and courteously. Minimize time in
the room. Maintain the greatest distance possible from the patient consistent with effective care.
Six feet is a safe distance for conversation, and visitors should be taught to keep this distance and
limit exposure to 10 to 30 minutes.
Concepts tested

Question 2950
The nurse is caring for a client who had abdominal surgery 2 days ago and develops a
temperature of 102.1°F and purulent drainage from the surgical incision. Which of the following
prescriptions from the primary healthcare provider (PCHP) should the nurse implement first?
A Infuse Cefazolin, 1 G, I.V. every 6 hours.
B Obtain wound culture and sensitivity (C&S).
C Irrigate wound with normal saline every 8 hours.
D Administer acetaminophen 650mg P.O. every 6 hours for temperature greater than 100.4° F.

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Question Explanation
Correct Answer is B
Rationale: The client is exhibiting signs of a post-surgical wound infection which requires
prompt treatment with appropriate antimicrobial therapy. The first nursing action should be to
obtain the wound culture prior to initiation of the prescribed broad-spectrum antimicrobial
therapy to isolate the microorganism for further targeted antimicrobial therapy. After obtaining
the wound culture, the nurse can then administer the prescribed Cefazolin, followed by
antipyretics, then cleansing the wound.
Concepts tested

Question 2951
The nurse is performing a dressing change for a client who had abdominal surgery 48 hours ago.
Which of the following client findings would be a priority for the nurse to notify the surgeon?
A Bruising around the surgical wound that is extending to the client’s right flank
B Moderate amount of serosanguinous drainage in the client’s surgical drain
C Crusting underneath the staples and around the surgical incision
D Small amount of purulent drainage from the client’s surgical incision

Question Explanation
Correct Answer is A
Rationale: The nurse should notify the surgeon immediately of bruising that is extending into the
client’s flank, which indicates a hematoma and internal hemorrhage. Hemorrhage following
surgery is a life-threatening complication and requires immediate intervention. Clients may have
a moderate amount of serosanguinous drainage within the first few days following surgery.
Crusting around the incision site and underneath the staples is an expected finding and indicates
wound healing. Purulent drainage from the surgical incision may indicate the development of
infection; however, it is not the priority over possible hemorrhage.
Concepts tested

Question 2952
The nurse responds to the room of a client who experienced a clonic seizure. The client is
observed on the floor and is awake. What is the nurse’s priority action to ensure the safety of the
client?
A Take the client’s blood pressure.
B Assess the client’s pupils.
C Call the client’s healthcare provider.
D Assist the client back into bed.

Question Explanation
Correct Answer is B
Rationale: The client fell from a standing position before the seizure activity. Falls to the ground
can result in head injuries. The nurse should assess the client’s neurological status before
performing other interventions. Taking the blood pressure is an important assessment. However,
a fall can result in head injuries that must be assessed first. Calling the healthcare provider is an
appropriate intervention. However, the nurse should obtain an accurate assessment before
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reporting the findings. Assisting the client back into bed should occur after the nurse ensures the
client is stable.
Concepts tested

Question 2953
The nurse is caring for a client on the antepartum unit who is experiencing late decelerations.
Which action by the nurse is appropriate at this time?
A Increasing the oxytocin infusion
B Applying supplemental oxygen
C Administering intravenous pain medication
D Preparing the room for a vaginal delivery

Question Explanation
Correct Answer is B
Rationale: Application of supplemental oxygen, increasing intravenous fluids, and position
changes are all appropriate interventions in the event of late decelerations. If oxytocin is being
administered, it should be discontinued rather than increased and pain medications should not be
given until the fetus recovers. Preparing the room for a vaginal delivery is only warranted if the
client has progressed into the second stage of labor.
Concepts tested

Question 2954
The post-anesthesia care nurse is monitoring a client who had an open reduction internal fixation
of the femur. Which finding would require immediate follow-up by the nurse?
A Impaired airway protection
B Unstable cardiovascular status
C Decreased oxygenation
D Diminished neurological status

Question Explanation
Correct Answer is A
Rationale: Routine post-anesthetic assessment is a requirement for the recognition of clinical
deterioration in post-operative patients. The ABCDE approach should be used in postoperative
assessment in both the post-anesthesia care unit as well as in the admitting floor unit. The
mnemonic “ABCDE” stands for Airway, Breathing, Circulation, Disability, and Exposure. A =
airway, B = breathing, C=circulation, D=disability (neurological status), E = exposure (skin). In
this case, the client’s immediate priority is the airway, which is likely compromised by a reduced
level of consciousness. The reduced O2 saturation will likely improve with a stable airway. Heart
rate and blood pressure are in the expected range after skeletal surgery.
Concepts tested

Question 2955
The nurse is monitoring a client who received external radiation to their chest wall for early signs
of skin breakdown. The nurse should observe the client for which finding?
A Abscess

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B Scarring
C Dryness
D Fibrosis

Question Explanation
Correct Answer is C
Rationale: Radiation damage to normal tissues can cause an inflammatory response. This can
lead to dryness, redness, pain, blisters, swelling, fibrosis, and scarring.
Concepts tested

Question 2956
The nurse is caring for a client with hypervolemia who has a serum potassium level of 2.5
mEq/L. Which of the following actions should the nurse take?
A Administer prescribed furosemide, 40 mg IV.
B Initiate continuous pulse oximetry monitoring.
C Request a prescription for 40mEq potassium chloride, IV push.
D Request a prescription to infuse 1 L normal saline over 4 hours.

Question Explanation
Correct Answer is B
Rationale: A potassium level of 2.5 mEq/L indicates hypokalemia. The nurse should initiate
continuous pulse oximetry monitoring so that the client’s fluid and electrolyte status can be
monitored closely for the development of pulmonary edema and hypoxia due to respiratory
muscle weakness from hypokalemia. The nurse should hold the prescribed furosemide and notify
the primary healthcare provider, as furosemide can cause worsening of the client’s hypokalemia.
Intravenous potassium should never be given IV push; this could cause cardiac arrest. There is
no indication for a fluid bolus of 1 L NS at this time as the client is experiencing volume
overload.
Concepts tested

Question 2957
The nurse is assessing a client who is unresponsive and notes the absence of palpable pulses.
When reviewing the cardiac rhythm strip, which abnormal rhythm should the nurse recognize the
client is experiencing?

A Atrial fibrillation
B Ventricular fibrillation
C Ventricular tachycardia
D Atrial tachycardia

Question Explanation

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Correct Answer is B
Rationale: Ventricular fibrillation (V-fib) is the abnormal cardiac rhythm associated with cardiac
arrest. V-fib will have a rapid, disorganized waveform with no identifiable complexes. Atrial
fibrillation will have a fast, irregular rate with no identifiable P waves. Atrial tachycardia will
have a regular rhythm with a rate over 100 and identifiable P waves on the rhythm strip.
Ventricular tachycardia will have a fast, regular rate with wide QRS complexes.
Concepts tested

Question 2958
A nurse is caring for a client who has a central venous catheter and suddenly develops chest pain,
dyspnea, dizziness, and tachycardia. The nurse suspects air embolism and clamps the catheter
immediately. What other action should the nurse do next?
A Administer high flow oxygen.
B Place client on left side in Trendelenburg position.
C Remove the catheter.
D Replace the infusion system.

Question Explanation
Correct Answer is B
Rationale: A central venous line is placed with the catheter tip in the subclavian or right atrium.
An open infusion line could lead to an air embolism entering the central vein, which can flow
into the right atrium. If an air embolism enters the right atrium, it can push up against the
pulmonary artery blocking the flow of blood. The nurse should close the system, then place the
client in the left side Trendelenburg position. This position will force the air embolism to the top
of the right atrium, eventually dissipating due to blood flow. Once the client is in position, then
the nurse will either replace a leaking infusion system, remove the catheter if indicated, and
apply high flow oxygen.
Concepts tested

Question 2959
The nurse is caring for a patient who has acute kidney injury after ingesting a toxic substance.
The client is receiving continuous renal replacement therapy. Which of the following
interventions will be included in the plan of care?
A Maintain the blood flow rate between 300 mL and 400 mL/minute
B Utilize strict sterile technique when accessing the temporary dialysis catheter
C Calculate the client’s net fluid loss each shift.
D Change the filter when membrane pressures begin to drop

Question Explanation
Correct Answer is B
Rationale: Continuous renal replacement therapies (CRRTs) may be indicated for patients with
acute kidney disease who are too clinically unstable for traditional hemodialysis. CRRT removes
blood from the client at a slower rate than traditional hemodialysis. Usually, between 150 and
250 mL/min. CRRT is performed using a temporary hemodialysis catheter, which is considered a
central line. Therefore, strict aseptic technique is required. The client’s net fluid loss is calculated

Page | 1172
hourly and programmed into the machine. Filter changes are indicated when membrane pressures
begin to climb.
Concepts tested

Question 2960
The nurse is educating an older client with osteoporosis on dietary management. What should the
nurse include in the teaching?
A “Drink no more than 1 alcohol drink per day.”
B “Regulate the amount of green leafy vegetables in your diet.”
C “Consume at least 700 mg of calcium a day.”
D “Limit the amount of carbonated beverages you drink.”

Question Explanation
Correct Answer is D
Rationale: Osteoporosis is characterized by low bone density and decreased calcium levels.
Carbonated beverages contain high amounts of phosphorus. Phosphorus increases the rate of
calcium loss in the body. High alcohol intake decreases bone formation and increases bone
absorption. Clients should drink no more than 2 to 3 drinks per day. Green leafy vegetables
contain vitamin K, a vitamin essential for bone metabolism. Green leafy vegetables should be
encouraged. Older adults should consume at least 1,000 mg of calcium daily.
Concepts tested

Question 2961
The nurse is providing care to a client post arterial revascularization surgery. Which intervention
will the nurse implement to promote circulation in the client?
A Provide the client with an ice pack for the extremities.
B Instruct the client to limit bending of the hip.
C Tell the client to elevate swollen legs above the level of the heart.
D Initiate a turning schedule while the client is in bed.

Question Explanation
Correct Answer is B
Rationale: Instructing the client to limit bending of the hip prevents clot formation after
revascularization surgery and promotes adequate blood flow. The client should limit bending at
the hip and knee. Providing the client with an ice pack will cause vasoconstriction, the opposite
intended effect of the procedure. Telling the client to elevate swollen legs above the level of the
heart slows arterial blood flow to the lower extremities. Legs should be elevated no higher than
the level of the heart. Initiating a turning schedule maintains skin integrity for clients at risk for
pressure ulcers. This activity does not directly promote circulation of the extremities.
Concepts tested

Question 2962
The nurse is performing tracheostomy care on an unconscious client. The nurse is preparing to
change the tracheostomy collar. Which action will the nurse perform prior to performing this
step?

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A Raise the head of the bed to a Fowler’s position.
B Apply sterile gloves to both hands.
C Ensure the oxygen source is applied.
D Call another nurse for assistance.

Question Explanation
Correct Answer is D
Rationale: The tracheostomy collar is used to prevent the tracheostomy tube from becoming
dislodged. As the collar is being replaced, another nurse or staff member should hold the tube in
place to prevent dislodgement. An unconscious client should be positioned laterally facing the
nurse. Changing the tracheostomy holder is not a sterile procedure. Clean gloves may be used.
The oxygen source should be applied until after the procedure is done.
Concepts tested

Question 2963
The nurse is caring for a client who is undergoing transcutaneous pacing for symptomatic
bradycardia. Which of the following instructions should the nurse provide to the client?
A “The procedure will start with the highest energy and may be decreased as needed to restore a
normal cardiac rhythm.”
B “Pacing electrodes will be applied to your chest and you will feel muscle contractions with
each heartbeat.”
C “This procedure will eliminate the possibility of future bradydysrhythmias from occurring.”
D “The energy delivery will be timed at a specific point within your current cardiac rhythm.”

Question Explanation
Correct Answer is B
Rationale: Transcutaneous pacing involves delivering electrical pulses to stimulate ventricular
depolarization in symptomatic bradycardia. The pacing stimulus is delivered using the lowest
energy required to stimulate a QRS complex on the ECG, indicating ventricular depolarization.
Transcutaneous pacing is an emergency procedure for profound bradycardia, it is a temporary
measure until a more permanent device such as a permanent pacemaker can be inserted.
Synchronized cardioversion involves delivering a dose of energy timed to the R wave of the
QRS complex, this is not required for transcutaneous pacing.
Concepts tested

Question 2964
The nurse is assessing a postoperative client with a Hemovac drain to the left knee. The client
appears restless and has cold, clammy skin. The Hemovac drain is completely expanded filled
with sanguineous drainage in the collection chamber. Which action does the nurse perform next?
A Documents the amount of output.
B Instructs the client to maintaining suction via compression.
C Empties the Hemovac collection chamber.
D Applies a pressure dressing to the site.

Question Explanation

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Correct Answer is D
Rationale: Closed drainage systems collect excess fluid or blood from surgical wounds.
Hemovac drains will expand as blood fills the chamber. The client’s symptoms are indicative of
wound hemorrhaging. The nurse should apply a pressure dressing to control the bleeding.
Documenting the amount of output is important; however, this action should be performed after
the client is stabilized. Educating the client on maintaining suction to the collection chamber is
important; however, the client is not stable, and this intervention is not indicated at this time.
Emptying the collection chamber will not stop the bleeding.
Concepts tested

Question 2965
A community health nurse is vaccinating a group of children for protection against measles. The
nurse knows that the vaccine will provide the clients with which type of immunity?
A Passive
B Natural
C Acquired
D Active

Question Explanation
Correct Answer is D
Rationale: Vaccines provide active immunity. Vaccines signal the immune system to produce
antibodies against the disease. Passive immunity occurs when antibodies are transferred to a
person via transfusions or from a mother to a newborn via the placenta. Natural immunity is a
natural defense mechanism to specific toxins or antigens. Acquired immunity is obtained after
actual exposure and infection with the disease.
Concepts tested

Question 2966
The nurse is caring for a client who received intravenous potassium chloride for a serum
potassium level of 2.2 mEq/L. Which of the following client findings indicates that the treatment
has been effective?
A Presence of U waves on the client’s electrocardiogram.
B Hyporeflexive deep tendon reflexes.
C Increased rate and depth of respirations.
D Hypoactive bowel sounds.

Question Explanation
Correct Answer is C
Rationale: Hypokalemia can cause severe disturbances in the cardiovascular, respiratory,
neurological, and musculoskeletal systems. A major cause of death from hypokalemia is
respiratory insufficiency due to respiratory muscle weakness. An increase in rate and depth of
respirations indicates that treatment with intravenous potassium has been effective. Hypoactive
bowel sounds, hyporeflexia, and U waves are all signs of severe hypokalemia, which indicate the
treatment has not been effective in reversing the client’s hypokalemia.
Concepts tested

Page | 1175
Question 2967
The nurse is providing care to a client with liver cancer. The client has been receiving external
beam radiation therapy (ERBT). Which symptom assessed by the nurse indicates an adverse
effect to ERBT?
A Ascites
B Diarrhea
C Anorexia
D Nausea

Question Explanation
Correct Answer is A
Rationale: External beam radiation therapy (ERBT) can cause radiation-induced liver disease
(RILD). RILD can be fatal and is characterized by jaundice, fluid accumulation in the abdomen
(ascites), and abnormal blood liver tests. Diarrhea is a common side effect of radiation therapy.
The nurse should ensure proper hydration. Nausea and anorexia or loss of appetite, are also
common side effects of radiation. These side effects should subside within a few weeks or after
treatment is completed.
Concepts tested

Question 2968
A nurse is teaching a client with hypertension about safely choosing over-the-counter (OTC)
medication. Which statement by the client indicates that the education has been effective?
A "I should never take any over-the-counter (OTC) medicine without first calling and checking
with the doctor's office."
B "I should always ask the pharmacist about how to take an over-the-counter (OTC) medicine. "
C "I will read all the directions on the label and ask the pharmacist if the directions are not clear.
"
D "Medicines that are available over-the-counter (OTC) are really safe or they would be
prescription medicines. "

Question Explanation
Correct Answer is C
Rationale: The client with hypertension should be taught to always read the labels on all over-
the-counter medications. Clients should look for warnings to those with high blood pressure (BP)
and to those who take blood pressure medications. Many OTC drugs and supplements can raise
BP or interact with BP medications. Be aware of over-the-counter cold and flu preparations that
contain decongestants, such as oxymetazoline, phenylephrine, and pseudoephedrine as they will
raise the BP. Other OTC drugs and substances that can raise blood pressure include alcohol,
caffeine, and non-steroidal anti-inflammatory drugs ( i.e., ibuprofen and naproxen sodium).
Many herbs and foods can interact with BP medications as well.
Concepts tested

Question 2969
The nurse is caring for a client receiving external beam radiation for the treatment of prostate
cancer. The client has asked for additional information on the reproductive effects of radiation
therapy. What statement would be included in the teaching?
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A “Sexual function should not be affected by the treatments”
B “Sperm banking is an option if you are considering starting a family”
C “Libido is usually unaffected by radiation therapy”
D &ldquo;Erectile dysfunction will likely resolve after completing treatments&rdquo;
“Erectile dysfunction will likely resolve after completing treatments”

Question Explanation
Correct Answer is B
Rationale: Sexual dysfunction occurs in 20~80% of patients who undergo radiation therapy.
Radiation therapy nearly always impairs fertility. Radiated prostate cells and seminal vesicles
produce semen that cannot transport the sperm well. Therefore, the nurse should counsel the
client on sperm banking. Sexual dysfunction is common in cancer. Prostate cancer by itself
reduces sexual desire and the frequency of sexual intercourse. The chance of maintaining erectile
function after radiation therapy has been reported to be approximately 50%, which is higher than
that of radical prostatectomy. Erectile dysfunction does not resolve after treatment.
Concepts tested

Question 2970
The nurse is caring for a client who had abdominal surgery 4 days ago. Which of the following
client findings is a priority to follow up?
A Client reports a popping sensation in the abdomen.
B Small amounts of purulent drainage at the incision site.
C Client reports increased sharp, continuous abdominal pain.
D Increased swelling and redness at the incision site.

Question Explanation
Correct Answer is A
Rationale: The client's report of a popping sensation is a symptom of possible dehiscence
(partial or complete separation of the tissue layers during the healing process) or evisceration
(total separation of the tissue layers, allowing the protrusion of visceral organs through the
incision). These surgical complications are an emergency and require immediate follow-up from
the nurse. The increased swelling and drainage may indicate infection and the pain also requires
assessment; however, the key is the priority finding.
Concepts tested

Question 2971
The charge nurse is observing a newly hired nurse irrigate a client’s stage 4 pressure injury.
Which of the following actions by the newly hired nurse requires intervention?
A Applying clean gloves and discarding the old dressing
B Cleansing the wound from the outer edges toward the center
C Irrigating the wound until the solution becomes clear
D Inserting the irrigation catheter into the wound until resistance is met

Question Explanation
Correct Answer is B

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Rationale: The charge nurse should follow up if the newly hired nurse is cleansing the wound
from the outer edge towards the center. Wounds should be cleansed from the cleanest area
towards the least clean. If the wound is circular, this would be from the center of the wound
outward. It indicates the correct technique for irrigating a wound if the newly hired nurse applies
clean gloves while discarding the old dressing, irrigates the wound until the solution runs clear
and is free from exudate, and only inserts the irrigating catheter into a wound until resistance is
met to avoid tissue damage.
Concepts tested

Question 2972
The nurse is in the room with a client who is experiencing a seizure. The client has visible
secretions in the oral cavity. Which action does the nurse take?
A Place the client in a supine position
B Open the client’s mouth
C Suction the visible secretions
D Insert a padded tongue blade

Question Explanation
Correct Answer is C
Rationale: Clients experiencing a seizure may experience autonomic manifestations including
salivation, incontinence, and vomiting. Oral secretions may cause aspiration if not removed. The
nurse should suction the visible secretions without attempting to open the client’s mouth. Placing
the client in a supine position will increase the risk of aspiration. Opening the client’s mouth
while there is stiffening of the muscles can lead to injury. Objects should never be inserted into
the oral cavity of a client having a seizure. This can lead to injury and aspiration.
Concepts tested

Question 2973
The nurse is caring for a client who is experiencing increased intracranial pressure. Which of the
following should be included in the client’s plan of care?
A Increase intracranial blood volume.
B Monitor for temperature elevation.
C Hold sedation medications.
D Perform neurological assessments every 30 minutes.

Question Explanation
Correct Answer is B
Rationale: Avoiding a spike in body temperature is important to avoid increasing the client’s
intracranial pressure (ICP) therefore frequent monitoring should be performed. For the client
who has an increased ICP, the nurse should strive to reduce intracranial blood volume. Sedation
is a common method of minimizing cerebral oxygen demand and is often used for clients with
elevated ICP. Lastly, while neurological assessments are often performed on these clients, every
30 minutes is excessive and would mean that the nurse would be waking the client frequently.
Concepts tested

Question 2974
Page | 1178
The post-anesthesia care nurse is monitoring a client who had a laparoscopic cholecystectomy.
Which findings would indicate to the nurse the client is safe to discharge?
A SaO2 of 95% on room air, vital signs stable for last 30 minutes, baseline neurological status
B Pain level reported as 3 out of 10, ability to move extremities, dressing dry and intact
C Urinary output of 30 mL/hr awake and alert, turning from side to side
D Temperature 99.2⁰F, occasional rhonchi on auscultation, strong cough

Question Explanation
Correct Answer is A
Rationale: A patient remains in the PACU until fully recovered from the anesthetic agent.
Priority indicators of recovery include stable blood pressure, adequate respiratory function, and
adequate oxygen saturation level compared with baseline. Additional indications are adequate
pain control, baseline ambulatory status, minimal nausea/vomiting, and minimal surgical site
drainage/bleeding.
Concepts tested

Question 2975
The nurse is reviewing the plan of care for a client with an internal radiation implant placed.
Which action on the plan should be revised?
A Applying gloves when emptying the client’s bedpan
B Keeping all the linens in the room until the implant is removed.
C Wearing a lead apron when providing direct care
D Placing the client in a semiprivate room at the end of the hallway

Question Explanation
Correct Answer is D
Rationale: A private room is necessary for a client with a radiation implant. The client emits
radioactivity and needs to limit exposing other people. The nurse should wear gloves when
emptying a bedpan, wear a lead apron, and keep all linens in the room to prevent contamination.
Concepts tested

Question 2976
The nurse is caring for a client with a serum calcium level of 15 mg/dL. Which of the following
actions should the nurse take?
A Reduce stimulation by keeping the room quiet.
B Request a prescription for an antidiarrheal medication.
C Provide foods that are rich in calcium to the client.
D Request a prescription for an intravenous normal saline infusion.

Question Explanation
Correct Answer is D
Rationale: A serum calcium level of 15 mg/dL indicates severe hypercalcemia. Hypercalcemia is
treated by fluid volume replacement with normal saline to correct hypercalcemia-induced urinary
salt wasting. Additionally, correcting the hypovolemia and the sodium in the IV fluid enhances
kidney excretion of calcium. An antidiarrheal medication may be needed for clients who are

Page | 1179
experiencing hypocalcemia, not hypercalcemia, due to the increased peristalsis that the
electrolyte abnormality causes within the gastrointestinal tract. Additionally, clients with
hypocalcemia may have increased excitability and would benefit from reduced stimuli. Clients
with hypercalcemia should have high-calcium and vitamin D foods removed from their diet until
the electrolyte abnormality resolves.
Concepts tested

Question 2977
The nurse is reviewing the cardiac telemetry for a client admitted with exacerbation of left-sided
heart failure. Which action should the nurse take?

A Assess the client’s pulse oximetry.

B Obtain serum cardiac enzymes.
C Request a prescription for IV fluids.
D Administer prescribed lisinopril.

Question Explanation
Correct Answer is A
Rationale: Premature ventricular contractions (PVCs) are early beats, generated from the
ventricles. PVCs indicate irritability of the ventricles, which can be caused by hypoxia,
electrolyte imbalance, or disease, such as cardiomyopathy. Cardiac enzymes are obtained when a
client is experiencing myocardial infarction, which would be indicated with an elevated ST
segment. A prescription for IV fluids would be appropriate when a client is experiencing
hypotension. Lisinopril, an ACE inhibitor, is indicated to decrease blood pressure.
Concepts tested

Question 2978
The nurse is caring for a client with sepsis who has a femoral arterial line placed. Which would
be the priority action for the nurse to take when monitoring the line?
A Palpate pedal pulses.
B Inspect insertion site.
C Flush line tubing with normal saline.
D Clean insertion site with chlorhexidine.

Question Explanation
Correct Answer is A
Rationale: An arterial line placed in the femoral artery requires the nurse to monitor the client’s
neurovascular and perfusion function. The nurse should palpate pedal pulses to evaluate that the
arterial line is not impeding blood flow to the lower extremity which can lead to impaired

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perfusion. The nurse will flush the line with normal saline, clean the insertion site with
chlorhexidine, and inspect the insertion site, but the priority is to evaluate perfusion.
Concepts tested

Question 2979
The nurse is caring for a client receiving hemodialysis three times weekly. The client has a new
arteriovenous fistula. Which of the following will be included in the plan of care?
A The fistula will be assessed for thrill and bruit each shift
B The client will be encouraged to eat a low protein diet
C Antihypertensive medications will be administered immediately before dialysis treatments
D The new access will be allowed to mature for six months.

Question Explanation
Correct Answer is A
Rationale: Fistulas should be assessed for a thrill and bruit each shift to assess for stenosis and
clotting. Hemodialysis patients are instructed to eat a moderate or high protein diet since dialysis
removes protein from the blood. Some antihypertensive agents are cleared by HD, including
beta-blockers so they are administered after the treatment. In addition, dialysis removes fluid,
and a reduction in blood pressure may occur during the treatment if the medication is
administered. AV fistulas are allowed to mature for 2 to 4 months.
Concepts tested

Question 2980
The nurse is providing education to a client with diabetes mellitus type 2 about diet. What should
the nurse include in the teaching?
A “Your carbohydrate intake should be 50 to 75% of your total daily calories.”
B “Include at least 14 grains of fiber for every 1,000 calories you ingest.”
C “Proteins should make up 10% of your daily food intake.”
D “Limit your sodium intake to 2,500 mg per day.”

Question Explanation
Correct Answer is B
Rationale: Clients with diabetes mellitus type 2 should follow a diet that is high in fiber and low
in saturated fat. Fiber improves carbohydrate metabolism and lowers total cholesterol.
Recommended fiber intake is 14 grains per 1,000 calories. Carbohydrates should be complex and
make up 45 to 65% of the total daily caloric intake. Proteins such as meats, eggs, and fish should
make up 15 to 20% of the total daily food intake. Sodium intake should be limited to 2,300 mg a
day in clients with diabetes.
Concepts tested

Question 2981
The nurse is providing care to a client who is postoperative from an above-the-knee amputation.
Which intervention should the nurse implement to prevent flexion contractures?
A Elevate the residual limb on several pillows.
B Have the client sit in a chair for 1 hour every shift.

Page | 1181
C Position the client prone several times a day for 20 minutes.
D Wrap the residual limb using an elastic bandage.

Question Explanation
Correct Answer is C
Rationale: Flexion contractions occur due to improper positioning after an amputation. A prone
position will promote the extension of the hip and prevent flexion contractures. Elevating the
residual limb on several pillows will place the hip in a prolonged flexed position and cause
contractures. Having the client sit for a prolonged period of time will flex the hip joint and
potentially cause contractures. Wrapping the residual limb using an elastic bandage will promote
shrinkage of the residual limb but will not prevent contractures.
Concepts tested

Question 2982
A nurse is caring for a client who has end-stage kidney disease (ESKD) and is receiving
prescribed epoetin alfa. Which of the following findings would indicate that the treatment is
having the intended effect?
A An increase in leukocytes
B An increase in platelets
C An increase in hematocrit
D An increase in erythrocyte sedimentation rate (ESR)

Question Explanation
Correct Answer is C
Rationale: In end-stage renal disease, erythropoietin production decreases and profound anemia
results, producing fatigue, angina, and shortness of breath. Anemia associated with ESKD is
treated with erythrocyte-stimulating agents (recombinant human erythropoietin). Erythrocyte
stimulation therapy is initiated to achieve a hematocrit of 33% to 38% and target hemoglobin of
12 g/dL, which generally reduces the symptoms of anemia.
Epoetin alfa is administered IV or subcutaneously three times a week in ESKD. It may take 2 to
6 weeks for the hematocrit to increase; therefore, the medication is not indicated for immediate
treatment of severe anemia. Leukocytes and platelets are unaffected by the administration of
epoetin. Increases in the erythrocyte sedimentation rate (ESR) indicate inflammation in the body.
Concepts tested

Question 2983
The nurse is caring for a client with an acute ischemic stroke who will be receiving prescribed
intravenous fibrinolytic therapy. Which of the following instructions should the nurse provide to
the client?
A “Your neurological status will be closely monitored every shift.”
B “You will need an indwelling urethral catheter placed following this procedure.”
C “Your blood pressure will be closely managed during and after administration of this
medication.”
D “You should expect severe headaches during the administration of this medication."

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Question Explanation
Correct Answer is C
Rationale: Clients who are receiving fibrinolytic therapy are at very high risk for intracerebral
hemorrhage as a complication of the therapy. Blood pressure will be closely monitored and
managed to reduce hypertensive episodes that may cause intracerebral hemorrhage. The client’s
neurological status will be monitored every 15 minutes during the infusion, and hourly thereafter
per standard protocols. Any invasive lines should be placed prior to fibrinolytic therapy infusion
and avoided for 24 hours after to reduce the risk of hemorrhage from the insertion site. The client
should be closely monitored for severe headaches, nausea, or vomiting, which may indicate a
complication of intracerebral hemorrhage.
Concepts tested

Question 2984
The nurse is assessing a postoperative client with a new colostomy. The client states that the
stoma protruded into the collection bag 30 minutes ago. What action does the nurse perform
next?
A Notify the healthcare provider.
B Tell the client that this is expected after surgery.
C Document the findings.
D Reassess the client in an hour.

Question Explanation
Correct Answer is A
Rationale: A stoma protruding into the collection bag is known as a prolapse. A prolapsed stoma
can lead to twisting of the bowel and impaired circulation. Given the timeframe of when the
prolapse occurred, the nurse should notify the healthcare provider immediately. This is not an
expected finding after surgery. Documenting the findings is a required intervention; however, the
nurse should notify the healthcare provider before documenting interventions. Reassessing the
client in an hour can lead to complications. The nurse should intervene immediately.
Concepts tested

Question 2985
The nurse is assessing a client following the placement of a right subclavian central line. The
nurse notes the client has an oxygen saturation of 88%, respiratory rate of 32, and a client report
of sudden onset of shortness of breath. Which finding observed by the nurse would indicate the
client is experiencing a pneumothorax?
A Absent breath sounds over the right upper lobe
B Paradoxical chest wall movement on the right
C Sudden loss of consciousness
D Muffled heart sounds

Question Explanation
Correct Answer is A
Rationale: Pneumothorax is a potential iatrogenic complication from subclavian central line
insertion. The apex of the lung is directly beneath the insertion site and can be punctured by the
needle. Paradoxical chest wall movement is associated with flail chest. Sudden loss of
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consciousness is not associated with central line insertion. Muffled heart sounds are often
associated with cardiac tamponade.
Concepts tested

Question 2986
A nurse is providing discharge education about newly prescribed levofloxacin to a client with a
history of diabetes type II who has hospital-acquired pneumonia. Which of the statements by the
client indicates an understanding of the teaching?
A “I can take an antacid with this medication if it upsets my stomach”
B “It is common to feel joint aches and soreness when on levofloxacin”
C “I will increase my intake of plain yogurt while on this prescription”
D “This medication may increase my blood sugar”

Question Explanation
Correct Answer is C
Rationale: Clients should be instructed to avoid antacids containing magnesium or aluminum;
any products containing iron, magnesium, calcium, or zinc at the same time or for 2 hours before
or after a dose of the fluoroquinolone. These medications decrease the effectiveness of the
antibiotic. The FDA has issued a black box warning for fluoroquinolones, alerting health
professionals to the risk of tendinitis and tendon rupture. Therefore, joint tenderness should be
reported immediately. Fluoroquinolones are known to have a potential risk of hypoglycemia
sometimes resulting in coma, occurring more frequently in the elderly and those with diabetes
taking an oral hypoglycemic medicine or insulin. Potent antibiotics increase the risk of
superinfection so increasing the intake of probiotics is encouraged.
Concepts tested

Question 2987
The nurse is planning care for a client with stage 2 human immunodeficiency virus (HIV).
Which intervention will the nurse perform to help manage wasting syndrome?
A Encourage independent activities of daily living.
B Assist with range of motion exercises.
C Serve foods with a high fat content.
D Provide an oral rinse after every meal.

Question Explanation
Correct Answer is D
Rationale: Wasting syndrome is a complication of HIV and is characterized by diarrhea, chronic
weakness, and weight loss of more than 10% of body weight. Providing oral rinses increases
appetite and decreases mouth pain associated with ulcerations. Activities of daily living (ADLs)
should be encouraged for every client. ADLs alone will not help manage wasting syndrome.
Assisting with range of motion is a musculoskeletal intervention and will not manage wasting
syndrome. Wasting syndrome causes fat intolerance. Foods should contain low-fat content to
decrease the complications of fat malabsorption, such as gallstones, abdominal pain, and gas.
Concepts tested

Question 2988
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The nurse is caring for a client who had abdominal surgery 1 day ago and has a hemovac in
place. Which of the following actions is most important for the nurse to take?
A Monitor the client’s hemoglobin and hematocrit.
B Evaluate the color and consistency of drainage once per shift.
C Ensure that the reservoir is compressed to provide suction.
D Secure the container to the client’s gown.

Question Explanation
Correct Answer is A
Rationale: The priority action for the nurse is to closely monitor the client’s hemoglobin and
hematocrit levels while surgical drains are in place. Clients are at risk for developing anemia and
associated complications. Evaluating the color and consistency of drainage each shift, ensuring
the reservoir is compressed, and securing the container to the client’s gown are all correct actions
and are standard care; however, the priority is to monitor for complications of blood loss.
Concepts tested

Question 2989
The nurse is caring for a client who is 9 weeks pregnant. Which statement made by the client
indicates a need for further assessment by the nurse?
A “I wake up every morning with so much nausea.”
B “I get bad stomach cramps throughout the day.”
C My breasts feel tender at the slightest touch.”
D “I feel the need to urinate very often.”

Question Explanation
Correct Answer is B
Rationale: Abdominal cramping during the first trimester is a concerning symptom and may be
indicative of an ectopic pregnancy. The nurse should further assess the client’s statement.
Nausea and breast tenderness are common discomforts during the first trimester of pregnancy.
Urinary frequency may occur during the first and third trimesters of pregnancy. The nurse should
encourage frequent bladder emptying and Kegel exercise to reduce stress incontinence.
Concepts tested

Question 2990
The nurse is caring for a client who suddenly develops slurred speech and a facial droop. What
diagnostic test would the nurse expect to be performed first?
A Computerized tomography scan
B Chest X-ray
C Echocardiogram
D Arterial blood gas

Question Explanation
Correct Answer is A

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Rationale: The client's symptoms are indicative of an acute stroke. The nurse would anticipate
that a non-contrast computerized tomography (CT) of the head will be done first because time is
of the essence with an acute stroke. The other tests may or may not be indicated for this client.
Concepts tested

Question 2991
The nurse in a long-term care facility is caring for an 89-year-old client with atrial fibrillation
and a history of multiple falls. The client's medications include amiodarone, atorvastatin, baby
aspirin and metoprolol. Which new finding should be of greatest concern to the nurse?
A Right-sided facial droop
B Bibasilar crackles
C SpO2 of 89% on room air
D Heart rate of 106

Question Explanation
Correct Answer is A
Rationale: The most concerning finding would be the development of a right-sided facial droop.
The client with atrial fibrillation is at increased risk of stroke, and this client's listed medications
do not include an anticoagulant, typically prescribed to prevent a stroke. Given the finding of
frequent falls, it is possible that the client is not on a stronger anticoagulant, such as warfarin,
due to an increased risk of intracranial hemorrhage after a fall. A SpO2 of 89% on room air, a
heart rate of 106 and crackles on auscultation are all concerning findings, but the possibility of a
stroke should be of the greatest concern to the nurse.
Concepts tested

Question 2992
An adult client who has been experiencing a seizure for approximately 15 minutes is brought to
the emergency department by private vehicle. Which intervention should the nurse
implement first?
A Obtain a STAT electroencephalogram.
B Administer levetiracetam intravenously.
C Administer lorazepam intravenously.
D Obtain a STAT 12-lead electrocardiogram.

Question Explanation
Correct Answer is C
Rationale: This client is experiencing status epilepticus and is in immediate need of medication
to stop the seizure. Of the provided options, the highest priority would be to administer the
intravenous (IV) lorazepam to stop the seizure. While levetiracetam, an anticonvulsant, may be
indicated for the client, lorazepam, a benzodiazepine, would be administered first in an attempt
to stop the seizure quickly. An electroencephalogram (EEG) is an important test when evaluating
for seizures, but it would not be highest priority at this time. A 12-lead electrocardiogram (ECG)
may be part of a more general diagnostic work-up for many clients, but it would be a lower
priority than stopping the seizures.
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Concepts tested

Question 2993
A postoperative client following a thyroidectomy suddenly develops difficulty breathing, stridor
and an increase in swelling of the anterior neck area. What should the nurse do first?
A Activate the hospital's emergency or rapid response system.
B Ask the charge nurse to come see the client immediately.
C Place a heart monitor on the client and observe for dysrhythmias.
D Check the client's blood pressure and heart rate.

Question Explanation
Correct Answer is A
Rationale: The client is demonstrating clinical manifestations of an airway obstruction related to
bleeding and/or swelling following the thyroidectomy. This is a life-threatening, medical
emergency and the nurse's first action should be to activate the hospital's emergency or rapid
response system. It is possible that the client will need an emergency surgical airway
intervention, such as a tracheostomy, to maintain a patent airway.
Concepts tested

Question 2994
The nurse on a postpartum nursing unit is receiving report about a client who had a normal
spontaneous vaginal delivery the night before. The client has been passing golf ball-sized clots
on her peri-pad for the last few hours. The client's most recent blood pressure is 88/56 mm Hg,
and her heart rate is 118 bpm. The nurse enters the client's room and notices blood oozing from
her intravenous insertion site. Which action should the nurse take first?
A Perform peri-care and change the client's peri-pad.
B Notify the client's health care provider.
C Palpate and massage the client's uterus.
D Encourage breastfeeding to promote uterine contractions.

Question Explanation
Correct Answer is B
Rationale: After a normal spontaneous vaginal delivery (NSVD), it is normal for a client to have
vaginal bleeding on their peri-pad. Postpartum hemorrhage (PPH) is defined as blood loss greater
than or equal to 500 mL after birth. If a patient is saturating more than one peri-pad in an hour or
passing several large clots, the patient could be experiencing PPH. This is an obstetric
emergency. Signs and symptoms of PPH include dizziness, hypotension, tachycardia, large clots
passed vaginally and heavy bleeding on the peri-pad. PPH can progress to a life-threatening
condition called disseminated intravascular coagulation (DIC). This can occur after an injury or
childbirth. Proteins in the blood that form blood clots travel to the injury site to help stop
bleeding. If these proteins become abnormally overactive throughout the body, DIC can ensue.
Small blood clots form in blood vessels throughout the body, and can clog the vessels and cut off
the normal blood supply to the organs. Signs and symptoms of DIC include severe bleeding,
oozing from puncture sites, hypotension, tachycardia, dizziness and hypoxia. The nurse should
suspect DIC and should notify the primary health care provider (HCP) immediately. Nursing
measures to monitor and control normal postpartum uterine bleeding can include uterine
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massage, breastfeeding and peri-care. The client in this scenario may be experiencing a medical
emergency (e.g., DIC), therefore the nurse should first notify the HCP
Concepts tested

Question 2995
The off-duty nurse is helping to administer first aid following a mass casualty incident in the
community. Emergency medical personnel at the scene have started to triage victims, using a
common, color-tagging system. Which tag color usually indicates the highest priority for a
victim to receive care?
A Green
B Red
C Yellow
D Black

Question Explanation
Correct Answer is B
Rationale: In a mass casualty incident (MCI), first responders often use a color-tagging system to
facilitate rapid triage of victims. Generally speaking, a green tag would indicate minor injuries, a
yellow tag would indicate more significant but not expected to be life-threatening injuries, a red
tag would indicate life-threatening injuries, and a black tag would identify a victim who has died,
is near death or has the lowest chance for survival. Victims assigned a red tag are
the highest priority for care and transport to the nearest hospital.
Concepts tested

Question 2996
The nurse is talking with a client during a home health visit. The client states, "my right arm and
right leg are beginning to feel heavy." The nurse notices the client is having trouble speaking and
has stopped moving the right side of their face. What action the nurse should take first?
A Call 911.
B Ask the client if they have a headache.
C Document the onset of symptoms in the medical record.
D Take the client's vital signs.

Question Explanation
Correct Answer is A
Rationale: The client is exhibiting signs of an acute stroke. A stroke is caused by a disruption in
the normal blood supply to the brain. A stroke is a medical emergency. The nurse in the home
health setting should call 911 first. While waiting for emergency medical help to arrive, the nurse
should gather additional data by obtaining vital signs and evaluating the client's neurological
status. The data should be recorded in the medical record.
Concepts tested

Question 2997

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The off-duty nurse witnesses a motor vehicle accident and is concerned that the driver of the
automobile may be injured. What should the nurse do first?
A Minimize movement of the driver's cervical spine.
B Consider scene safety to prevent further injury.
C Check the driver's respiratory rate.
D Check the driver's pulse.

Question Explanation
Correct Answer is B
Rationale: When attempting to render aid after a motor vehicle collision, it is critically important
that the responder first consider scene safety. Responders should assess the scene for risks to
safety to prevent further injury to themselves, the victim and other motorists on the road.
Minimizing the movement of the driver's cervical spine, checking the driver's pulse and checking
the driver's respiratory rate may all be indicated in the scenario, but scene safety should be
considered first.
Concepts tested

Question 2998
An adult client in the waiting room of an outpatient clinic is found to have become unresponsive.
The nurse is unable to palpate the client’s carotid pulse. Emergency medical services have been
requested by calling 911. What should the nurse do next?
A Wait for the emergency medical services technicians to arrive.
B Use a jaw-thrust maneuver to open the client's airway.
C Begin chest compressions.
D Deliver two rescue breaths.

Question Explanation
Correct Answer is C
Rationale: According to basic life support (BLS) guidelines by the American Heart Association
(AHA), chest compressions are the next step in initiating cardiopulmonary resuscitation (CPR)
for an unresponsive client in whom a carotid pulse cannot be palpated. After the initial round of
30 chest compressions, the nurse should open the client's airway with a head tilt-chin lift
maneuver (or a jaw-thrust maneuver if spinal cord injury is suspected) and deliver two breaths. It
would not be appropriate to wait to start CPR until emergency medical services technicians
arrive because immediate action is needed.
Concepts tested

Question 2999
An off-duty nurse witnesses a person collapse in a grocery store, and the individual is now
unresponsive. Multiple bystanders are present. What should the nurse do first?
A Deliver two rescue breaths.
B Begin chest compressions.
C Run to get the store's automated external defibrillator.
D Check for a carotid pulse and instruct a bystander to call 911.

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Question Explanation
Correct Answer is D
Rationale: The off-duty nurse's first action when encountering this unresponsive individual who
just collapsed should be to check for a pulse and to ensure the activation of 911 emergency
response. While chest compressions may very well be needed, the nurse should first check for a
carotid pulse. If a carotid pulse cannot be palpated in this unresponsive individual,
cardiopulmonary resuscitation (CPR) chest compressions should be initiated. An automated
external defibrillator (AED) should be incorporated into the response once it is available.
However, the nurse should stay with the victim, begin CPR and assign the task of obtaining the
AED to someone else at the scene.
Concepts tested

Question 3000
An off-duty nurse arrives at a park and is told by a bystander that a child is choking and needs
assistance. The bystander has already called 911. The nurse observes an approximately 8-year-
old child with cyanosis and an inability to breathe who remains conscious and standing. What
should the nurse do next?
A Deliver two rescue breaths.
B Stand behind the child and administer abdominal thrusts.
C Instruct the child to lay down and begin CPR.
D Check the child's carotid pulse.

Question Explanation
Correct Answer is B
Rationale: For a conscious choking victim, according to basic life support (BLS) guidelines by
the American Heart Association (AHA), the next action by the nurse should be to perform
abdominal thrusts (i.e., the Heimlich Maneuver) to attempt to clear the airway obstruction.
Attempting to deliver rescue breaths or checking the carotid pulse of a conscious choking victim
would not be indicated. If the child were to become unconscious, then chest compressions should
be initiated.
Concepts tested

Question 3001
The nurse enters the room of an adult client in cardiac arrest with cardiopulmonary resuscitation
already in progress. The client's bedside telemetry monitor shows ventricular fibrillation. What
should the nurse do next?
A Assist with the insertion of a large-bore IV catheter.
B Quickly leave the room and notify the client's next-of-kin.
C Assist with preparing the client for defibrillation.
D Prepare to administer two rescue breaths.

Question Explanation
Correct Answer is C
Rationale: Ventricular fibrillation (V-Fib) is a life-threatening dysrhythmia that requires
immediate defibrillation to attempt to restore a viable cardiac rhythm. V-Fib will cause death

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within minutes due to the complete lack of cardiac output and tissue perfusion. The other actions
should be implemented after defibrillation has been performed or attempted.
Concepts tested

Question 3002
An adult client arrives at the clinic after being stung by a bee. The nurse notes that the client is
having difficulty breathing, is audibly wheezing and has swollen lips. What is the
nurse's highest priority?
A Administer epinephrine.
B Administer a bronchodilator.
C Obtain an arterial blood gas.
D Obtain a home medication list.

Question Explanation
Correct Answer is A
Rationale: The client's condition indicates the high likelihood of a life-threatening anaphylactic
reaction to a bee sting, with an obstructed airway due to bronchoconstriction and a high potential
for hypoxemia. While obtaining a home medication list and obtaining arterial blood gases may
be part of the care provided to the client, the highest priority is to administer epinephrine.
Epinephrine is a critical drug in the treatment of anaphylaxis. Relieving the vasoconstriction
effects on bronchial muscles with epinephrine could be life-saving in this situation. A
bronchodilator may also be prescribed, but not before epinephrine has been administered.
Concepts tested

Question 3003
The nurse in the prenatal clinic is developing a plan of care for a client with preeclampsia. Which
interventions should the nurse include? Select all that apply.
A Count and record fetal movement daily
B Avoid all sexual activity
C Limit sodium intake
D Self-monitor blood pressure daily
E Maintain complete bedrest
F Use acetaminophen for headache

Question Explanation
Correct Answer is A, C, D, F
Rationale: Preeclampsia is defined as an elevated BP (≥140/90 mm Hg) after the 20th week of
pregnancy on more than one occasion, and proteinuria. Recommended interventions include
accurate, regular monitoring of BP and education on when to report readings to the health care
provider, fetal movement counts and lowering or limiting sodium intake to avoid fluid retention.
Headaches are common with preeclampsia and using acetaminophen for pain management
would be appropriate. Maintaining complete bedrest or abstaining from all sexual activity is no
longer recommended or indicated at this time.
Concepts tested

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Question 3004
The nurse in the emergency department is caring for a pregnant client at 32-weeks gestation with
suspected placental abruption. Which order from the health care provider should the nurse
implement first?
A Type and crossmatch for 2 units of packed RBCs
B Administer 100% oxygen via nonrebreather mask
C Initiate continuous fetal heart rate monitoring
D Start a normal saline IV infusion at 150 mL per hour

Question Explanation
Correct Answer is B
Rationale: Abruptio placentae, or placental abruption, means the premature detachment of the
placenta, wholly or partially, from the uterine wall. Immediate birth, i.e., delivery, is the
treatment of choice if the fetus is near term or the bleeding is moderate to severe or the life of the
mother or fetus is in jeopardy. In this scenario, the nurse should use the Airway-Breathing-
Circulation (A-B-C) approach to prioritize the ordered interventions. The nurse
should first administer the oxygen to prevent hypoxia in the fetus. Then the nurse should
implement the other interventions.
Concepts tested

Question 3005
The nurse in a well-baby clinic is speaking with the mother of a 3-week-old newborn. Which
statement by the mother should be of highest concern to the nurse?
A “I have not been able to empty my breasts completely with each feeding.”
B “No matter how hard I try, I don't feel any love for my baby.”
C “I have not been doing my Kegel exercises as much as I should.”
D “I think my baby is not gaining as much weight as it should.”

Question Explanation
Correct Answer is B
Rationale: The postpartum period is a time of great adjustment and change for the new parent.
The nurse's role should focus on supportive care and monitoring for postpartum complications
such as postpartum depression (PPD). Up to 20% of new mothers experience PPD. Symptoms of
PPD include intense sadness lasting longer than two weeks, severe and labile mood swings,
feelings of fear, anxiety or anger and worries about being an incompetent parent or not loving the
child. Although all of the mother's statements should be followed-up by the nurse, the mother’s
statement about trying but not being able to feel love for their child should be of highest concern.
Concepts tested

Question 3006
A client with a known large abdominal aortic aneurysm develops a sudden change in level of
consciousness and tachycardia. The client's blood pressure is 72/48 mm Hg. What should the
nurse do first?
A Activate the hospital's emergency response team.
B Obtain a 12-lead electrocardiogram.

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C Conduct a complete head-to-toe physical assessment.
D Page the client's health care provider.

Question Explanation
Correct Answer is A
Rationale: The client is exhibiting signs and symptoms of an abdominal aortic aneurysm (AAA)
rupture. The nurse's first action should be to activate the hospital's emergency response team, as
this client needs immediate advanced care. The nurse is anticipating the need for rapid action and
surgical intervention to avoid the death of the client. While notifying the client's health care
provider and obtaining a 12-lead electrocardiogram (ECG) may be needed, activating the
emergency response team should be done first. Similarly, the nurse does not have time complete
a head-to-toe physical assessment before activating the emergency response team.
Concepts tested

Question 3007
The nurse is participating in a disaster simulation that involves a school bus accident. The nurse
is assigned to care for the following four clients in a rural hospital's emergency department.
Which client should the nurse see first?
A The client with a penetrating abdominal wound
B The client with multiple facial abrasions
C The client with a third degree burn to the arm
D The client with an open humerus fracture

Question Explanation
Correct Answer is A
Rationale: Part of a nurse's role is being a part of disaster management and assisting in client care
throughout all aspects of health care delivery. To better prepare nurses for disaster situations,
simulation is a method used to evaluate preparedness. The nurse needs to be able to respond to
disasters in the community and keep clients safe. Answering this specific scenario requires the
application of survival potential priority setting frameworks. A client with a penetrating
abdominal wound should be seen first because a penetrating injury usually causes internal
injuries, such as bleeding, which can quickly lead to death.
Concepts tested

Question 3008
The nurse is caring for a client with a medical history of peripheral artery disease, hypertension
and smoking. The client reports severe pain in the right lower leg that started very suddenly and
did not get better after receiving an analgesic. What action should the nurse take first?
A Notify the health care provider.
B Administer an additional dose of the analgesic.
C Check the client’s pedal pulse.
D Offer the client an ice pack for the pain.

Question Explanation
Correct Answer is C

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Rationale: Peripheral artery disease (PAD) refers to excessive plaque buildup in the arterial
walls. Excessive plaque buildup, due to atherosclerosis, can have an impact on perfusion to
limbs. The client is exhibiting symptoms of an acute arterial occlusion. This occlusion usually
causes severe pain, loss of pulses and skin color changes. The nurse should follow the nursing
process and first perform an assessment, i.e., check the pulse in the affected extremity. Based on
the findings (e.g., an absent pulse), the nurse should notify the health care provider right away
because this would signal a medical, possibly surgical, emergency. Ice would be contraindicated
as that would further reduce tissue perfusion to the leg.
Concepts tested

Question 3009
A client presents to the emergency department with a prolonged asthma attack that did not
resolve after the client used a metered-dosed inhaler at home. Which medication should the nurse
plan to administer first for this client?
A Intravenous azithromycin
B Nebulized albuterol
C Oral prednisone
D Fluticasone inhaler

Question Explanation
Correct Answer is B
Rationale: The nurse would anticipate that nebulized albuterol would be given first in this
situation to address the acute asthma attack through bronchodilation. While oral prednisone may
be used in the treatment of this client, it would be given after administration of an inhaled B2-
adrenergic agonist like albuterol. There is no information provided that would indicate antibiotic
therapy is needed for the client. A fluticasone inhaler may be part of long-term asthma
management for this client, but is not recommended as a rescue treatment for acute asthma
attacks
Concepts tested

Question 3010
The home health care nurse is caring for a client who has epilepsy. While the nurse is providing
care, the client has a seizure. Which intervention would be most appropriate to prevent an injury
to the client?
A Lowering the client to the ground
B Loosening clothing around the waist
C Placing a pillow under the client's head
D Asking the client to state where they are

Question Explanation
Correct Answer is A
Rationale: Epilepsy is a disorder that involves two or more unprovoked seizures. A seizure is an
abnormal discharge of electrical activity in the brain which can cause alterations in motor
function, sensation, consciousness, behavior and autonomic function. During a seizure, clients
may suddenly lose consciousness and fall to the ground, increasing their risk of breaking a bone
or suffering a head injury. The most appropriate intervention at this time is to prevent further
Page | 1194
injury by lowering the client to the ground and placing them in the recovery position to prevent
aspiration. Clothing should be loosened around the neck, not the waist, to ensure a patent airway.
Once the client is more awake, the nurse can reoriented them to their surroundings.
Concepts tested

Question 3011
The nurse is caring for a 78-year-old client with influenza who reports dyspnea on exertion. The
client’s respirations are shallow and 32 breaths per minute. Which action should the nurse
perform first?
A Auscultate lung fields for breath sounds.
B Notify respiratory therapy to administer a nebulizer treatment.
C Apply a non-rebreather mask at 100% oxygen.
D Evaluate the client’s 24-hour intake and output.

Question Explanation
Correct Answer is A
Rationale: Older adult clients with influenza are at risk for developing respiratory complications
such as pneumonia. Shallow respirations and tachypnea can indicate impending acute respiratory
failure. Using the nursing process to prioritize what to do first, the nurse should further assess
the client to collect more data. Based on the assessment findings, the nurse will then decide
which action would be most appropriate to take next.
Concepts tested

Question 3012
The home health nurse is reviewing the plan of care for a client with advanced heart failure who
reports activity intolerance. Which nursing intervention should the nurse add to the care plan?
A Encouragement of adequate fluid intake
B Use of incentive spirometry
C Utilization of compression stockings
D Use of oxygen as needed

Question Explanation
Correct Answer is D
Rationale: In the advanced stages of heart failure (HF), cardiac output and tissue perfusion, i.e.,
oxygenation, will be decreased. Client reports of exertional dyspnea with even the slightest
activity are common. Therefore, addressing the low oxygenation by using supplemental oxygen
via a nasal cannula will help with the activity intolerance and should be added to the client’s plan
of care. The other interventions do not address the problem of activity intolerance caused by low
tissue perfusion and are actually contraindicated with HF (e.g., encouraging fluid intake).
Concepts tested

Question 3012
The postpartum nurse is caring for a mother who vaginally delivered a full-term infant four hours
ago. The mother is experiencing heavy vaginal bleeding. Which intervention should the nurse
implement first?

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A Firmly massage the mother's uterine fundus
B Instruct the mother to remain on strict bedrest
C Start an IV infusion of normal saline
D Request a transabdominal ultrasound

Question Explanation
Correct Answer is A
Rationale: During the immediate postpartum period, the nurse should closely assess the mother
for signs and symptoms of postpartum hemorrhage (PPH) (e.g., heavy vaginal bleeding,
hypotension, tachycardia). PPH is most often caused by uterine atony. Uterine massage promotes
uterine contractions and tone, which decreases bleeding. Uterine massage involves placing a
hand on the woman's lower abdomen and stimulating the uterus by repetitive massaging or
squeezing movements. The nurse should first provide uterine massage to see if the vaginal
bleeding will decrease. It is premature to implement the other interventions at this time.
Concepts tested

Question 3013
The automated external defibrillator (AED) has been applied to a client receiving
cardiopulmonary resuscitation. Indicate how the nurse will proceed by placing the following
actions in the correct order.

1. Allow time for the AED to administer a shock.

2. Press the shock button on the AED.
3. Wait for the AED to analyze the client’s heart rhythm.
4. Immediately resume CPR.
5. Press the analyze button when the AED prompts the nurse to do so.
6. Call out “stand clear” when the AED prompts the nurse to administer a shock.
Question 3 Answer Choices
A 5, 3, 6, 2, 1, 4
B 3, 5, 2, 6, 1, 4
C 6, 5, 3, 2, 1, 4
D 3, 5, 2, 6, 1, 4

Question Explanation
Correct Answer is A
Rationale: The American Heath Association (AHA) guidelines for CPR recommend rapid CPR
implementation including the use of an AED. AEDs provide early interpretation of the client's
cardiac rhythm. It provides step-by-step instructions on how to proceed with defibrillation if
indicated.
Concepts tested

Question 3014
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?

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A Wear a swimsuit cover-up when going to the pool
B Apply ice packs to the affected area to reduce itching
C Use a mild soap and tepid water to clean the affected area
D Wear a supportive, tight-fitting bra during therapy

Question Explanation
Correct Answer is C
Rationale: Radiation can lead to skin changes or skin reactions in the treatment area. Skin
changes are commonly seen between the gluteal folds, perineum, collar line, and breast. The goal
of skincare is to prevent skin breakdown and infection. Clients should be instructed to avoid
wearing tight-fitting bras or belts over the treatment areas. During treatment, clients should avoid
exposing their treatment areas to direct sunlight and should also avoid swimming in salt water
and chlorinated pools. Clients should also avoid exposing their treatment area to extremes in
temperature (hot or cold). To keep the affected area clean, use a mild soap and tepid water.
Concepts tested

Question 3015
The nurse is caring for a client with a pressure ulcer on their heel that is covered with hard, dry
black tissue. Which action should the nurse take?
A Apply a wet-to-dry dressing
B Remove the eschar
C Leave the pressure ulcer as is
D Apply a hydrocolloid dressing

Question Explanation
Correct Answer is C
Rationale: If the black tissue (eschar) is dry and intact, no treatment is necessary; the stable
eschar serves as a natural cover. Mechanically removing (i.e., debriding) the eschar is typically
performed by the health care provider, not the nurse. The other actions are not appropriate or
indicated for this stage of pressure ulcer.
Concepts tested

Question 3016
A client is transferred from the post-anesthesia care unit to the medical-surgical unit after an
appendectomy. Which action should the nurse on the medical-surgical unit perform first?
A Orient the client to the unit
B Take the client’s vital signs
C Review the postoperative orders
D Ask the client about pain

Question Explanation
Correct Answer is B
Rationale: Although all these actions are appropriate, the first assessment or data collected
should be the client’s vital signs. After surgery, a client may still experience side effects from the
surgery and the anesthetic agents used. Therefore, vital signs provide important information

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about the client’s hemodynamic and respiratory status. Then, the nurse should evaluate the
client’s level of pain and implement interventions to alleviate the client’s pain.
Concepts tested

Question 3017
The nurse is caring for a client admitted with a phosphorus level of 1.5 mg/dL. Which statement
by the client should alert the nurse to collect further data about possible causes for the phosphate
imbalance? Select all that apply.
A "I take a calcium supplement with every meal."
B "I have a history of decreased kidney function."
C "I had my parathyroid gland surgically removed."
D "I snack on nuts in between meals."
E "I do not eat any meat or dairy products."

Question Explanation
Correct Answer is A, E
Rationale: Hypophosphatemia refers to a below-normal concentration of phosphorus in the ECF
(serum phosphate less than 2.5 mg/dL). The most common causes of hypophosphatemia are
depletion of phosphorus because of insufficient intestinal absorption, hypercalcemia,
transcompartmental shifts, and increased renal losses. Lack of parathyroid hormone (PTH) after
removal of the parathyroid gland leads to decreased blood levels of calcium (hypocalcemia) and
increased levels of blood phosphorus (hyperphosphatemia), not hypophosphatemia. Nuts are
high in organic phosphorus and are considered good snack foods. Meats and dairy products are
high in phosphate, and a lack of intake of those foods can lead to a low serum phosphorus level.
Concepts tested

Question 3018
A client is admitted for hypovolemia associated with multiple draining wounds. Which is
the best method for the nurse to use to evaluate the client's fluid balance?
A Hourly urine output
B Presence of edema
C Skin turgor
D Daily weight

Question Explanation
Correct Answer is D
Rationale: Daily weight is the most easily obtained and accurate means of assessing a client's
fluid volume status. Skin turgor varies considerably with age. Marked excess fluid volume may
already be present before fluid moves into the interstitial space and causes edema. Although very
important, hourly urine outputs do not take into account fluid intake or fluid loss through
insensible loss, sweating, or loss from the gastrointestinal (GI) tract or wounds.
Concepts tested

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Question 3019
The nurse is caring for a client who is recovering from a right total hip arthroplasty. The client
reports a sudden onset of chest pain and difficulty breathing. What action should the nurse
take first?
A Elevate the head of the bed
B Obtain the client's vital signs
C Auscultate the client's lung fields
D Notify the health care provider

Question Explanation
Correct Answer is A
Rationale: The client is exhibiting clinical manifestations of a pulmonary embolism (PE). A PE
is a medical emergency, which requires immediate action from the nurse. Deep vein thromboses
(DVTs) can occur after a total hip arthroplasty due to immobilization during and after surgery.
By elevating the head of the bed, the nurse will decrease dyspnea associated with the PE. The
nurse should then assess the client and report the clinical manifestations to the HCP.
Concepts tested

Question 3020
Paramedics are transporting a client suspected of carbon monoxide poisoning to the hospital.
Which treatment should the emergency room nurse plan for?
A Hyperbaric oxygen therapy
B Therapeutic hypothermia
C Chelation therapy
D Naloxone administration

Question Explanation
Correct Answer is A
Rationale: Carbon monoxide poisoning leads to displaced oxygen from hemoglobin as carbon
monoxide has a stronger affinity for the hemoglobin molecule. The binding of carbon monoxide
to hemoglobin leads to reduced oxygen delivery to tissues and organs. Clients with carbon
monoxide poisoning require 100% supplemental oxygen and, in some cases, hyperbaric oxygen
therapy may be prescribed. Hyperbaric oxygen therapy increases the dissociation of carbon
monoxide from the hemoglobin molecule. Chelation therapy is used for poisoning with mercury
or lead. Naloxone is an opioid antagonist. Therapeutic hypothermia is typically used after a
cardiopulmonary arrest.
Concepts tested

Question 3021
The nurse is caring for a client who was admitted with a diagnosis of renal calculi. The client
reports moderate-to-severe flank pain and nausea. The client’s oral temperature is 100.8°F
(38.2°C). Which goal is the priority for this client?
A Maintain fluid balance
B Manage pain
C Control nausea

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D Prevent infection

Question Explanation
Correct Answer is B
Rationale: The priority nursing goal for a client diagnosed with renal calculi, i.e., kidney stones,
is typically focused on managing the client's pain because the pain tends to be quite severe. The
other goals are also important, but since the client does not appear to currently experience a fluid
imbalance, alleviating the acute pain is the priority for this client. If nausea remains unresolved
after the pain has been relieved, then the nurse should consider administering an antiemetic.
Concepts tested

Question 3022
The nurse is providing discharge education to a client hospitalized for an acute exacerbation of
rheumatoid arthritis. The nurse includes information focusing on conserving energy. Which
statements by the client demonstrate the teaching has been effective? Select all that apply.
A "I will set priorities and complete the important tasks first."
B "If possible, I will delegate some things to my friends or family."
C "I will schedule activities throughout the day instead of trying to complete everything in the
morning."
D "I will sit on a tall kitchen stool instead of standing when I am preparing meals."
E "On days of increased pain, I will stay in bed and relax instead of being active."

Question Explanation
Correct Answer is A, B, C, D
Rationale: Rheumatoid arthritis is a chronic, systemic, progressive autoimmune disease
involving the joints. As the disease progresses, the client's joints will become increasingly
inflamed and painful. An important topic to teach these clients focuses on maintaining consistent
activity and energy conservation. Regular exercise is essential for clients with arthritis to prevent
complications. The client should be as active as possible and not be immobile on days of
increased pain. Regarding energy conservation, important concepts include pacing, prioritizing,
and delegating activity. The client should rest when possible.
Concepts tested

Question 3023
A community health clinic nurse is interviewing a client who is experiencing lightheadedness.
The client reports a history of arthritis and is taking ibuprofen for the pain. The client is pale with
a blood pressure of 88/40 mmHg. The client’s pulse is 114 bpm, the respiratory rate is 22 breaths
per minute, and the oral temperature is 98.2°F (36.7°C). Which additional information should the
nurse solicit from the client? Select all that apply.
A Color of bowel movements
B Presence of photophobia
C Presence of tingling or numbness in the extremities
D Presence of bruises
E Frequency and amount of ibuprofen used

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Question Explanation
Correct Answer is A, D, E
Rationale: The therapeutic effects of nonsteroidal anti-inflammatory drugs (NSAIDs), such as
ibuprofen, are due to the ability of the medications to inhibit the synthesis of prostaglandins by
blocking COX-1 and COX-2 enzymes. The COX-1 enzymes have many roles in the body, such
as blood clotting, stomach lining protection, and maintaining sodium and water balance in the
kidneys. When taking this medication, inhibition of the COX-1 enzyme causes an inability of
COX-1 to protect the gastrointestinal (GI) lining. These actions put clients at risk for a loss of GI
lining integrity and GI bleeds. The nurse should recognize the client's skin color and changes in
vital signs as indicating possible anemia related to GI bleeding. The nurse should investigate the
risk by asking the client how often and how much ibuprofen is taken per day. The nurse should
also question the color of bowel movements and any abnormal bruising. Black, tarry stools could
indicate a GI bleed. These risks are also increased in clients taking acetylsalicylic acid (i.e.,
aspirin). Tingling, numbness, and photophobia are not side effects seen with ibuprofen use or
overuse.
Concepts tested

Question 3024
The nurse performs 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. Which action
should the nurse take?
A Check the pulse oximetry reading
B Start an IV infusion of 5% dextrose
C Ask another nurse to perform a second blood glucose check
D Repeat the test in two hours

Question Explanation
Correct Answer is D
Rationale: After birth, the infant’s glucose supply from the placenta is no longer available, and
the newborn’s glucose levels will decline. Hypoglycemia is a frequent problem encountered in
newborns. However, serum glucose of 45 mg/dL is within the expected newborn range of 40 to
90 mg/dL. Newborns who weigh more than 8.8 pounds (4 kg), are large for their gestational age,
or have a gestational age of fewer than 37 weeks are considered at risk for hypoglycemia. Due to
the weight of this newborn, a repeat blood glucose test is indicated. The other actions are not
appropriate for this infant.
Concepts tested

Question 3025
A client is evaluated in the emergency department for an ankle sprain. Which discharge
instructions should the nurse provide? Select all that apply.
A "It is important to avoid standing or walking without crutches until after your follow-up
visit."
B "You should apply an ice pack to your ankle for 20 to 30 minutes at a time, 3 to 4 times a
day."
C "Rest your foot and ankle tonight, but start strengthening exercises tomorrow morning."

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D "To help decrease swelling, it is important to keep your ankle elevated when you are
resting."
E "Wrap your foot and ankle tightly with the elastic wrap and leave on overnight."

Question Explanation
Correct Answer is A, B, D
Rationale: A sprain is a common musculoskeletal injury resulting from the excessive stretching
of a ligament. Initial treatment of a sprain would include rest, ice, compression, and elevation.
Strengthening exercises may induce a re-injury and should not be performed. Education should
include rest, including using the proper method of walking with crutches and resting the
extremity. Education should also include ice. Cold therapy should be applied for 20 to 30
minutes at a time, 3 to 4 times a day. Teach the client about appropriate compression. The elastic
wrap should be tight enough to provide support but not so tight that it impedes circulation.
Elastic wraps should be removed when sleeping. Elevating the extremity above the level of the
heart will help reduce swelling.
Concepts tested

Question 3026
The nurse is providing self-care instructions to a client with peripheral vascular disease. Which
client statement indicates the need for additional teaching?
A "I should not walk around my home without wearing shoes."
B "I will trim my toenails every week to prevent ingrown toenails."
C "I will try different resources to help me stop smoking cigarettes."
D "If pain occurs, I will limit my activity until the pain goes away."

Question Explanation
Correct Answer is B
Rationale: Clients with peripheral vascular disease (PVD) or diabetes should not cut their nails,
corns, and calluses. They should have them trimmed by their provider, nurse, or another provider
who specializes in foot care. Clients who have vascular disease have decreased circulation and
often experience reduced sensation in one or both feet. They should wear cotton socks, and they
should always wear shoes when out of bed. Pain is a defining characteristic of PVD. This pain,
termed intermittent claudication, will occur during activity due to the oxygen perfusion abilities
not meeting the oxygenation demands of the muscles at work. Clients should verbalize
understanding that it is important to rest until the pain subsides. Smoking is a significant risk
factor for PVD, and the nurse should inform the client of smoking cessation resources and
advocate for a pharmacological smoking cessation treatment if indicated.
Concepts tested

Question 3027
The nurse in the primary care office is speaking with a client who has contact dermatitis on both
hands. The client wants to know how to manage the condition. Which interventions should the
nurse recommend to the client? Select all that apply.
A Applying a cold pack to the area can help
B Corticosteroid cream is acceptable to use

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C Using soap without fragrance is recommended
D Avoid heat that can exacerbate symptoms
E Rubbing the area can alleviate symptoms
F Frequent handwashing is important

Question Explanation
Correct Answer is B, C, D
Rationale: Exposure to heat or cold may cause or exacerbate contact dermatitis. Rubbing the area
may also exacerbate or spread symptoms. While washing hands after exposure to possible
irritants is recommended, frequent handwashing is not. Soap with fragrance is an external irritant
and may exacerbate symptoms, so fragrance-free soap is recommended. A barrier cream
containing a corticosteroid is the most frequently prescribed topical ointment.
Concepts tested

Question 3028
The nurse is caring for a client who experienced second-degree burns over 50% of their body.
The nurse understands that which medication is used for the prevention of stress ulcers for this
client?
A Bumetanide 2 mg PO every six hours
B Ibuprofen 400 mg PO every eight hours
C Furosemide 40 mg IV daily
D Pantoprazole 40 mg IV daily

Question Explanation
Correct Answer is D
Rationale: Curling's ulcers are stress ulcers that occur in clients with severe burns. These ulcers
occur within 24 hours of the injury due to the decreased blood flow to the gastrointestinal tract.
This leads to a reduction in the protective layer of mucosa while a simultaneous increase in
hydrogen ions occurs. Curling's ulcers generally manifest themselves as gastric bleeding and are
prevented by administering proton-pump inhibitors, such as pantoprazole. Other factors that
prevent these stress ulcers are early enteral feeding, H2 histamine blockers, and medications that
protect the mucosa. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, should
be used with caution due to the risk of further decreasing the protective gastric mucosa. In severe
burn clients, the priority is fluid resuscitation and increasing cardiac output. Therefore, diuretics
such as furosemide or bumetanide are contraindicated.
Concepts tested

Question 3029
The nurse is reviewing discharge instructions with a client who has been prescribed
ciprofloxacin following a minor burn injury. Which statement by the client requires additional
teaching?
A "After healing, I should have no scarring from this burn."
B "I can take ibuprofen for the pain related to this burn."
C "I will protect my skin from the sun with sunscreen and clothing."
D "I will not take ciprofloxacin prior to sun exposure."

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Question Explanation
Correct Answer is D
Rationale: Ciprofloxacin is an antibiotic that is associated with causing photosensitivity. Clients
should be instructed to protect their skin from sun exposure while taking this medication.
Appropriate methods to protect the skin are to limit sun exposure and to wear sunscreen and
protective clothing. For a superficial-thickness burn, no scarring will occur, and healing should
take 3 to 6 days. The client may take a nonsteroidal anti-inflammatory drug (NSAID), such as
ibuprofen, to alleviate the pain associated with the burn. It is inappropriate for the client to stop
taking their antibiotic. However, if the client cannot avoid sun exposure, the nurse may contact
the health care provider and request that the antibiotic be changed to one that does not cause
photosensitivity.
Concepts tested

Question 3030
The home health nurse is visiting a client who has peripheral artery disease. It is winter time and
cold outside. While observing the client getting dressed, which clothing choice by the client
should the nurse question?
A A polyester fleece inner layer
B A fleece hat with ear protection
C Two pairs of cotton socks
D Wind-protecting pants and jacket

Question Explanation
Correct Answer is C
Rationale: Clients with peripheral artery disease (PAD) are at risk for frostbite or hypothermia. It
is therefore important for the nurse to ensure that the client understands how to prevent injury by
dressing appropriately for cold weather. When cotton becomes damp or wet, it doesn't insulate
well. Non-cotton materials are preferred. Additionally, a double layer of socks may become
constricting and further decrease circulation. Instead, the client should carry an extra pair of
socks if needed. The other clothing choices are appropriate.
Concepts tested

Question 3031
The nurse is reviewing the medical record of a client with recurring, nonhealing venous stasis
ulcers to the lower extremities. Which findings are most likely contributing to the nonhealing of
the client's wounds? Select all that apply.
A The client is 74-years-old.
B The client's body mass index (BMI) is 16.5.
C The client has a history of seasonal allergies.
D The client's ethnicity is Asian American.
E The client has a history of benign prostatic hyperplasia.
F The client smokes one pack of cigarettes per day.

Question Explanation

Page | 1204
Correct Answer is A, B, F
Rationale: A number of factors can affect the skin's ability to heal once injured. Factors include
chronic disease, age, presence of an infection (systemic or local), nutritional status, substance
abuse, and smoking. The client's medical record shows a number of factors that are affecting the
healing of the wounds for this client. The client is undernourished or malnourished (BMI less
than 18), a smoker (nicotine causes vasoconstriction, increased coagulability, and decreased
oxygen delivery to tissues), and older (the aging process causes a decrease in collagen synthesis
and epithelialization). The client's ethnicity and history of benign prostatic hyperplasia and
allergies do not affect wound healing.
Concepts tested

Question 3032
A client with eczematous dermatitis (eczema) of the hands asks the nurse how to treat the
excoriation and scaling of the palmar surface of both hands. What is the best response by the
nurse?
A "You should take OTC diphenhydramine orally three times a day."
B "You should soak both hands in lukewarm water twice a day."
C "You should wear disposable gloves during the day."
D "You should apply antibacterial cream to both hands."

Question Explanation
Correct Answer is B
Rationale: Soaking the hands in lukewarm water, ideally with colloidal oatmeal added to it, is
the best response. Soaking the hands will debride crust and scales and soften the skin.
Diphenhydramine is an antihistamine that can reduce itching but will not help with scaly,
excoriated skin. In addition, the sedative effects of the medication can be dangerous and the drug
should be taken only as needed, preferably at bedtime. Wearing gloves is not appropriate because
it will trap moisture and warmth, most likely aggravating eczema. An antibacterial cream is not
indicated at this time unless the client develops a localized infection.
Concepts tested

Question 3033
The home health nurse is reviewing the medical record of a client with recurring oral candidiasis.
Which prescribed medication is most likely causing the client's condition?
A Fluticasone (nasal spray)
B Detemir insulin (injection)
C Budesonide (inhaler)
D Metformin (tab)

Question Explanation
Correct Answer is C
Rationale: Budesonide is an inhaled glucocorticoid used in the treatment of asthma and chronic
obstructive pulmonary disease (COPD). The most common adverse effects are oropharyngeal
(oral) candidiasis and dysphonia (hoarseness and difficulty speaking). Both effects result from
the local deposition of inhaled glucocorticoids. To minimize these effects, clients should rinse
the mouth with water and gargle after each administration. Using a spacer device can help too. If
Page | 1205
candidiasis develops, it can be treated with an antifungal drug. The other medications are not
likely to cause oral candidiasis.
Concepts tested

Question 3034
The home health nurse is caring for a 6-year-old client with cerebral palsy. The client's parent
reports to the nurse that the child's older sibling was just diagnosed with impetigo.
What priority intervention should the nurse add to the client's plan of care?
A Contact the client's pediatrician for a prescription for an oral antibiotic as a preventative
measure
B Start applying a topical anti-inflammatory cream to the client's skin to prevent the client from
becoming infected
C Instruct the client's parent to keep the client isolated in their room until the sibling's infection
has resolved
D Instruct the parent to provide the infected child with washcloths and towels separate from the
client's

Question Explanation
Correct Answer is D
Rationale: Impetigo is a common and highly contagious, bacterial skin infection that mainly
affects infants and children. Impetigo usually appears as red sores on the face, especially around
a child's nose and mouth and on hands and feet. The sores burst and develop honey-colored
crusts. The priority nursing functions related to bacterial skin infections are to prevent the spread
of infection and to prevent complications. Impetigo can easily spread, and hand washing is
mandatory before and after contact with an affected child. The infected child should be provided
with washcloths and towels separate from those of other family members, and the infected child's
clothes should be changed daily and washed in hot water. A topical bactericidal ointment can be
used if the client becomes infected too. An anti-inflammatory cream, such as hydrocortisone,
will not prevent the client from becoming infected. Antibiotics should not be prescribed for
prevention in this situation. Oral or parenteral antibiotics (penicillin) are reserved for severe
cases of an actual infection. Keeping the client isolated is not necessary or appropriate in a home
setting.
Concepts tested

Question 3035
The nurse at the outpatient clinic is reviewing after-visit instructions with a client diagnosed
with Staphylococcus aureus cellulitis to the right thigh area. Which statement by the client
indicates an understanding of the instructions?
A "This infection is a result of my diabetes and not preventable."
B "The infection is contagious, and I need to make sure to cover it completely."
C "I will apply an ice pack to the area to reduce the swelling."
D "I will take all of the antibiotic pills until they are gone."

Question Explanation
Correct Answer is D

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Rationale: Cellulitis is an inflammation of the subcutaneous tissue. Staphylococcus aureus and
group A beta-hemolytic streptococci are common organisms responsible for causing bacterial
skin infections such as cellulitis. It is important to complete the entire course of the prescribed
antibiotic to prevent recurrence or drug resistance. Cellulitis of this type is not typically
contagious. Although being a diabetic predisposes the client for developing an infection in
general, cellulitis tends to occur following a break in the skin that becomes infected. The client
should apply moist heat, not cold, to the area.
Concepts tested

Question 3036
The nurse in a walk-in care clinic is reviewing the medical record of a client who is being treated
for frostbite on their toes. Which medical condition most likely placed the client at a higher risk
for this type of injury?
A Systemic lupus erythematosus
B Diabetes mellitus
C Hyperthyroidism
D Aortic stenosis

Question Explanation
Correct Answer is B
Rationale: Diabetic neuropathy is a complication of diabetes mellitus that is characterized by
decreased sensation in the lower extremities. Clients with diabetic neuropathy are at risk for
hypothermal tissue injuries (i.e., frostbite) because they may not feel the pain associated with
cold exposure making them unaware of soft tissue injury until it is severe. Diabetes most
likely contributed to this client's frostbite injury. There is no immediate increased risk for
hypothermal tissue injuries with the other conditions.
Concepts tested

Question 3037
A client presents with a burn that is painful, pale, and waxy with large flat blisters. The client
asks the nurse about the severity of the burn. What is the best response by the nurse?
A "The burn is similar to a sunburn."
B "The burn is a partial-thickness burn."
C "The burn is a first-degree burn."
D "The burn is a full-thickness burn."

Question Explanation
Correct Answer is B
Rationale: The wound described is a deep partial-thickness burn. A superficial, i.e., first-degree,
burn or sunburn is bright red and moist and might appear glistening with blister formation. A
full-thickness burn involves all layers of the skin and may extend into the underlying tissue and
is usually not painful.
Concepts tested

Question 3838

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A client presents with a small, elevated, and ulcerated skin lesion on the upper back. The lesion
has irregular edges that vary in color. The nurse knows that this finding could be associated with
which type of skin cancer?
A Actinic keratosis
B Basal cell carcinoma
C Melanoma
D Squamous cell carcinoma

Question Explanation
Correct Answer is C
Rationale: Melanomas tend to appear as lesions with irregular edges, which are small in size, flat
or elevated, and eroded or ulcerated. They can be black, brown, gray, or white in color. The most
common sites of melanoma include the back, chest, or legs. Squamous cell carcinoma is more
commonly found in sun-exposed areas, such as the face and hands. Basal cell carcinoma lesions
tend to look like sharply defined, pearly, and flat or barely elevated plaques.
Concepts tested

Question 3839
A client has received instructions about the management of their chronic dermatitis. Which
action by the client indicates an understanding of the instructions?
A The client avoids use of antihistamines when a flare-up occurs.
B The client requests to be prescribed oral corticosteroids.
C The client applies warm compresses to relieve itching.
D The client avoids itching and scratching the affected area.

Question Explanation
Correct Answer is D
Rationale: Excessive itching can cause excoriation of the skin potentially resulting in
inflammation and infection. Cool compresses may cause vasoconstriction and decrease itching.
Heat will exacerbate itching. Oral antihistamines are sometimes recommended to provide relief
from itching, although they may cause drowsiness. Topical corticosteroids are also sometimes
prescribed because they may numb the itch receptors.
Concepts tested

Question 3840
The nurse in a long-term care facility is reviewing the plan of care for a client with quadriplegia.
Which risk assessment scale should be included for this particular client?
A The Hendrich Scale
B The Wong-Baker Scale
C The Braden Scale
D The Hamilton Scale

Question Explanation
Correct Answer is C

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Rationale: A client who has paralysis of all four limbs (quadriplegia) is at risk of developing a
pressure ulcer. A pressure ulcer is tissue damage caused when the skin and underlying soft tissue
are compressed between a bony prominence and an external surface for an extended period of
time. The Braden Scale is used for predicting pressure ulcer risk and should be included in this
client's plan of care. The Hendrich Scale is used for fall risk. The Wong-Baker Scale uses visual
faces to assess pain. The Hamilton Scale is used to rate anxiety.
Concepts tested

Question 3841
A client has herpes simplex I with visible cold sores on the lips. Which intervention
is most important for the client to implement to prevent spreading the infection?
A Do not scratch the affected area
B Avoid sharing towels
C Wash hands frequently
D Take antiviral medication as prescribed

Question Explanation
Correct Answer is B
Rationale: Sharing any items (towels, lipstick, toothbrush, utensils, cups, etc.) that may touch the
mouth has the highest risk of spreading infection from one individual to another. Washing hands
and not touching/scratching the affected area are proactive measures to prevent spreading the
infection but are not the priority. Taking antiviral medication as prescribed will promote healing.
Concepts tested

Question 3842
A client presents at an urgent care center after burning their hand while cooking. The client's
burn wound has an intact skin surface with redness and blistering that covers their posterior
hand. How should the nurse describe this wound when documenting it in the client's medical
record?
A A partial-thickness wound
B A superficial-thickness wound
C A full-thickness-wound
D A deep full-thickness wound

Question Explanation
Correct Answer is A
Rationale: Burn wounds are classified as superficial-thickness, partial-thickness, full-thickness,
and deep full-thickness. The wound described here is a partial-thickness wound. It involves the
entire epidermis and varying depths of the dermis. These wounds are red, moist, and blanch
when pressure is applied. When small vessels are damaged, they may leak plasma causing blister
formation. The correct answer is a partial-thickness wound.
Concepts tested

Question 3843

Page | 1209
The school nurse in an elementary school identifies an outbreak of head lice (pediculosis).
Which interventions should the nurse implement to prevent the spread of the infestation? Select
all that apply.
A Reassure students that itching of the scalp is a common symptom
B Notify the local health department of the outbreak
C Provide individual headsets or ear buds for each student
D Instruct school parents, teachers and volunteers on how to detect lice and nits
E Do not permit children to share bike helmets

Question Explanation
Correct Answer is A, C, D, E
Rationale: Sharing items that touch the head, such as helmets, headsets, hats, combs, towels, etc.,
is a primary source of spreading pediculosis. Itching is a common and early sign of infestation
and should be investigated immediately. Instructing parents and school personnel how to detect
lice and nits will foster early recognition and treatment. Head lice is not a reportable disease.
Concepts tested

Question 3844
The nurse in a long-term care facility is reviewing the medical record of a newly admitted client.
Which of the following factors put the client at an increased risk for developing a pressure
ulcer? Select all that apply.
A The client has a body mass index (BMI) of 30.
B The client has diabetes mellitus.
C The client is receiving an immunosuppressant drug for rheumatoid arthritis.
D The client is alert and oriented to person, place, time, and situation.
E The client has a history of exercise-induced asthma.

Question Explanation
Correct Answer is A, B, C
Rationale: Obesity or low body weight are risk factors for pressure ulcer injury. A BMI of 30
puts the client in the obese range, causing increased pressure while sitting or lying in bed.
Diabetes mellitus may cause sensory altercations, which also is a risk factor. Immunosuppressant
drugs may suppress or reduce the strength of the body's immune system. Exercise-induced
asthma is not a direct risk factor, and there is no indication the client is in respiratory distress.
Clients who are confused may not report or sense pain or discomfort, which could decrease their
ability to protect skin integrity, relieve pressure, maintain hygiene, or report discomfort.
Concepts tested

Question 3845
A nurse witnesses a child lose consciousness from choking on a hotdog in a public park. What
should the nurse do first?
A Attempt a single finger sweep to remove the food
B Start 100 to 120 chest compressions per minute
C Open the airway and give two rescue breaths
D Activate the emergency response system

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Question Explanation
Correct Answer is D
Rationale: Activating the emergency response system should be done first so that emergency
medical services (EMS) personnel can arrive quickly and support the nurse's resuscitation
efforts.
Concepts tested

Question 3846
The nurse in a pediatrician's office is performing a physical assessment on a 3-year-old with
suspected Kawasaki disease in the acute stage. Which findings should the nurse
anticipate? Select all that apply.
A Persistent diarrhea
B Peeling skin on hands and feet
C Enlarged cervical lymph nodes
D Rash triggered by sunlight
E Strawberry tongue
F Bilateral conjunctivitis
G Intermittent low-grade fever

Question Explanation
Correct Answer is B, C, D, E, F
Rationale: Kawasaki disease is an acute illness that causes systemic inflammation in the blood
vessels. The illness typically occurs in children under the age of five. Diagnosis is based on
clinical presentation. There is no specific test to diagnose Kawasaki disease. Clinical
manifestations in the acute phase include a high grade, persistent fever that is unresponsive to
antipyretics or antibiotics. Other clinical manifestations include erythema of the hands and feet,
peeling of the hands and feet, bilateral conjunctivitis, erythema in the oral cavity including lips
and tongue (strawberry tongue), rash triggered by sun exposure, and enlarged lymph node(s).
Diarrhea is not typically seen with Kawasaki disease.
Concepts tested

Question 3847
The nurse in a pediatrician's office is completing the health history on an infant boy. The parent
comments, "He tastes salty when I kiss him." Based on this comment, for which genetic disorder
should the infant be screened?
A Sickle cell anemia
B Cystic fibrosis
C Congenital hypothyroidism
D Phenylketonuria

Question Explanation
Correct Answer is B
Rationale: Cystic fibrosis (CF) is an inherited disorder where a gene mutation causes the cystic
fibrosis transmembrane conductance regulator (CFTR) protein to not work properly causing

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thick mucus in vital organs (especially the lungs). This mutation also causes an increase in
sodium and chloride in saliva and sweat making the skin of infants and children with CF taste
salty when kissed. Congenital hypothyroidism, sickle cell anemia, and phenylketonuria do not
cause an increase in sodium in saliva or sweat.
Concepts tested

Question 3848
The nurse in a pediatric hospital is admitting an infant with respiratory syncytial virus (RSV)
infection. Which interventions should the nurse include in the infant's plan of care? Select all that
apply.
A Initiate contact precautions
B Suction as needed
C Administer antibiotics
D Give acetaminophen for fever
E Administer IV fluids
F Provide chest physiotherapy
G Use humidified oxygen

Question Explanation
Correct Answer is A, B, D, E, G
Rationale: Respiratory syncytial virus (RSV) is a respiratory illness that causes cold-like
symptoms but can be a much more serious illness in infants. Humidified oxygen should be
administered at a concentration that maintains an oxygen saturation at or above 90%. Infants
with thick nasal secretions benefit from suctioning. Contact precautions are initiated to decrease
the spread of the virus. IV fluids should be administered until the acute phase of the illness is
over or the infant is able to effectively breastfeed or bottle-feed. Acetaminophen is used to
reduce fever. Chest physical or physiotherapy (CPT) is not recommended for management of
RSV. Antibiotics are not used for a viral infection.
Concepts tested

Question 3849
The nurse in a community clinic is completing the health history of a young child who presents
with a low-grade fever, runny nose, and paroxysmal, violent coughing spells for one week. The
nurse should review the medical record for evidence of which vaccine administration?
A Hib
B HBV
C MMR
D Tdap

Question Explanation
Correct Answer is D
Rationale: Pertussis (whooping cough) is a highly contagious respiratory tract infection caused
by the bacterium Bordetella pertussis. Clinical manifestations of pertussis include rhinorrhea
(runny nose), fever, and a cough that has a high-pitched sound and tends to be sudden and
violent (paroxysmal) causing vomiting and fatigue. Pertussis is prevented by administration of

Page | 1212
the tetanus, diphtheria, and pertussis (Tdap) vaccine; therefore, the nurse should look for
evidence of administration because the child's presenting symptoms suggest pertussis. The MMR
vaccine protects against measles, mumps, and rubella. The Hib vaccine protects against
infections caused by H. influenza type b. The HBV vaccine protects against the hepatitis B virus.
Concepts tested

Question 3850
The nurse in a pediatrician's office is assessing an infant with a ventriculoperitoneal shunt to treat
hydrocephalus. Which finding might indicate a possible shunt malfunction?
A Lethargy
B Loose stools
A Dry mucous membranes
D Depressed fontanels

Question Explanation
Correct Answer is A
Rationale: Hydrocephalus is an increased accumulation of cerebral spinal fluid in the brain
resulting in increased intracranial pressure (ICP) and is commonly treated with insertion of a
ventriculoperitoneal (VP) shunt. The major complications of VP shunts are infection and
malfunction. All shunts are subject to mechanical difficulties, such as kinking, plugging, or
separation and migration of tubing. Malfunction is most often caused by mechanical obstruction
either within the ventricles from particulate matter (tissue or exudate) or at the distal end from
thrombosis. A non- or malfunctioning VP shunt will lead to an increased ICP. Changes in the
level of consciousnessm such as lethargy, are an early sign. The other findings are not typically
associated with an increase in ICP.
Concepts tested

Question 3851
The nurse in the urgent care center is caring for a 20-year-old client who sustained a sprained
ankle while playing sports. Which instructions should the nurse give the client to prevent a future
sprain injury? Select all that apply.
A Take ibuprofen 30 minutes before starting any sports activity.
B Wear snug, well-fitting shoes that go up to the ankle.
C Warm up for several minutes before starting the activity.
D Use appropriate protective equipment with the activity.
E Encourage stretching before and after any sports activity.

Question Explanation
Correct Answer is B, C, D, E
Rationale: A sprain occurs when there is a sudden, abnormal movement around the joint that can
lead to stretching and/or tearing of the ligaments attached to the joint. Stretching before and after
exercising increases the ligaments pliability and decreases the risk for injury. Gradually warming
up prior to engaging in physical activity provides the muscles with increased circulation and

Page | 1213
loosens up joints; both will decrease the risk for strains or sprains. Wearing proper fitting shoes
enhances stability and wearing appropriate protective gear provides protection and decreases the
likelihood of sprains. Taking ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID), to
decrease inflammation would be appropriate after a musculoskeletal injury, but will not help to
prevent one.
Concepts tested

Question 3852
The nurse is caring for a client who is experiencing an acute gout attack. Which action should the
nurse implement?
A Administer indomethacin.
B Restrict sodium intake.
C Provide a high-protein diet.
D Monitor liver enzymes.

Question Explanation
Correct Answer is A
Rationale: Gout is a disease where uric acid crystals form and accumulate in joints and other
tissues. During an acute gout attack, the client experiences pain and inflammation in the joints.
The nurse should administer a non-steroidal anti-inflammatory medication such as indomethacin
to help decrease pain and inflammation. Restricting sodium would not benefit the client and
providing a high-protein diet may make the situation worse. There is no need to monitor liver
enzymes with an acute gout attack.
Concepts tested

Question 3853
The home health nurse is discussing safety concerns with a client who has osteoporosis. Which
interventions should the nurse recommend to the client? Select all that apply.
A Request a referral for physical therapy.
B Increase intake of dairy products.
C Provide assistive devices, if needed.
D Go for a jog or run several times a week.
E Enroll in a smoking cessation program.

Question Explanation
Correct Answer is A, B, C, E
Rationale: Clients with osteoporosis have fragile bones and are at risk for fractures. The nurse
should encourage coordination with physical therapy to increase muscle strength, balance and
decrease the likelihood of a fall. The nurse would also provide assistive devices if the client
requires them. Not all clients with osteoporosis will need an assistive device. Due to the impact
on joints that occurs with running, the nurse should not recommend jogging or running to a client
with osteoporosis. Low-impact activities such as walking would be better. Since smoking
decreases tissue perfusion in general and impacts bone development, the client should stop
smoking. Dairy products are high in calcium and will help with strengthening bones.
Concepts tested

Page | 1214
Question 3854
The nurse is developing a plan of care for an older adult client who will be undergoing a total hip
arthroplasty. To improve the client’s postoperative recovery, which interventions should the
nurse include? Select all that apply.
A The use of assistive devices for ambulation
B Administration of subcutaneous warfarin
C Preoperative pain control with naproxen
D Application of sequential compression device
E Instruction on plantar and dorsiflexion exercises

Question Explanation
Correct Answer is A, D, E
Rationale: Due to the client’s age and the surgical procedure, the client is at risk for a venous
thromboembolism. The nurse should include the use of sequential compression devices to
decrease venous stasis along with providing instruction on plantar and dorsiflexion exercises.
Warfarin is administered orally; it does not come in an injectable form. The client will most
likely need assistive devices initially for safe ambulation postoperatively. Preoperatively, the
nurse should not use naproxen to control pain because it is a nonsteroidal anti-inflammatory drug
(NSAID) and can increase the risk of bleeding during surgery.
Concepts tested

Question 3855
The nurse observes an unlicensed assistive person (UAP) providing care to a client who had a
total hip arthroplasty 24 hours ago. Which action by the UAP would require the nurse to
intervene immediately?
A Placing a raised toilet seat in the client's bathroom.
B Reminding the client not to cross their legs.
C Standing by the client's non-operative side during ambulation.
D Placing non-slip foot wear on the client prior to ambulation.

Question Explanation
Correct Answer is C
Rationale: When assisting the client during ambulation following a total hip arthroplasty, the
UAP should stand on the operative side (i.e., the side of the surgery) to help provide support to
the client because that is the client's weaker side. The other actions are appropriate for this client
and do not require intervention by the nurse
Concepts tested

Question 3856
The nurse is admitting a 73-year-old client who has a fractured right hip. Which interventions
should the nurse include in the client’s plan of care? Select all that apply.
A Place the client on continuous pulse oximetry.
B Palpate the client’s bilateral pedal pulses every four hours.
C Perform daily circulation, motion and sensation checks on the client’s right leg.

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D Ask about the client’s pain level with every set of vital signs.
E Reposition the client every hour to prevent skin breakdown.

Question Explanation
Correct Answer is A, B, D
Rationale: The client with a hip fracture is at risk for impaired perfusion to the affected
extremity. Monitoring bilateral pedal pulses allows the nurse to compare the pulse strength in the
injured site with that in the non-injured site. A decrease in the injured leg could signal a decrease
in circulation that would require immediate intervention. A fat embolism is also a risk with a hip
fracture and continuous pulse oximetry would allow the nurse to identify hypoxia quickly which
could be associated with a fat embolism. Clients with a hip fracture usually experience great pain
and assessing pain with each set of vital signs is key to effective pain management. Circulation,
motion and sensation checks should be completed at least every four hours, not daily.
Repositioning the client every hour is unnecessary and will only increase the client’s pain level
even more
Concepts tested

Question 3857
The office nurse is teaching a client with gout how to manage the disease. Which actions should
the nurse recommend to the client? Select all that apply.
A Limit the intake of shellfish and red meats.
B Take the prescribed prednisone regularly.
C Implement stress reduction techniques.
D Make sure to drink at least 2,000 mL of water daily.
E Limit the consumption of alcohol.

Question Explanation
Correct Answer is A, C, D, E
Rationale: Gout is a disease where uric acid crystals form and accumulate in joints and other
tissues. Gout attacks may be brought on by excessive alcohol intake, increased stress and a diet
high in purine. Clients should be encouraged to have a low-purine diet by limiting red meats and
shellfish, along with drinking alcohol in moderation. The client should be encouraged to drink at
least 2,000 mL of water daily to maintain hydration and prevent the buildup of uric acid. Stress
management can decrease the likelihood of triggering an acute attack. Prednisone is
used during an acute attack, but it does not prevent an attack from occurring.
Concepts tested

Question 3858
A client who has been newly diagnosed with carpal tunnel syndrome asks the nurse why they
are having pain and tingling in their fingers. Which is the best response from the nurse?
A "The pain and tingling is caused by uric acid crystals collecting in the small joints of your
fingers."
B "The pain and tingling is caused by compression of the median nerve in your wrist."
C "The pain and tingling is due to sclerotic plaques along the nerves in your hand."
D "The pain and tingling is caused by the fluid build-up in the soft tissue of your fingers."

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Question Explanation
Correct Answer is B
Rationale: Carpal tunnel syndrome (CTS) is a common, repetitive motion-related condition in
the wrist. The carpal tunnel is a rigid canal lying between the carpal bones and a fibrous tissue
sheet called the flexor retinaculum. A group of nine tendons, enveloped by synovium, share
space with the median nerve in the carpal tunnel. When the synovium becomes swollen or
thickened, the median nerve is compressed. This causes pain, numbness and painful tingling in
the client's fingers and hand. CTS typically does not cause soft tissue fluid build-up. Uric acid
crystals collecting in small joints is seen with gout. Sclerotic plaques along nerve fibers tend to
occur with multiple sclerosis (MS). Therefore, the best response includes information about the
median nerve in the wrist being compressed.
Concepts tested

Question 3859
The nurse in an urgent care clinic is evaluating a client's understanding of discharge instructions
for a second-degree ankle sprain. Which statement by the client requires follow-up by the nurse?
A "I will apply ice intermittently for the first 24 to 48 hours."
B "I will do gentle stretching and range of motion exercises daily."
C "I will elevate my ankle to decrease pain and swelling."
D "I will apply a compression bandage and wear an ankle brace."

Question Explanation
Correct Answer is B
Rationale: A sprain is excessive stretching of the ligament with tearing of the ligament fibers.
Twisting motions from a fall or sports activity typically precipitate the injury. A second-degree
sprain is classified as moderate. Second-degree sprains require immobilization with an elastic
bandage and ankle brace, splint or cast. Recommendations for caring for a client with a sprain
include rest, use of ice for the first 24 to 48 hours, application of a compression bandage for a
few days to reduce swelling and provide joint support and elevation of the affected extremity
(RICE). It is recommended not to stretch or use the sprained joint for approximately a week,
sometimes longer, to allow it to heal properly. The nurse should follow up and advise the
client not to perform stretching and range of motion exercises.
Concepts tested

Question 3860
The nurse in an assisted living facility comes upon an 85-year-old client lying on the bathroom
floor. The nurse observes a deformity in the left leg and the client is unable to move the leg. The
client is alert and oriented but in severe pain. Which action should the nurse take first?
A Administer pain medication.
B Elevate the extremity above heart level
C Apply an ice pack to the site.
D Immobilize the fracture with a splint.

Question Explanation
Correct Answer is D
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Rationale: It appears that the client suffered a bone fracture in the left leg. After confirming that
the client's respiratory and neurologic status is stable, the nurse should immobilize the fracture
with a splinting device. This will prevent movement of the extremity by the client and further
pain or bleeding along the fracture into the surrounding tissues. Next, the nurse should notify the
health care provider or call emergency medical services to transport the client to the nearest
emergency room.
Concepts tested

Question 3861
A client is admitted to the orthopedic nursing unit with a fractured right tibia. The client is
reporting pain. Which action should the nurse take first?
A Place an ice pack on the fracture site to reduce edema.
B Contact the health care provider.
C Check the pulse and capillary refill in the right foot.
D Administer acetaminophen 650 mg PO as ordered.

Question Explanation
Correct Answer is C
Rationale: The nurse should first collect more data about the client's pain. Compartment
syndrome is a potential complication with an acute fracture and the nurse should evaluate tissue
perfusion in the affected extremity to make sure that the pain is solely related to the acute
fracture. Signs of compartment syndrome include worsening pain, weak peripheral pulses,
edema, slow capillary refill and paresthesia (i.e., numbness, tingling). If the nurse suspects that
compartment syndrome is occurring, the health care provider (HCP) must be notified
immediately. After ruling out compartment syndrome, the nurse can proceed with administering
an analgesic and applying ice.
Concepts tested

Question 3862
The nurse is caring for a client with a femur fracture. Which assessment findings require the
nurse's immediate action? Select all that apply.
A Absent pulse in affected extremity
B Allergy to penicillin
C Blood pressure of 88/54 mm Hg
D Palpable hard mass near fracture site
E Shortness of breath
F Pain level of 5 (0 to 10 scale)
G History of deep vein thrombosis

Question Explanation
Correct Answer is A, C, D, E
Rationale: Complications related to fractures, especially of the long bones such as the femur, can
include fat embolism, compartment syndrome and hemorrhage. Findings seen with compartment
syndrome will include worsening pain, paresthesia (numbness, tingling), pallor (coolness and

Page | 1218
loss of color) and weak, diminished or absent pulse. A fat embolism will typically travel to the
pulmonary vasculature and cause respiratory symptoms. Hemorrhage near the fracture site will
manifest with swelling, bruising/hematoma, hypotension and tachycardia. The other findings are
important to note but are not life-threatening and should be addressed at a later time.
Concepts tested

Question 3863
The nurse is reviewing the chart of a client who was admitted after having been found lying on
the bathroom floor in their home. The client's family reports that the client could have been lying
on the floor for over 12 hours. Which laboratory result should be of greatest concern to the
nurse?
A Serum glucose level of 162 mg/dL
B Serum white blood cell count of 14,000/mm3
C Serum hemoglobin level of 10.8 g/dL
D Serum creatinine level of 4.2 mg/dL

Question Explanation
Correct Answer is D
Rationale: When a person falls and lies immobile for an extended period of time, muscle tissue
will start to break down. This is called rhabdomyolysis. Rhabdomyolysis leads to the release of
myoglobin (muscle protein) into the bloodstream. Myoglobin breaks down into substances that
will damage the kidneys, causing acute kidney injury (AKI) as evidenced by the client's severely
elevated creatine level. (A normal range would be between 0.5 to 1.2 mg/dL). Although the
client's other lab values are also outside of the normal range, the values are not as severely
elevated or decreased as the creatinine level which represents the greatest concern to the client's
condition at this time.
Concepts tested

Question 3864
The nurse is reviewing the chart of a client with suspected osteoporosis. Which diagnostic test to
confirm the diagnosis should the nurse plan for?
A Computerized axial tomography scan
B Dual-energy X-ray absorptiometry scan
C Magnetic resonance imaging scan
D Positron-emission tomography scan

Question Explanation
Correct Answer is B
Rationale: Osteoporosis is a metabolic disease in which bone mineralization results in decreased
bone density. A dual-energy X-ray absorptiometry (DEXA) scan is a painless scan that measures
bone mineral density (BMD) in the hip, wrist or vertebral column. It is the recommended test for
the diagnosis of osteoporosis. Magnetic resonance imaging (MRI), computerized axial
tomography (CAT) and positron-emission tomography (PET) scans are imaging tests used for
evaluating a range of musculoskeletal diseases, but they are not typically used to diagnose
osteoporosis.
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Concepts tested

Question 3865
The nurse notices bone growths on the distal interphalangeal joints of a client with osteoarthritis.
How should the nurse document these findings?
A Bouchard's nodes
B Heberden's nodes
C Dermatofibromas
D Neurofibromatosis

Question Explanation
Correct Answer is B
Rationale: Bony outgrowths found on the distal interphalangeal joint (closest to the fingernail
and furthest away from the body) are called Heberden's nodes. If the bony outgrowth was found
on the proximal interphalangeal joint (the middle joint of the finger, closest to the body), they
would be Bouchard's nodes.
Concepts tested

Question 3866
The nurse is developing a plan of care for a client with acute rheumatoid arthritis.
Which priority interventions should the nurse include? Select all that apply.
A Managing stress
B Establishing a weight loss goal
C Preserving joint function
D Relieving pain
E Preventing joint deformity

Question Explanation
Correct Answer is C, D, E
Rationale: Pain relief is a high priority during the acute phase of RA because the pain is typically
severe and interferes with the client's ability to function. Preserving joint function and preventing
joint deformity are high priorities during the acute phase to promote an optimal level of
functioning and reduce the risk of contractures. Managing stress and establishing a goal for a
healthy weight are also important, but can wait to be addressed until the acute episode has
resolved.
Concepts tested

Question 3867
A client has received education from the nurse about their new diagnosis of systemic lupus
erythematosus. Which statement by the client indicates that additional teaching is needed?
A "I will avoid foods that contain high levels of vitamin K."
B "I may feel more tired and fatigued than I used to."
C "I will monitor my body temperature carefully."
D "I will protect my skin from the sun when I'm outside."

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Question Explanation
Correct Answer is A
Rationale: Systemic lupus erythematosus (SLE) is a chronic, progressive, inflammatory
connective tissue disorder that can cause major body organs and systems to fail. Clients with
SLE should avoid prolonged sun exposure. The nurse should instruct clients to wear long sleeves
and a large brimmed hat when outdoors. They should use sun blocking agents with a sun
protection factor (SPF) of 30 or higher on exposed skin surfaces. It is expected for clients with
SLE to experience fatigue, so they should allow time to rest when needed. Clients with SLE
should monitor their body temperature carefully because this is typically the first sign of an
exacerbation, during which the client can become critically ill. There is no established diet
recommendation for clients with SLE, except to eat a well-balanced diet. Avoiding foods that
contain vitamin K is not necessary, so this statement should be followed up on.
Concepts tested

Question 3868
The nurse should provide which dietary instruction to a client with osteoporosis?
A "Decrease your intake of foods that contain vitamin D."
B "Eat more bananas to increase your potassium intake."
C "Decrease your intake of nuts and seeds."
D "Eat more dairy products to increase your calcium intake."

Question Explanation
Correct Answer is D
Rationale: Osteoporosis causes a reduction in skeletal bone mass, leading to porotic and brittle
bones. To offset this reduction, the nurse should advise the client to increase calcium intake by
consuming more dairy products, which provide about 75% of the calcium in the average diet.
Decreasing vitamin D intake is incorrect as vitamin D helps facilitate calcium utilization. None
of the other options would stop osteoporosis from worsening.
Concepts tested

Question 3869
The nurse in a rehabilitation facility is caring for a client who had a total left hip arthroplasty,
using a posterior approach, three days ago. Which intervention should the nurse make sure to
include in the client's plan of care?
A Keep the client's affected hip bent at least 90 degrees.
B Apply an abduction pillow while the client is in bed.
C Rest the client's heels flat on the bed, in line with the hip.
D Instruct the client to cross their legs at their ankles only.

Question Explanation
Correct Answer is B
Rationale: Clients who have had a total hip arthroplasty (THA), i.e., hip replacement, are at risk
for post-operative hip joint dislocation. An abduction pillow should be used to prevent the client
from closing or crossing their legs while in bed, causing adduction beyond the midline of the
body, which can lead to dislocation of the new joint. The client's heels should be elevated off the
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bed, not flat on the bed, to prevent pressure injury to the heels. The affected hip should not be
flexed to 90 degrees. Even crossing the legs at the ankles should be discouraged and prevented
with this type of hip surgery.
Concepts tested

Question 3870
The nurse is reviewing the medical record of a client who has been diagnosed with osteoporosis.
The nurse identifies which risk factors for this condition? Select all that apply.
A The client weighs 200 lbs. (90.7 kg) with a height of 5 feet 2 inches (157 cm).
B The client has a 30 pack per year smoking history.
C The client takes 10 mg of prednisone daily.
D The client is a 75-year-old Caucasian female.
E The client performs weight-bearing exercises six days a week.

Question Explanation
Rationale: Osteoporosis is the loss of bone density that leads to weakness of the bone. Risk
Correct Answer is B, C, D
factors for osteoporosis include being a postmenopausal woman (lack of estrogen), smoking, thin
stature, steroid use, lack of weight-bearing exercise, such as prolonged immobility or a sedentary
lifestyle, and ethnicity. Steroid use is associated with osteoporosis because it impacts the body's
ability to rebuild new bone. Smoking is also associated with osteoporosis. Performing weight-
bearing exercise increases bone strength and promotes bone development. A client who is 5 feet
2 inches (157 cm) in height and weighs 200 lbs. (90.7 kg) is considered obese and obesity is
associated with osteoarthritis, not osteoporosis.
Concepts tested

Question 3871
The nurse is caring for a client when the client starts to have a tonic-clonic seizure. Which
intervention should the nurse implement first?
A Administer the prescribed lorazepam
B Check the pulse
C Prepare for suctioning
D Turn the client on their side

Question Explanation
Correct Answer is D
Rationale: During a seizure, the nurse should use the airway-breathing-circulation prioritization
approach. A tonic-clonic seizure causes a person to lose consciousness and have violent muscle
contractions. Clients can vomit during a seizure and, therefore, protecting and maintaining an
open airway should be done first. This can be accomplished by turning the client on their side.
This position assists in maintaining an open airway, draining secretions, and reduce the risk of
aspiration, if vomiting occurs. After this intervention, the nurse can prepare for possible suction
and administer medications as prescribed.

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Concepts tested

Question 3872
A 16-year-old adolescent is admitted for Ewing's sarcoma of the tibia. In discussing the care with
the parents, the nurse should understand that the initial treatment for this diagnosis usually
includes which approach?
A Bone marrow graft in the affected leg
B Amputation of the affected leg
C Chemotherapy with adjunctive radiation
D Surgical excision of the mass

Question Explanation
Correct Answer is C
Rationale: Ewing’s sarcoma is a rare type of cancerous tumor that grows on a person’s bones or
cartilage or nerves that surround the bone. Though there are different types of Ewing’s sarcoma,
the pelvis is typically where the tumor forms and then progresses to the femur. If left untreated,
the tumor can spread to other bones, bone marrow, and other vital organs such as the heart,
lungs, and kidneys. The initial treatment of Ewing’s sarcoma is chemotherapy which may be
combined with radiation to reduce the size of the tumor. Once the tumor is reduced in size, the
next step is surgical excision of the tumor or oftentimes amputation of the affected leg or arm.
Concepts tested

Question 3873
The nurse is performing an assessment on an infant recently diagnosed with cystic fibrosis.
Which of the following findings should the nurse anticipate?
A Watery nose
B Persistent cough
C Weight gain
D Loose stools

Question Explanation
Correct Answer is B
Rationale: Cystic fibrosis (CF) is an inherited disease that causes the lungs and digestive system
to be severely damaged. Respiratory symptoms include persistent cough with thick, sticky
mucus, wheezing, breathlessness and frequent lung infections. The child’s nasal passages could
become inflamed leading to a stuffy nose. Digestive symptoms include foul-smelling greasy
stools, poor weight gain, and intestinal blockage that could lead to severe constipation.
Respiratory failure is the most dangerous consequence of CF. The nurse must perform a
thorough respiratory assessment and notify the health care professional immediately if signs or
symptoms of respiratory distress are observed.
Concepts tested

Question 3874
A client is admitted with low T3 and T4 levels and an elevated thyroid stimulating hormone
(TSH) level. On initial assessment, the nurse should anticipate which of these findings?

Page | 1223
A Tachycardia
B Lethargy
C Diarrhea
D Heat intolerance

Question Explanation
Correct Answer is B
Rationale: The thyroid gland produces two hormones, triiodothyronine (T3) and thyroxine (T4).
These hormones help regulate metabolism, stimulate the sympathetic nervous system, regulate
body temperature, heart rate, and brain development. If these levels are low, the client will suffer
from an underactive thyroid gland known as hypothyroidism. With low T3 and T4, the nurse can
expect the client to show symptoms of weight gain, constipation, feeling tired, having an
intolerance to cold, bradycardia, and/or memory loss. If T3 and T4 are low, the pituitary gland
will attempt to stimulate the thyroid by stimulating TSH, which will be elevated.
Concepts tested

Question 3875
The nurse is assessing a client with portal hypertension. Which of the following assessment
findings is consistent with the client's diagnosis?
A Blurred vision
B Dilated pupils
C Expiratory wheezes
D Abdominal distension

Question Explanation
Correct Answer is D
Rationale: Portal hypertension can occur in a client with right-sided heart failure, cirrhosis of the
liver, or cancer. Portal hypertension can lead to ascites causing increased abdominal distension,
pain, and difficulty breathing due to the buildup of fluid. Fluid builds up in the peritoneal cavity
due to increased portal pressure and decreased colloid osmotic pressure. Decreased osmotic
pressure is due to low serum albumin which causes fluids to leave the intravascular space and
leak into the interstitial space in the body. Other manifestations include gastrointestinal bleeding,
encephalopathy or confusion, and reduced levels of platelets.
Concepts tested

Question 3876
The home health nurse is developing a plan of care for an older adult client diagnosed with
shingles (herpes zoster) lesions to the face and left eye. What is the priority nursing problem?
A Pain related to nerve root inflammation and skin lesions
B Knowledge deficit related to disease process
C Risk for impaired skin integrity related to skin lesions
D Risk for social isolation due to pain and location of rash

Question Explanation
Correct Answer is A

Page | 1224
Rationale: Shingles is a reactivation of the herpes zoster virus responsible for chickenpox. It is
characterized by a vesicular rash in a unilateral dermatomal distribution. The first symptom of
shingles is usually pain, tingling, or burning before the blisters form. The pain and burning may
be severe, and can lead to long-term residual pain, known as postherpetic neuralgia. Using
Maslow's hierarchy of needs and considering acute vs. at risk for problems, pain is
the priority nursing problem for this client.
Concepts tested

Question 3877
The nurse is eating in the hospital cafeteria when a toddler at a nearby table begins to choke on a
piece of food and turns slightly blue. What initial action should the nurse take?
A Give the child water to help with swallowing
B Perform abdominal thrusts
C Begin mouth to mouth resuscitation
D Call for the emergency response team

Question Explanation
Correct Answer is B
Rationale: The initial response should be to perform abdominal thrusts. Since this child is
actively choking, it would be essential to begin this step in order to dislodge the foreign object.
Once this action is being done, the nurse should yell for help or for someone to call the rapid
response team. If the child stops breathing and/or is unconscious the nurse should open the
mouth and look for the object, if no object is seen perform mouth to mouth resuscitation using a
barrier device, continue to do the Heimlich remover, and call for help.
Concepts tested

Question 3878
The nurse in a neonatal unit is caring for a newborn with a myelomeningocele with an intact sac.
Which type of dressing should the nurse use to cover the sac?
A Hydrocolloid dressing
B Kurlix gauze, wrapped around the spine and abdomen
C Sterile pressure dressing
D Sterile, moist nonadherent dressing

Question Explanation
Correct Answer is D
Rationale: A meningocele is a neural tube defect where a sac is protruding from the spinal
column. If not covered, there is a high risk of infection and it is essential to protect the exposed
area of the spine. The nurse should apply a moist, sterile nonadherent dressing to prevent drying
of the area. Dressings are to be changed frequently to keep the area moist. Treatment includes
surgical closure and closing the overlying meninges and the skin. The other dressing choices are
not appropriate for this condition.
Concepts tested

Question 3879

Page | 1225
The nurse is caring for a 16-year-old client who had surgical repair of a fractured femur 14 hours
ago. Assessment findings include tachycardia, increased shortness of breath, a temperature of
100.2 F (37.8 C), feelings of anxiety, and an oxygen saturation level of 88%. The nurse
immediately notifies the health care provider, recognizing that the client is at risk for which
complication?
A Atelectasis
B Sepsis
C Fat embolism
D Compartment syndrome

Question Explanation
Correct Answer is C
Rationale: Since the client recently had an orthopedic surgery, these symptoms are cardinal signs
of fat embolism. A fat embolism is a piece of intravascular fat that lodges within a blood vessel
and causes obstruction of blood flow. While fat emboli can generally resolve on their own, this
complication can lead to fat embolism syndrome which can cause inflammation, multi-organ
failure, and neurological changes that may be fatal. Early-onset of sepsis wouldn’t appear until at
least day 2 or 3, not within 14 hours of the procedure. Compartment syndrome does not cause
increased shortness of breath or anxiety. Atelectasis occurs when ventilation is decreased and
secretions accumulate.
Concepts tested

Question 3880
A client has been diagnosed with Zollinger-Ellison syndrome. Which information is most
important for the nurse to reinforce?
A It is a condition in which one or more tumors called gastrinomas form in the pancreas or in the
upper part of the small intestine (duodenum)
B Treatment consists of medications to reduce acid and heal any peptic ulcers and, if possible,
surgery to remove any tumors
C With the average age of diagnosis at 50 years, the peptic ulcers may occur at unusual areas of
the stomach or intestine
D It is critical to promptly report any signs of abdominal pain or gastric bleeding to your health
care provider

Question Explanation
Correct Answer is D
Rationale: Night-time awakening with burning, cramp-like abdominal pain, vomiting (even
hematemesis), and change in appetite are some of the findings of peptic ulcers. Abdominal pain,
rigidity and tenderness can signal perforation of the ulcer and should be reported to the provider
immediately. Zollinger-Ellison syndrome can occur in both children and adults. All of the other
options are correct information about this syndrome but are less important to reinforce when
teaching the client.
Concepts tested

Question 3881

Page | 1226
The nurse admits a 7-year-old to the emergency department after a leg injury. The X-ray reveals
a fracture to the growth plate. While speaking with the child's parents, what response by the
nurse is most appropriate when discussing the outcome of this injury?
A "In some instances this type of injury can cause stunted bone growth."
B "Bone growth is stimulated in the affected leg as therapy is initiated."
C "This type of injury shows more rapid union than that of younger children."
D "The injury is expected to heal quickly because of the bone's strong outer surface."

Question Explanation
Correct Answer is A
Rationale: A growth plate fracture affects the layer of growing tissue near the end of the bone.
This area is the softest and weakest section of the skeletal system and any injury may affect how
the bone will grow. If left untreated or treated improperly, the injury could result in a crooked or
shorter than its opposite limb. Serious injuries usually require a cast or a splint. If the injury is
not aligning into the joint, surgery may be necessary. Out of the other options, this is the most
appropriate response.
Concepts tested

Question 3882
During the morning rounds, the nurse observes that a client diagnosed with heart failure has
developed sudden anxiety, diaphoresis and dyspnea. The nurse auscultates crackles bilaterally.
Which nursing intervention should be performed first?
A Sit the patient on the edge of the bed
B Take the client's vital signs
C Administer the PRN IV morphine
D Contact the health care provider

Question Explanation
Correct Answer is A
Rationale: Place the client in a sitting position with legs dangling to pool the blood in the legs.
This helps to diminish venous return to the heart and minimize the pulmonary edema and helping
the client breathe more easily. The next actions would be to contact the heath care provider, then
take the vital signs and then administer the IV morphine. Intravenous diuretics will also be
indicated to reduce the fluid volume excess.
Concepts tested

Question 3883
A male client at a public health clinic is diagnosed with epididymitis. Which additional
information is most important for the nurse to obtain?
A "Were you ever tested for a sexually transmitted infection?"
B "Did you know that a consequence of epididymitis is infertility?"
C "What are you taking for pain and does it provide total relief?"
D "Do you have any questions about your care?"

Question Explanation

Page | 1227
Correct Answer is A
Rationale: Epididymitis is an inflammation of the epididymis which is a coiled tube at the back
of the testicle which helps store sperm. Symptoms may include a swollen or reddened scrotum,
testicular pain, penile discharge, and/or blood in the semen. This is most often caused by a
bacterial infection, including sexually transmitted infections (STI) such as chlamydia or
gonorrhea. Therefore, it is most important to inquire about testing for an STI so that the client
can be treated and educated on prevention, as necessary.
Concepts tested

Question 3884
The visiting nurse is evaluating an ambulatory client who reports weight gain and increased
swelling in their feet and ankles during the day that disappears while they sleep. The client has a
history of emphysema. Which follow-up question would be most appropriate?
A "Did you start a new exercise regimen recently?"
B "Do you use any tobacco products?"
C "Have you made any significant changes to your usual diet?"
D "Do you have any shortness of breath with activities?"

Question Explanation
Correct Answer is D
Rationale: The client seems to be exhibiting signs and symptoms of heart failure (HF); in
particular, right-sided HF. To gather further information, the most appropriate follow-up
question from the nurse would be to inquire about any shortness of breath on exertion. Other
signs and symptoms of HF include fatigue, weakness, swelling of the feet and ankles, ascites,
bounding pulses and rapid or irregular heartbeat. The other questions do not relate to the
symptoms the client is reporting.
Concepts tested

Question 3885
The pediatric emergency room nurse is triaging several children. Which of the following children
is at highest risk for an adverse respiratory event?
A A child with a congenital heart defect
B A child found submerged under water
C A child with a fractured leg
D A child with an acute febrile illness

Question Explanation
Correct Answer is B
Rationale: The child who was found submerged under water is at highest risk for an adverse
respiratory event such as acute respiratory failure and respiratory arrest due to the likely
aspiration of water into the lungs.
Concepts tested

Question 3886
The nurse is caring for a client diagnosed with testicular cancer. Which risk factor supports this
diagnosis?
Page | 1228
A Undescended testis
B Genital herpes
C Older than 60 years of age
D Benign prostatic hyperplasia

Question Explanation
Correct Answer is A
Rationale: Testicular cancer is a rare cancer of the male testes that is common in males between
the ages of 15 to 45. Factors that increase a male's risk of testicular cancer include an
undescended testicle or testi (cryptorchidism), abnormal testicle development, family history,
age (typically occurs in younger males, median age 33), and race (occurs more often in whites).
The other conditions are not generally associated with an increased risk for testicular cancer.
Concepts tested

Question 3887
A client is brought to the emergency department with a blood glucose level of 52 mg/dL. The
client appears weak, tired, but is awake and talking. After drinking 4-ounces of juice, the client's
blood glucose does not rise above 70 mg/dL. Which actions by the nurse would
represent appropriate care of this client? Select all that apply.
A Determine blood sugar management medications
B Offer a 12-ounce (355 mL) can of cola with added sugar
C Recheck blood sugar in 15 minutes
D Offer 8-ounce (237 mL) glass of milk
E Instruct the client to not take more insulin today

Question Explanation
Correct Answer is A, C, D
Rationale: Treatment for hypoglycemia is to consume approximately 15-20 grams of glucose or
simple carbohydrates. Common examples of 15 grams of simple carbohydrates include: 2
tablespoons of raisins; 118 mL of juice or regular soda (not diet); 237 mL of nonfat or 1% milk;
and 1 tablespoon of honey. In a clinical setting, the client may also be given glucose tablets. If
after 15 minutes the blood sugar is still below 70 mg/dL (3.89 mmol/L), the client can be given
another 15-20 grams of simple carbohydrates (this is also known as the "15 - 15 rule.") It's
always a good idea to confirm how the client manages his/her diabetes.
Concepts tested

Question 3888
The medical-surgical nurse is developing a plan of care for a client with sickle cell disease who
was admitted for an acute sickle cell crisis. Which intervention is the priority?
A Ambulate in hallway four times a day
B Encourage increased caloric intake
C Administer prescribed analgesics
D Increase fluid intake to 3 to 4 liters a day

Question Explanation

Page | 1229
Correct Answer is C
Rationale: Sickle cell crisis is pain that begins suddenly and may last several hours or even days.
This crisis beings when sickled red blood cells block small blood vessels that carry blood to a
person’s bones. This can cause a person to have severe pain in their back, knees, legs, arms, and
chest. The pain can be described as throbbing, sharp, dull, or stabbing. Although all of
interventions are appropriate for the client in sickle cell crisis, the priority intervention is
effective pain management and administering prescribed analgesics.
Concepts tested

Question 3889
The nurse in a public health clinic is caring for a female client diagnosed with genital herpes who
reports dysuria, dyspareunia, leukorrhea, and lesions of the labia and perianal skin. Which
interventions should the nurse include in the discharge instructions? Select all that apply.
A Soak in a tub of hot water
B Apply a wrapped ice pack to the sores
C Use lubrication during sexual intercourse
D Increase fluids to dilute urine
E Apply petroleum jelly to blistered areas
F Avoid any tight clothing

Question Explanation
Correct Answer is B, D, E, F
Rationale: Genital herpes is a sexually transmitted infection caused by the herpes simplex virus.
Genital herpes can cause pain, itching, and sores/lesions/blisters to the genital and anal area.
Other symptoms include painful urination, pain during sexual intercourse, and a whitish or
yellowish discharge of mucus from the vagina. Interventions should include keeping the area
clean to prevent blisters/ulcers from becoming infected. To reduce pain, the client should wrap
an ice pack and apply to the sores, apply petroleum jelly to any blisters/sores to reduce pain
during urination, drink sufficient amounts of fluids to help make passing urine less painful, and
avoid tight clothing to reduce irritation to the blisters/sores. Clients with active lesions should not
soak in hot water or have sexual intercourse until they are finished with their treatment and the
lesions (blisters/ulcers) have disappeared.
Concepts tested

Question 3890
A nurse is caring for an 83-year-old client diagnosed with Parkinson's disease. Which findings
should the nurse anticipate?
A Muscle rigidity and a shuffling gait
B Muscle spasm and a bent over posture
C Nonintention tremors and urgency with voiding
D Voluntary tremor and jerky movement of the elbows

Question Explanation
Correct Answer is A

Page | 1230
Rationale: Clients with Parkinson's disease have a very distinctive gait with quick short steps
(shuffling) that may increase in speed so that they are unable to stop, as well as muscle rigidity.
In the other options, only one of the two findings listed is associated with Parkinson's disease:
clients may have nonintention tremors, but there is no urgency with voiding; their posture may
be "bent over," but there are no muscle spasms; and while they may experience a cogwheel or
jerky movement of the elbows, their tremors are not voluntary.
Concepts tested

Question 3891
A client diagnosed with gouty arthritis is admitted with severe pain and cellulitis of the right
foot. Which intervention would be essential for the nurse to include in the client's plan of care?
A High protein diet of beef
B Hot compresses to affected joints
C Active range of motion exercises
D Fluid intake of at least 3000 mL/day

Question Explanation
Correct Answer is D
Rationale: Fluid intake should be increased to prevent precipitation of urate in the kidneys; a lack
of sufficient fluids enhances the formation of urate renal calculi or kidney stones. Treatment for
acute attacks include supportive measures, such as applying ice and resting the affected joint.
The client should avoid eating foods high in purines, such as organ meats (liver), and limit eating
beef, pork and lamb.
Concepts tested

Question 3892
The nurse is providing the client who takes digoxin and furosemide with dietary instructions.
The nurse should reinforce that the combination of these medications can result in which
outcome?
A Edema
B Irritability
C Arrhythmias
D Oliguria

Question Explanation
Correct Answer is C
Rationale: Furosemide is an effective diuretic but electrolyte depletion may occur. Concurrently
taking furosemide and digoxin exaggerates the metabolic effects of hypokalemia, especially
alterations in cardiac rate and rhythm, and contributes to digitalis toxicity. Digitalis toxicity may
stimulate almost every known type of dysrhythmia. The effects of hypokalemia include fatigue
(not excitability) and polyuria (not oliguria); digitalis toxicity can cause nausea, vomiting,
anorexia and weight loss (not weight gain). Foods rich in potassium include avocados, bananas,
peas and beans, spinach and tomatoes.
Concepts tested

Question 3893
Page | 1231
The nurse is caring for two children who have had surgical repair of congenital heart defects. For
which defect is it the highest priority to assess for findings of heart conduction disturbance?
A Ventricular septal defect
B Aortic valve stenosis
C Patent ductus arteriosus
D Atrial septal defect

Question Explanation
Correct Answer is A
Rationale: While assessments for conduction disturbance should be included following repair of
any defect, it is a priority for ventricular septal defect. A ventricular septal defect is an abnormal
opening between the right and left ventricles. The atrioventricular bundle (bundle of His) is a
part of the electrical conduction system of the heart. It extends from the atrioventricular node
along each side of the interventricular septum and then divides into right and left bundle
branches. Surgical repair of a ventricular septal defect consists of a purse-string approach or a
patch sewn over the opening. Either method involves manipulation of the ventricular septum,
thereby increasing risk of interrupting the conduction pathway. Consequently, postoperative
complications often include conduction disturbances.
Concepts tested

Question 3894
A parent brings a 3 month-old infant into the clinic, reporting that the child seems to be spitting
up all the time and has a lot of gas. The nurse expects which findings on the initial history and
physical assessment?
A Increased sleeping and fatigue
B Diarrhea and poor skin turgor
C Restlessness and irritability
D Increased temperature and lethargy

Question Explanation
Correct Answer is C
Rationale: This infant could be experiencing gastroesophageal reflux or perhaps an allergic
response to the formula. Restlessness, irritability and increased mucus production can develop if
an allergy is present. Soy-based formula may be recommended when allergies to the proteins in
cow's milk formulas are suspected. Protein hydrolysate formulas are available when babies have
a milk or soy allergy. Reflux would be treated with an acid-reducing medication such as
ranitidine and positioning with the head elevated after feeding and while sleeping to reduce
symptoms causing esophageal irritation.
Concepts tested

Question 3895
A client is recently diagnosed with Barrett's esophagus. Which of the following statements made
by the client demonstrates that further teaching is needed about this illness?
A "I will buy a wedge pillow to raise the head of my bed."

Page | 1232
B "I will cut back on my smoking to 1 pack a day."
C "I should avoid eating anything for two hours before I go to sleep."
D "I will need regular endoscopies to monitor this illness."

Question Explanation
Correct Answer is B
Rationale: Barrett's esophagus is a complication of gastroesophageal reflux disease (GERD) and
is associated with an increased risk for esophageal cancer. Endoscopies are used to monitor the
progression of the disease and catch any cancer in its earliest stages. Treatment for Barrett's
esophagus is the same as for GERD. Lifestyle changes include weight loss, avoiding acidic foods
and fluids, not eating 90-120 minutes before bedtime, and sleeping with the head of the bed
elevated or in a left side-lying position. Cutting back on smoking is too ambiguous. Since
smoking aggravates GERD and is linked to the development of cancer, this client should be
advised about smoking cessation programs.
Concepts tested

Question 3896
The nurse is caring for a 68-year-old male client who had a transurethral resection of the prostate
(TURP) 12 hours ago. The client has an indwelling 3-way catheter with continuous bladder
irrigation. Which finding requires the nurse's immediate intervention?
A Minimal drainage into the urinary collection bag
B Light-pink urine with a continuous stream into the collection bag
C Occasional suprapubic cramping about every hour
D Reports of a feeling of discomfort from the urinary catheter

Question Explanation
Correct Answer is A
Rationale: All of the options, except the lack of drainage into the collection bag, are expected
findings after this procedure. Urine will be bright red from bleeding immediately after the
procedure, lightening over time as bleeding decreases. A lack of drainage needs to be reported
immediately because minimal urinary drainage puts the client at risk for bladder rupture. The
cause of this is likely to be a blood clot in the catheter or obstructing the catheter tip, which
requires sterile irrigation of the catheter to restore its patency. The flow rate of the continuous
irrigation would need to be slowed until urine flow has been restored. In some facilities, an order
for syringe bladder irrigation as needed is a standing order accompanying the orders for
continuous bladder irrigation
Concepts tested

Question 3897
A nurse at a pediatric clinic examines a toddler with a possible diagnosis of neuroblastoma.
Which findings are consistent with the client's diagnosis?
A Hearing loss and ataxia
B Lymphedema and nerve palsy
C Abdominal mass and weakness
D Headaches and vomiting

Page | 1233
Question Explanation
Correct Answer is C
Rationale: Neuroblastoma is a type of cancer that commonly arises in and around the adrenal
glands. This cancer may also develop in other areas of the abdomen in which the client will
complain of abdominal pain or feel a mass underneath the skin. The client may also have
changes in bowel habits such as constipation or diarrhea and unexplained weight loss. Client’s
will complain of weakness due to the symptoms of the cancer.
Concepts tested

Question 3898
A nurse is caring for a child diagnosed with Reye's syndrome. Which action should be given
the highest priority by the nurse?
A Assist with range of motion
B Assess level of consciousness
C Provide good skin care
D Monitor intake and output

Question Explanation
Correct Answer is B
Rationale: Reye’s syndrome is a rare disorder that causes liver and brain damage. This syndrome
may happen at any age; however, it is more prevalent with children. Reye’s syndrome occurs
after a child has had a recent viral infection, like the flu or chickenpox. Signs and symptoms may
include confusion, seizures, and loss of consciousness that would require emergency treatment.
The highest priority for the nurse would be to assess the child’s level of consciousness. The other
interventions may occur after if there are no complications.
Concepts tested

Question 3899
The nurse is caring for a client with a deep vein thrombosis. Which finding would require the
nurse's immediate attention?
A Pulse rate of 98 beats per minute
B Respiratory rate of 32
C Temperature of 102 F (38.8 C)
D Blood pressure of 94/50

Question Explanation
Correct Answer is B
Rationale: A deep vein thrombosis (DVT) is a blood clot formed in a vein deep in the body.
Typical location of a DVT is in the lower leg or thigh and causes increased swelling, redness,
and pain. If left untreated, the clot can travel to the lungs and cause respiratory distress. A clot
that forms in the lung is called a pulmonary embolism (PE). The clot lodges in one of the
pulmonary arteries and can cause lung damage and hypoxia. The most common symptoms of a
PE are sudden shortness of breath, a rapid respiratory rate, and chest pain.
Concepts tested

Page | 1234
Question 3900
The nurse is caring for a 68-year-old client who had a total hip replacement three days ago.
Which client statement requires the nurse's immediate attention?
A "It seems that the pain medication is not working as well today."
B "I have to use the bedpan to pass my water at least every hour."
C "I have bad muscle spasms in my lower leg, below the incision."
D "I seem to have trouble breathing when I am resting in bed."

Question Explanation
Correct Answer is D
Rationale: The nurse would be concerned about all of these comments, however the most life
threatening is the respiratory focus (think ABCs). Clients who have had hip or knee surgery are
at risk for developing pulmonary embolism. Sudden dyspnea, tachycardia and a feeling of
impending doom are classic findings of pulmonary embolism. Muscle spasms do not require
immediate attention. Frequent urination may indicate a urinary tract infection, particularly since
the client likely had an indwelling urinary catheter during surgery. Although the thought that
medication is not effective requires further investigation, it is not life-threatening.
Concepts tested

Question 3901
During evening rounds, the nurse notices a foul smell in the room of a client diagnosed with
pneumonia who was started on intravenous (IV) antibiotics 10 hours ago. Which statement by
the client would best indicate a possible complication of this diagnosis?
A "I have been coughing up foul-tasting, brown, thick sputum."
B "I feel hot on and off and have been sweating all day."
C "I have been incontinent of urine and need to change my pad often."
D I have a sharp pain in my chest when I take a breath."

Question Explanation
Correct Answer is A
Rationale: Foul smelling and tasting sputum signals the possible development of a lung abscess,
a complication of pneumonia, particularly in aspiration pneumonia. This puts the client in grave
danger because abscesses are often caused by anaerobic organisms. This client most likely would
need a change of antibiotics. Sharp chest pain on inspiration called pleuritic pain is an expected
finding with this type of pneumonia. The other options are expected in the initial 24 to 48 hours
of therapy for any type of infection.
Concepts tested

Question 3902
A client is recovering from an acute myocardial infarction. Which action by the nurse would best
prevent complications associated with the Valsalva maneuver in this client?
A Maintain the client on strict bed rest
B Administer antiarrhythmic medications PRN as ordered
C Administer stool softeners every day as ordered
D Assist the client with use of the bedside commode

Page | 1235
Question Explanation
Correct Answer is C
Rationale: After myocardial infarction, the Valsalva maneuver can cause cardiac arrhythmias.
Administering stool softeners every day will prevent the client from straining or bearing down on
defecation (the Valsalva maneuver). If constipation occurs, laxatives would be necessary to
prevent Valsalva. If the client experiences cardiac arrhythmias associated with straining on
defecation, then administering antiarrhythmics would be appropriate. Maintaining bed rest with
use of a bedpan can increase the likelihood of straining and difficulty with defecation as well as
increased myocardial oxygen consumption, so use of the bedside commode is also appropriate to
achieve this goal in this client.
Concepts tested

Question 3903
The home health nurse is developing a teaching plan for a client with Class III left-sided heart
failure. Which intervention is the priority?
A Rest in an armchair instead of lying in bed
B Record and monitor weights daily
C Engage in moderate exercise 2 to 3 times a week
D Limit the intake of foods high in sodium

Question Explanation
Correct Answer is B
Rationale: Heart failure (HF) is a condition that is characterized by fluid volume excess or
overload. The best way for the client to monitor their fluid balance is by weighing themselves
daily. An increase in their weight above a couple of pounds over 1 to 2 days can indicate
worsening of their HF and the client should be instructed to notify their health care provider right
away.
Concepts tested

Question 3904
The clinic nurse is reinforcing discharge instructions to an older adult client with type 2 diabetes
mellitus. The nurse should teach the client to contact the health care provider immediately for
which finding?
A An open, reddened wound on the heel
B Nausea with indigestion
C Temperature of 102.2°F (39.0°C) with dysuria
D Insomnia with daytime fatigue

Question Explanation
Correct Answer is C
Rationale: Clients with type 2 diabetes are at risk for developing many systemic complications,
including infections. A fever and painful urination (dysuria) can indicate a urinary tract infection
(UTI). Because a UTI can quickly lead to urosepsis in high-risk client, these findings are
the priority to report to the health care provider. An open wound is also important to report, but
Page | 1236
not before the fever and dysuria. Nausea and indigestion could indicate gastroparesis; which is
common due to vagus nerve damage secondary to long-standing hyperglycemia. Insomnia with
daytime fatigue may indicate obstructive sleep apnea. However, the complaints are not exclusive
to type 2 diabetes or as urgent as the other findings.
Concepts tested

Question 3905
The nurse is admitting a client with a diagnosis of testicular cancer. The nurse should expect the
client to have which of the following findings?
A Heaviness in the affected testicle
B Scrotal discoloration
C Sustained painful erection
D Inability to achieve erection

Question Explanation
Correct Answer is A
Rationale: The testicles are located in the scrotum. Testicular cancer can occur in one testicle;
however, 2-3% of tumors can occur in both testicles. The first sign of testicular cancer often is a
firm, smooth, painless mass which is accompanied by a feeling of heaviness in the affected
testicle. Other symptoms of testicular cancer include a feeling of swelling in the scrotum,
discomfort in the scrotum, ache in the lower back, and pelvis area. In advanced stages symptoms
include abdominal mass, coughing, weight loss, fatigue, pallor and lethargy. Scrotal
discoloration is not a finding of testicular cancer. Sexual performance (e.g., ability to have an
erection and a painful erection) is not affected by testicular cancer.
Concepts tested

Question 3906
The nurse is assessing a client with left-sided heart failure who exhibits fatigue, hypotension,
crackles to auscultation and dyspnea on exertion. Which nursing problem is the priority for this
client?
A Decreased cardiac output
B Fluid volume excess
C Pain
D Impaired gas exchange

Question Explanation
Correct Answer is D
Rationale: Although all of the problems are important for the nurse to address, the nurse should
use the airway-breathing-circulation (ABC) approach to prioritize. Due to the heart or "pump"
failure, the client will experience excess fluid volume, a decrease in cardiac output which causes
a decrease in blood pressure and pulmonary congestion due to the left ventricle's inability to
pump and empty effectively. This leads to fluid backing up into the lungs (pulmonary edema).
The pulmonary congestion or edema will interfere with the much needed exchange of oxygen,
causing hypoxemia, dyspnea and general activity intolerance. Therefore, the priority will be to
provide the client with supplemental oxygen to support the heart and lungs in meeting the body's
tissue perfusion needs.
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Concepts tested

Question 3907
The nurse is caring for a preterm newborn who develops nasal flaring, cyanosis and diminished
unilateral breath sounds. The client is diagnosed with a spontaneous pneumothorax. Which of the
following procedures should the nurse prepare the client for first?
A Cardiopulmonary resuscitation
B Insertion of a chest tube
C Assisted ventilation
D Humidified oxygen using face mask

Question Explanation
Correct Answer is B
Rationale: Premature infants, infants on mechanical ventilators or who have lung diseases (such
as respiratory distress syndrome) are at risk for pneumothorax. If a newborn's breathing is
labored or if the level of oxygen in the blood declines, the air must be removed rapidly from the
chest cavity by inserting a chest tube. Asymptomatic pneumothorax can be treated by placing the
infant in a 100% oxygen hood; oxygen will enter the stomach when a face mask is used.
Concepts tested

Question 3908
The nurse is admitting a client through the emergency department who is 28-weeks pregnant and
has a tentative diagnosis of placenta abruptio. Which of the following actions should the nurse
take first?
A Administer oxygen by mask at 100%
B Check fetal heart rate every 15 minutes
C Insert urethral catheter and monitor urine output hourly
D Start a second IV with an 18 gauge cannula

Question Explanation
Correct Answer is A
Rationale: Placenta abruptio is the separation of the placenta from its attachment to the uterus
wall. Administration of oxygen in this situation is the priority; it will increase the oxygen in the
mother's and the fetus' circulation. This action will minimize complications of hypoxia.
Additional treatment includes IV fluids and possibly a blood transfusion, which is why starting a
second line with a large gauge needle is required. The fetus will be monitored for signs of
distress. Additional treatment depends on the severity of the separation and the location of the
separation.
Concepts tested

Question 3909
The nurse is assessing a client with left-sided heart failure. Which finding requires the
nurse's immediate attention?
A Nocturia
B Pulse oximeter 85%

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C Diaphoresis
D Pulse 100 bpm

Question Explanation
Correct Answer is B
Rationale: Left-sided heart failure is characterized by a low cardiac output. As a result, there is a
decrease in the amount of oxygen and nutrients that is delivered to other body systems. The
inability of the left ventricle to empty itself can lead to pulmonary congestion and pulmonary
edema. This would cause poor gas exchange, hypoxia as evidenced by cyanosis or general
weakness. An oxygen saturation of 88% or less indicates hypoxemia and would require the
nurse's immediate attention. The hyoxemia is related to low cardiac output with low oxygen
distribution and pulmonary congestion. Tachycardia, diaphoresis and nocturia can also be
common occurrences in clients with heart failure or left-sided heart failure. However, these
findings are not high priority. The pulse rate is high due to a compensatory mechanism from low
cardiac output and hypoxia. Diaphoresis can occur secondary to a stress response from the heart
failure.
Concepts tested

Question 3910
The nurse is assessing a toddler diagnosed with croup. Which of the following findings requires
the nurse's immediate attention?
A Coughing up copious secretions
B Apical pulse of 130
C Lethargy for the past hour
D Respiratory rate of 54

Question Explanation
Correct Answer is D
Rationale: Croup is a viral or bacterial invasion of the upper airway that extends throughout the
larynx, trachea, and bronchi. This invasion leads to edema and obstruction of the airway. This
condition is seen more commonly in children ages 6 months to 6 years. Characteristic
manifestations of croup include a barking cough and hoarseness. Typically, clients with croup
have copious secretions. It is a normal finding of the condition. Because croup is an infection,
clients will typically present with malaise, fatigue and a low-grade fever. Findings of impending
airway obstruction in croup include increased respiratory rate and pulse; substernal, suprasternal,
and intercostal retractions; nostril flaring and increased restlessness or agitation. The normal
respiration rate in a 1 to 3 year-old child is 24 to 40 breaths/min, the normal pulse rate is 90 to
150 bpms.
Concepts tested

Question 3911
The nurse is reinforcing teaching about preventing episodes of agitation in a client with
dementia. Which statement by the caregiver would indicate a correct understanding of the
teaching?
A "I will encourage her to drink coffee when she is tired."
B "I will leave the TV on during the night to provide background noise."

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C "I will speak in a loud voice to make sure she hears me clearly."
D "I will use a consistent routine for our activities each day."

Question Explanation
Correct Answer is D
Rationale: Dementia is a syndrome that is characterized by a slow, progressive decline in
cognitive function. Two important actions that are necessary for a client with dementia are
preventing overstimulation and providing a structured and orderly environment to reduce and
prevent episodes of anxiety and agitation. Environmental distractions and noise should be kept to
a minimum. Raising one's voice should be avoided, since it may make the client more agitated.
Clients with dementia may have sleep disturbances, thus caffeinated beverages or having a TV
on at night should be avoided because those actions are likely to further disrupt the client's ability
to sleep.
Concepts tested

Question 3912
The nurse is planning care for a client with Alzheimer's disease. The client has episodes of bowel
and bladder incontinence. Which intervention should the nurse include in the client's plan of
care?
A Limit PO fluid intake to reduce episodes of incontinence.
B Schedule toileting for the client every two hours during the day.
C Place a picture of a toilet on the client's bathroom door.
D Wake the client at night to ask about their toileting needs.

Question Explanation
Correct Answer is B
Rationale: When planning care for a client with Alzheimer's disease the nurse should promote
bowel and bladder continence. The client may need prompting from health care personnel to
complete the act of toileting. The client may remain continent of bowel and bladder for long
periods if taken to the bathroom or given a bedpan or urinal every two hours or more often
during the day. The nurse encourages the client to drink adequate fluids to promote optimal
voiding. Placing a picture on the bathroom door may help the client identify the bathroom if they
have been voiding in inappropriate places like the sink or a wastebasket. Clients with
Alzheimer's disease often have difficulty sleeping, so their treatment and medication schedule
should be adjusted to provide uninterrupted sleep.
Concepts tested

Question 3913
A client is admitted to the emergency department with acute onset of left hemiplegia. The nurse
should prepare the client for which diagnostic procedure?
A Computerized tomography scan
B Cerebral arteriogram
C Lumbar puncture
D Positron emission tomography scan

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Question Explanation
Correct Answer is A
Rationale: Acute onset hemiplegia is indicative of a stroke and a computerized tomography (CT)
scan without contrast is the most commonly used diagnostic test to quickly determine if a client
suffered a stroke. The other diagnostic tests are not indicated at this time.
Concepts tested

Question 3914
The nurse is reviewing the medical record of a client admitted with acute kidney injury. Which
findings would support this diagnosis? Select all that apply.
A Hematuria
B Decreased glomerular filtration rate
C Hypokalemia
D Elevated creatinine level
E Proteinuria
F Decreased blood area nitrogen

Question Explanation
Correct Answer is A, B, D, E
Rationale: Acute kidney injury (AKI) is the rapid loss of kidney function due to some form of
damage. A clinical manifestation of AKI includes an elevated blood urea nitrogen level due to
the breakdown of protein. Protein is then released into the bloodstream and is filtered through the
kidneys. Through a urine analysis protein can be found, which is not typically present. Increased
levels of protein can damage the kidney, causing an elevated creatinine level, a decreased
glomerular filtration rate and hematuria and can cause the release of cellular potassium into body
fluids. This can cause hyperkalemia, not hypokalemia.
Concepts tested

Question 3915
A client comes to the community health clinic with symptoms of gonorrhea. Which intervention
should the nurse implement first?
A Instruct the client to notify past sexual partners.
B Discuss the risk of infertility with the client.
C Obtain information about the client's recent sexual encounters.
D Collect a urethral swab from the client.

Question Explanation
Correct Answer is C
Rationale: The nurse should first obtain information from the client about their recent sexual
encounters. This will provide further insight and assist other health care providers who are
coordinating care. The nurse should prepare for a urethral swab, but this should not be the first
intervention. The nurse must provide sensitive care because some people are reluctant to seek
health care when problems first arise. Sexually transmitted infections can cause emotional

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distress and may progress without symptoms. It would be important for the client to speak to any
sexual partners that may have a risk of contracting the infection, but this should not be the first
thing. Discussing the risk of infertility would not be appropriate at this time.
Concepts tested

Question 3916
The nurse is developing as plan of care for a postoperative client following a radical left
mastectomy. Which nursing problem should be the priority for this client?
A Acute pain related to the surgery
B Risk of infection of the surgical site
C Anxiety related to the cancer diagnosis
D Impaired left arm circulation (lymphedema)

Question Explanation
Correct Answer is A
Rationale: A radical mastectomy is performed to treat invasive breast cancer and involves the
removal of the breast, the nipple and areola, as well as a portion of the axillary lymph nodes.
Using Maslow's hierarchy of needs to prioritize nursing care and interventions, the acute post-
surgical pain (a basic, physiological need) is the priority problem. Next, the nurse should focus
on prevention of lymphedema, alleviating the client's anxiety and monitoring for signs of
infection at the surgical site.
Concepts tested

Question 3917
The nurse is teaching a client about prevention of recurrent kidney stones. Which statement by
the client would indicate that additional teaching is needed?
A "I will make sure I drink plenty of water throughout the day."
B "I will contact my health care provider if I am having difficulty urinating."
C "I will monitor the color of my urine."
D "I will follow a low-calcium diet and avoid dairy products."

Question Explanation
Correct Answer is D
Rationale: The client's statement regarding a low-calcium diet and avoiding dairy products
would require further teaching from the nurse. Low-calcium diets are not generally
recommended as this can lead to osteoporosis. Clients should be drinking fluids, preferably
water, at least every 1 to 2 hours throughout the day. This can flush the system and prevent the
occurrence of kidney stones. Clinical manifestations of kidney stones include pain, infection and
difficulty with urination. Clients should notify their health care providers at the first sign of a
urinary tract infection, as this can be caused by a kidney stone obstructing the flow of urine.
Concepts tested

Question 3918
The nurse is caring for a client who had a small bowel resection two days ago. The client reports
that the pain has significantly increased over the last two hours and does not get better after

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receiving an analgesic. Which additional findings are indicative of a postoperative complication
the client might be experiencing? Select all that apply.
A Serosanguineous fluid in the surgical drain
B Nausea and vomiting
C Taut, distended abdomen
D Hyperactive bowel sounds
E Tenderness at the incision site

Question Explanation
Correct Answer is B, C, D
Rationale: A non-mechanical obstruction, or paralytic ileus, is a complication of bowel surgery
due to the manipulation of the intestines during surgery. The pain associated with a non-
mechanical obstruction is constant and diffuse. The client may also have distention in the upper
abdominal or epigastric region, decreased or absent bowel sounds, and nausea and vomiting.
Increased bowel sounds, especially loud, gurgling sounds, result from increased motility of the
bowel (borborygmus) and are sometimes heard above a complete intestinal obstruction.
Tenderness at the incision site and serosanguineous fluid in the surgical drain are expected two
days after a bowel resection.
Concepts tested

Question 3919
The nurse is caring for a client who is experiencing an exacerbation of ulcerative colitis. Which
manifestations would the nurse expect to see with this client? Select all that apply.
A Abdominal pain relieved by defecation
B Mucous noted in the stool
C Crackles in the lower lung fields
D Frequent bloody stools
E Fever of 104°F (40°C)

Question Explanation
Correct Answer is A, B, D
Rationale: Due to the inflammatory nature of ulcerative colitis (UC), clients suffering from this
illness will experience frequent, bloody stools that often contains mucous. Clients will often
report lower abdominal pain that is relieved by defecation. Anemia can be associated with
prolonged intestinal bleeding and dehydration may occur related to decreased absorption. Clients
with UC may have a low-grade fever, but a high fever such as 104°F (40°C), would be more
likely to be associated with an infection or peritonitis.
Concepts tested

Question 3920
The nurse is caring for a client who has a history of peptic ulcer disease. The nurse notes the
abdomen is rigid and the client complains of severe pain with palpation. What is
the priority action by the nurse?
A Review the client's record for NSAID use.
B Notify the health care provider of the findings.

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C Record the findings in the client's record.
D Ask the client about dietary habits.

Question Explanation
Correct Answer is B
Rationale: A complication of peptic ulcer disease (PUD) is perforation. When perforation
occurs, gastrointestinal contents will leak into the peritoneal cavity, causing peritonitis. This is a
surgical emergency. While the client with PUD may complain of epigastric pain or tenderness,
severe pain and a rigid abdomen are not expected finding. Past medication use and dietary habits
are important to note, but alerting the HCP is the priority.
Concepts tested

Question 3921
The nurse in the primary care office is reviewing after-visit instructions with a client who was
recently diagnosed with gastroesophageal reflux disease (GERD). Which action should the client
implement to decrease the symptoms associated with GERD?
A Eliminate dairy products from the diet.
B Increase oral fluid intake to 4 liters a day.
C Avoid caffeinated and carbonated beverages.
D Limit foods high in fiber.

Question Explanation
Correct Answer is C
Rationale: GERD means the chronic backward flow (reflux) of stomach contents into the
esophagus. This reflux produces symptoms (i.e., heartburn) by exposing the esophageal mucosa
to the irritating effects of acidic gastric or duodenal contents, resulting in inflammation. The
most common cause of GERD is excessive relaxation of the lower esophageal sphincter (LES).
Because caffeinated beverages, such as coffee, tea and cola, and the carbonation in carbonated
beverages will further lower the LES pressure, increasing the risk for gastric reflux and
esophageal irritation, those drinks should be avoided. The other actions will not help with the
symptoms of GERD.
Concepts tested

Question 3922
The nurse in the primary health care provider's office is speaking with a 40-year-old male client
whose most recent hemoglobin A1C level was 9%. The client states that he is motivated to make
lifestyle changes to better manage his disease. What interventions should the nurse recommend
for this client? Select all that apply.
A Minimize intake of caffeinated beverages.
B Start a weight loss program until BMI is below 25.
C Schedule an appointment with a registered dietitian.
D Engage in regular physical activity, such as walking.
E Eliminate all consumption of alcohol.
F Check the blood sugar several times a day, ideally before eating.

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Question Explanation
Correct Answer is B, C, D, F
Rationale: The client's hemoglobin A1C level indicates the client is not managing their diabetes
well. An A1C level of 7% or less is the goal for clients with diabetes. Effective diabetes
management should include daily or more frequent blood sugar monitoring, learning how to
count carbohydrates and eat appropriately-sized meals, maintaining a healthy weight (i.e., a BMI
between 18.5 and 24.9, per CDC guidelines) and engaging in regular physical activity. Avoiding
caffeine or eliminating all alcoholic beverages is not required.
Concepts tested

Question 3923
The nurse is caring for a client who has type I diabetes mellitus. Upon entering the room, the
nurse notes the client has rapid, deep respirations, and is lethargic and difficult to arouse. What
should the nurse do first?
A Check the client’s blood sugar.
B Administer glucagon per protocol.
C Review when the last dose of insulin was given.
D Review the client’s insulin pump settings.

Question Explanation
Correct Answer is A
Rationale: Rapid, deep respirations and a decreased level of consciousness are signs that the
client may be in diabetic ketoacidosis (DKA). Onset of DKA can be rapid with precipitating
factors associated with infection, surgery or stress. Due to the acidotic state within the body, the
respiratory system attempts to “blow off” CO2 to correct the metabolic acidosis, hence the rapid,
deep respirations. Glucagon is given in cases of hypoglycemia and should not be given until the
blood sugar level has been verified. While reviewing the last dose of insulin and verifying that
the insulin pump is working correctly are important, it is essential to check the blood sugar first.
Assessment is the first step in the nursing process and will help the nurse decide what to do next.
Concepts tested

Question 3924
The nurse in the emergency department is admitting a client with a reduced level of
consciousness due to severe hypothyroidism. Which intervention should the nurse
implement first?
A Orient the patient to person, time and place.
B Administer propranolol as prescribed.
C Implement warming blankets as indicated.
D Provide supplemental oxygen.

Question Explanation
Correct Answer is D
Rationale: Myxedema coma is a complication of poorly treated hypothyroidism, and occurs
when levels of thyroid hormone are critically low. Low thyroid levels can result in a reduction in
metabolism and significant cardiac dysfunction. This can result in decreased cardiac output, poor
oxygenation to tissues and organs, and ultimately tissue and organ failure. For those with
Page | 1245
myxedema coma, appropriate interventions include administration of propranolol, utilization of
warming blankets to prevent hypothermia and reorientation to person, time and place. However,
the priority is to maintain respiratory functioning and to provide airway support. Therefore,
monitoring oxygen saturation levels and providing supplemental oxygen should be done first.
Concepts tested

Question 3925
The nurse is caring for a client who has suspected Cushing's disease. The nurse should monitor
for which potential symptoms? Select all that apply.
A Tachycardia and panic attacks
B Changes in visual acuity
C Polyuria and polydipsia
D History of pathologic fractures
E Large fat pads on the back and shoulders

Question Explanation
Correct Answer is D, E
Rationale: Cushing's disease occurs when there is an excess amount of cortisol. The nurse must
understand that glucocorticoids, including cortisol, regulate metabolism and immune function,
and play a role in the regulation and distribution of serum calcium levels. Therefore, deposition
of fat pads on the back and shoulders, as well as fractures secondary to osteoporosis, are signs
and symptoms of Cushing's disease that the nurse should be able to recognize. The nurse should
understand that tachycardia and panic attacks, as well as to polyuria, are not often associated
with Cushing's disease, but are instead associated with other endocrine conditions. Tachycardia
and panic attacks are sometimes seen with adrenal tumors, such as pheochromocytoma. Polyuria
and polydipsia may be associated with both diabetes insipidus and diabetes mellitus, and changes
in vision can be associated with advanced diabetes mellitus.
Concepts tested

Question 3926
Which assessment findings should make the nurse suspect that the client might have
amyotrophic lateral sclerosis (ALS)?
A Complaints of double vision and light sensitivity
B Loss of sensation in the extremities
C Progressive hearing loss in the last month
D Fatigue, progressive muscle weakness and twitching

Question Explanation
Correct Answer is D
Rationale: Amyotrophic lateral sclerosis (ALS) typically has a gradual onset, which is generally
painless. Progressive muscle weakness is the most common initial symptom in ALS. Other early
symptoms vary but can include tripping, dropping things, abnormal fatigue of the arms and/or
legs, slurred speech, muscle cramps and twitches and/or uncontrollable periods of laughing or
crying.
Concepts tested

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Question 3927
The nurse is reviewing the chart of a client with Parkinson's disease. Which manifestations
would the nurse expect to find? Select all that apply.
A Postural instability
B Rigidity
D Anuria
E Epistaxis
F Akinesia
G Tremors
H Jaundice

Question Explanation
Correct Answer is A, B, F, G
Rationale: Parkinson's disease is a result of an imbalance in dopamine and acetylcholine (AcH).
In Parkinson's disease, dopamine levels are low and the client loses the ability to refine voluntary
movement. AcH secreting neurons remain active, creating an imbalance between excitatory and
inhibitory neuronal activity. The resulting excessive excitation of neurons prevents a person from
controlling or initiating voluntary movement. Parkinson's disease is characterized by four
cardinal symptoms/clinical manifestations: tremors, rigidity, akinesia and postural instability.
Jaundice, epistaxis (nosebleed) and anuria (low or no urine output) are not expected
manifestations of a client with Parkinson's disease.
Concepts tested

Question 3928
The nurse is providing care to an 80-year-old client with the diagnosis of advanced Parkinson's
disease. The nurse should know that the greatest risk to the client is related to which finding?
A Extreme weakness in the lower extremities
B Dizziness and syncopal episodes
C Difficulties with reading and seeing at night
D Drooling and coughing when eating

Question Explanation
Correct Answer is D
Rationale: Although all of the findings pose a safety risk to the client, drooling and coughing
while eating are indicative of dysphagia. Dysphagia, a common finding with advanced
Parkinson's disease, puts the client at an increased risk for aspiration of oral secretions or
choking on food, which can cause airway and/or breathing problems. Using the ABC
prioritization strategy, the nurse should recognize this finding as the greatest risk.
Concepts tested

Question 3929
The nurse is planning care for a client diagnosed with Guillain-Barré syndrome. Which problem
should the nurse identify as a priority?
A Altered bowel elimination

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B Partial or total immobility
C Nutritional deficits
D Difficulty breathing

Question Explanation
Correct Answer is D
Rationale: Guillain-Barré syndrome (GBS) is an acute autoimmune disorder characterized by
varying degrees of motor weakness and paralysis. Difficulty breathing is the priority problem
because acute respiratory failure due to muscle weakness and respiratory paralysis can occur,
requiring ventilatory support. The other problems are also potential problems but are not life-
threatening. The nurse should prioritize using the ABC decision-making approach.
Concepts tested

Question 3930
The home health nurse is reviewing the medical record of a client with closed-angle glaucoma in
both eyes. Which statement by the client would support this diagnosis?
A "I can't see out of my left eye."
B "I have constant blurred vision."
C "I have specks floating in my eyes."
D "I have to turn my head to see around the room."

Question Explanation
Correct Answer is D
Rationale: As intraocular pressure rises in glaucoma, there is a slow, progressive loss of the
peripheral visual field in the affected eye(s). If untreated or uncontrolled, it eventually can lead
to blindness. The client's statement that they have to turn their head to be able to see indicates a
loss of peripheral vision. Tiny, painless particles floating inside the eye are called floaters that
can be harmless or signal retinal detachment. Blurred vision can have many causes, including
refractive errors, chronic dry eyes, cataracts and macular degeneration. Complete, unilateral loss
of vision is typically seen with a stroke or other intracerebral process.
Concepts tested

Question 3931
The nurse working in a medical office answers a phone call from a client. The client asks how to
improve symptoms of their migraine headache. The nurse should advise the client to use which
interventions? Select all that apply.
A Apply a cold cloth to their forehead.
B Rest in bed and watch television.
C Wear sunglasses while indoors.
D Lie down in a darkened room.
E Drink an 8 oz. glass of red wine.
F Take 600 mg ibuprofen as prescribed.

Question Explanation
Correct Answer is A, C, D, F

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Rationale: Migraine headache is an episodic familial disorder manifested by unilateral,
frontotemporal, throbbing pain in the head, which is often worse behind one eye or ear. It is often
accompanied by sensitive scalp, anorexia, photophobia, phonophobia and nausea, with or
without vomiting. The priority for interdisciplinary care of the client experiencing a migraine is
pain management, which may be achieved by abortive and preventative drug therapy, as well as
non-drug measures. The client may be able to alleviate pain by lying down in a dark room. The
client may want both eyes covered and a cool cloth on their forehead. If the client falls asleep,
they should remain undisturbed until awakening. Sunglasses may eliminate symptoms of
photophobia. Bright lights and noise should be avoided (watching television). Alcohol is a
migraine trigger and should be avoided.
Concepts tested

Question 3932
The nurse in a primary care office is performing an assessment on an older adult client. The
client appears tired, pale, and malnourished. The client reports drinking several alcoholic
beverages a day and worsening dyspnea on exertion. Based on the assessment findings, which
lab test is the priority?
A Complete blood count
B Ammonia level
C Chest x-ray
D Liver enzymes

Question Explanation
Correct Answer is A
Rationale: The assessment findings and client reports point to anemia as the cause for the
client's symptoms. Anemia is a reduction in the number of red blood cells (RBCs) and the
amount of hemoglobin and hematocrit. It is most commonly caused by nutritional deficits as
seen with malnutrition, chronic alcoholism and an iron- and folic acid-deficient diet. Therefore, a
complete blood count or CBC lab test which includes an RBC, hemoglobin and hematocrit level,
is the priority.
Concepts tested

Question 3933
The nurse is caring for a client with chronic renal failure who is undergoing peritoneal dialysis.
The nurse notes that the dialysate solution is instilling very slowly. Which of the following
actions would be appropriate for the nurse to implement? Select all that apply.
A Check tubing and catheter for kinks
B Assess for headache and hypertension
C Assess for bruit or vibration
D Reposition the client

Question Explanation
Correct Answer is A, D
Rationale: Peritoneal dialysis instills fluid into the peritoneal cavity via an access device. One of
the causes for the solution to not be instilling at the prescribed rate would be a kink in the
catheter, thus checking for kinks in the catheter or tubing is an appropriate action. Repositioning
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the client may facilitate the flow of the dialysis solution. A bruit or vibration would be
appropriate for the client receiving hemodialysis through an AV shunt or graft. A headache or
hypertension may occur in the client receiving hemodialysis.
Concepts tested

Question 3934
The nurse in an urgent care clinic is discharging a client diagnosed with pyelonephritis due to a
urinary tract infection. Which instruction is most important to include?
A "Increase your fluid intake to 3 to 4 liters a day."
B "Schedule an appointment for a repeat urinalysis in one week."
C "Monitor your blood pressure at home daily."
D "Notify your health care provider if you do not start feeling better in a few days."

Question Explanation
Correct Answer is D
Rationale: Pyelonephritis is an inflammation of the kidney, generally caused by a bacterial
infection. Usually, initial treatment consists of a broad-spectrum antibiotic and symptoms should
start to improve once the client has started the antibiotic. However, if the symptoms do not
improve, the client may require a different antibiotic. Therefore, it is most important for the
client to notify their health care provider if their symptoms do not improve in a few days. The
client should also increase their fluid intake and may require a repeat urinalysis, but those actions
are not as important. At home monitoring of the blood pressure is not required in this situation.
Concepts tested

Question 3935
The nurse is caring for a client who fell two hours ago while alone in their room. The client
appears tired and disoriented. What should the nurse do first?
A Use a gait belt to assist the client to their bed for a nap.
B Ensure fall precautions are included in the client's plan of care.
C Reorient the client to their surroundings, date and time.
D Gather data about the client's baseline neurologic status.

Question Explanation
Correct Answer is D
Rationale: The nurse should follow the nursing process and collect data first. Based on the data
collected, the nurse will then be able to identify and make a clinical decision about which
interventions are the priority to implement. The client in this scenario suffered an unwitnessed
fall and may have hit their head. A decrease or change in the level of consciousness is typically
the first sign of deterioration in neurologic status. By establishing the client's baseline data, the
nurse can detect subtle changes in the client's neurologic status. This enables the health care team
to prevent or treat the potentially life-threatening complications of a head injury. Reorientation,
fall precautions and use of a gait belt would be beneficial for a client with a history of falling, but
obtaining a neurological baseline is the priority in this scenario.
Concepts tested

Question 3936
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The nurse is reinforcing teaching for a client with Bell's palsy. Which statement by the client
indicates that additional teaching is needed?
A "I will wear an eye patch at night while I sleep."
B "I will eat and drink using the strong side of my mouth."
C "I will rest my facial muscles because they are recovering."
D "I will apply warm, moist heat to my face."

Question Explanation
Correct Answer is C
Rationale: Bell's palsy is a form of acute facial paralysis. The disorder is characterized by a
drawing sensation and the paralysis of all facial muscles on the affected side. The client cannot
close the eye, wrinkle the forehead, smile, whistle or grimace. Nursing care is directed toward
managing the major neurologic deficits and providing psychosocial support. Because the eye
does not close, the client should wear an eyepatch or tape their eye closed at bedtime to protect
their cornea from drying and developing subsequent ulceration or abrasion. The client should eat
and drink using the unaffected side of their mouth. Simple massage techniques, the application of
warm, moist heat and facial exercises should be explained to the client. The client's statement
about resting their facial muscles is incorrect because they should be taught to exercise their
facial muscles to aid in the recovery.
Concepts tested

Question 3937
The client was admitted two days ago with a diagnosis of myocardial infarction (MI). When
assessing this client, the nurse notes the client’s temperature is now 101.1°F (38.5°C). What is
the most appropriate nursing intervention?
A Increase the client’s fluid intake
B Send blood, urine and sputum for cultures
C Call the health care provider (HCP) immediately
D Administer PRN acetaminophen as ordered

Question Explanation
Correct Answer is D
Rationale: After a myocardial infarction, leukocytosis can occur on day 2, because the body is
undergoing a systemic inflammatory response. Nursing interventions should be to reduce the
temperature, which would be the administration of the acetaminophen. It is not necessary to do
further cultures or to notify the HCP at this time.
Concepts tested

Question 3938
A nurse enters a client's room to discover that the client has no pulse or respirations. After calling
for help, what is the first action the nurse should take?
A Start a peripheral IV

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B Establish an airway
C Obtain the crash cart
D Initiate chest compressions

Question Explanation
Correct Answer is D
Rationale: As per the latest American Heart Association guidelines for Basic Life Support, when
finding an unresponsive, apneic client, the nurse should call for help, then begin chest
compressions for 2 minutes, then check the airway and provide rescue breaths.
Concepts tested

Question 3939
The nurse is assigned to care for a client diagnosed with HIV/AIDS. A first-semester nursing
student asks the nurse how a diagnosis of AIDS is determined, other than a positive HIV test.
What response by the nurse is the best explanation for how AIDS is diagnosed?
A "Having a CD4+ lymphocyte count less than 400 and a positive Western Blot test."
B "The presence of any number of opportunistic infections and testing positive on the viral load
test."
C "Having symptoms of anxiety, dementia, depression and insomnia, along with a low viral
load."
D "Having a CD4+ lymphocyte count less than 200 and one or more AIDS defining
conditions."

Question Explanation
Correct Answer is D
Rationale: A CD4+ lymphocyte count is normally 600 to 1000 cells per cubic millimeter of
blood. The Centers for Disease Control defines AIDS as someone who has a positive HIV blood
test, one or more opportunistic infections (such as candidiasis and Kaposi's sarcoma) and a CD4+
lymphocyte count of less than 200. The ELISA Test is used to detect HIV infection; the Western
Blot test is used to confirm a positive ELISA test. A viral load test measures the amount of virus
in the blood; individuals with higher viral loads are at greatest risk for progressing from HIV
infection to AIDS.
Concepts tested

Question 3940
The nurse in an outpatient surgery center is caring for a client after cataract surgery. Which
statement by the client indicates an understanding of the discharge instructions?
A "I will not take tub baths until my incisions are fully healed."
B "I will not drive until I have permission from my doctor."
C "I will follow a soft diet at home for the next five days."
D "I will refrain from wearing my sunglasses for one week."

Question Explanation
Correct Answer is B

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Rationale: After cataract surgery to the eyes, the client will experience changes in their vision.
The teaching priority after cataract surgery pertains to safety due to impaired vision. The client
should be advised to refrain from driving, operating machinery and participating in certain sports
until given specific permission from the ophthalmologist. Clients should wear sunglasses to
protect their eyes when outdoors and in brightly-lit rooms. Eating a modified diet or refraining
from tub baths isn't necessary following this type of surgery.
Concepts tested

Question 3941
The nurse is providing discharge information to a client with glaucoma. Which instruction
should the nurse include?
A "Avoid overusing your eyes.”
B "Decrease your fluid intake to control the intraocular pressure."
C "Eye medications will need to be administered lifelong."
D <span style="font-weight: 400;">"Decrease the amount of salt in your diet."</span>
"Decrease the amount of salt in your diet."

Question Explanation
Correct Answer is C
Rationale: The administration of eye drops is a critical component of the treatment plan for the
client with glaucoma. The client needs to be instructed that medications will need to be taken for
the rest of their life. Limiting fluid and salt intake will decrease systemic fluid volume but is
usually not indicated for glaucoma. Overuse of eyes can be misinterpreted and difficult to adhere
to.
Concepts tested

Question 3942
A nurse is caring for a client diagnosed with Cushing's syndrome. While reviewing the client's
medical record, which risk factor most likely caused the client to have this syndrome?
A Long-term use of steriods
B Chronic kidney disease
C Tumor in the hypothalamus
D Decreased levels of cortisol

Question Explanation
Correct Answer is A
Rationale: Cushing's syndrome is different from Cushing's disease and most commonly
develops as a side effect of long-term use of corticosteroids. This syndrome refers to the clinical
manifestations caused by excessive levels of cortisol, including hyperglycemia and fluid
retention, which can subsequently cause edema, hypertension, weight gain, glucose intolerance
and protein wasting. Chronic kidney disease is not a risk factor for Cushing's syndrome.
Concepts tested

Question 3943
A school nurse is talking with a teen who comes into the health office complaining about not
feeling well. The nurse notices that the teen is breathing rapidly, has fruity-smelling breath and is
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clenching their abdomen. The teen's medical records indicate that they have diabetes mellitus
type 1. What is the most likely cause of the teen's symptoms?
A Diabetic ketoacidosis
B Acute kidney failure
C Acute pancreatitis
D Respiratory failure

Question Explanation
Correct Answer is A
Rationale: Diabetic ketoacidosis (DKA) is a serious complication related to the deficiency of
insulin in individuals with type 1 diabetes mellitus. The most common cause for DKA is poor
adherence to insulin treatment or not taking insulin altogether. Manifestations include
hyperglycemia, abdominal pain, nausea, vomiting, fruity-smelling breath (due to the build-up of
ketones), frequent urination and deep, rapid respirations (Kussmaul's) due to the metabolic
acidosis. Respiratory failure, kidney failure and pancreatitis would not cause DKA or the
symptoms the teen is exhibiting.
Concepts tested

Question 3944
A nurse working in a nursing home is caring for an 80-year-old client with diabetes mellitus type
2. The nurse notes that the client is exhibiting new confusion, polyuria, an elevated temperature
and hypotension. What is the most likely cause of the client's symptoms?
A Insulin shock
B Hyperosmolar hyperglycemic state
C Acute kidney failure
D Stroke

Question Explanation
Correct Answer is B
Rationale: The client is exhibiting signs of hyperglycemic-hyperosmolar state (HHS). HHS is a
hyperosmolar (increased blood osmolarity) state caused by hyperglycemia. HHS occurs most
often in older clients with type 2 diabetes mellitus (DM). HHS results from a sustained osmotic
diuresis. As serum concentrations of glucose exceed the renal threshold, the kidney's capacity to
reabsorb glucose is exceeded, resulting in polyuria. The osmotic diuresis/polyuria will lead to
decreased blood volume, dehydration, hypotension, shock and death if not caught early and
treated aggressively. The other answers are incorrect.
Concepts tested

Question 3945
The nurse is teaching a client with diabetes mellitus about diabetes management during an acute
illness. Which statement by the client demonstrates an understanding of the nurse’s teaching?
A "I will double my insulin dose while I'm sick."
B "I should not be alarmed if I need less insulin because that is expected when I am sick."
C "It is important I check my blood glucose more frequently when I'm sick."
D "It is normal for my blood sugar to be lower than normal while I'm sick."

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Question Explanation
Correct Answer is C
Rationale: An acute, short-term illness tends to raise blood sugar levels. This means that clients
usually need more, not less, insulin. The client should not "double" their insulin dose without
first checking their blood sugar level and discussion with their health care provider (HCP).
During an acute illness, clients should check their blood sugar more frequently to monitor for
greater fluctuations in normal levels and adjust medication doses as instructed by their HCP.
Concepts tested

Question 3946
The nurse is caring for a client who has been diagnosed with syndrome of inappropriate
antidiuretic hormone (SIADH). Which interventions are appropriate for this client? Select all
that apply.
A Administration of a loop diuretic
B Implementation of a fluid restriction
C Administration of vasopressin
D Implementation of a low-sodium diet
E Monitoring of intake and output

Question Explanation
Correct Answer is A, B, E
Rationale: Syndrome of inappropriate antidiuretic hormone (SIADH) is the result of excess
antidiuretic hormone secretion, leading to fluid retention, fluid volume overload and dilutional
hyponatremia. Appropriate interventions include closely monitoring intake and output and
restricting fluids. Furthermore, administering a diuretic will promote diuresis and help get rid of
excess fluid. Vasopressin is an analog of antidiuretic hormone (ADH) and would worsen the
client's condition. Vasopressin is used with diabetes insipidus, not SIADH. The client should be
eating foods high in sodium, not low, to help with the hyponatremia.
Concepts tested

Question 3947
The nurse is reviewing the medical record of a client with acute pancreatitis. The nurse should
recognize which information as the most likely risk factor for the client's illness?
A Diabetes
B Intravenous heroin use
C Obesity
D Gallstones

Question Explanation
Correct Answer is D
Rationale: Although a number of factors can cause acute pancreatitis, the most common cause in
the U.S. is gallbladder disease and gallstones. The second most common cause is chronic alcohol
intake. Obesity is a risk factor for developing gallbladder disease. Elevated blood glucose levels

Page | 1255
can occur with pancreatitis due to impaired insulin metabolism. Intravenous IV drug use is not
typically associated with acute pancreatitis.
Concepts tested

Question 3948
The nurse at the outpatient surgery center is speaking with a client who is scheduled for a
colonoscopy the next morning. Which information about the procedure should the nurse make
sure to include? Select all that apply.
A "Make sure to drink the entire bowel preparation liquid."
B "You should only consume clear liquids for the next 12 to 24 hours."
C "You will have an intravenous catheter inserted prior to the procedure."
D "Remember to stop eating any food six hours before you come to the center."
E "You will be required to lay still for 6 to 8 hours after the procedure."

Question Explanation
Correct Answer is A, B, C, D
Rationale: A colonoscopy is used to visualize the large bowel. It is used to detect sources of
bleeding, colon cancer, polyps or other abnormalities. To help cleanse the bowel, the client
should be on a clear liquid diet for 12 to 24 hours prior to the procedure. In addition, the client
will be required to drink an oral liquid preparation (e.g., sodium phosphate, Phospho-Soda or
GoLYTELY). Watery diarrhea usually begins in about an hour after starting the bowel
preparation process. Intravenous access is necessary for the administration of moderate sedation
during the procedure. The client should be NPO 4 to 6 hours before the procedure. The client
will not be required to lay still for 6 to 8 hours after the colonoscopy.
Concepts tested

Question 3949
The nurse is observing an unlicensed assistive person (UAP) on the nursing unit. For which
action by the UAP should the nurse intervene immediately?
A The UAP uses hand sanitizer upon exiting the room of a client with Clostridium difficile.
B The UAP applies a surgical mask before entering the room of a client on droplet precautions.
C The UAP dons gloves before emptying the urinary drainage bag of a client.
D The UAP washes their hands after emptying the colostomy pouch of a client.

Question Explanation
Correct Answer is A
Rationale: Clostridium difficile (C. diff) is a gastrointestinal infection that is easily spread in
health care settings. It is important for the client with C. diff to be placed on contact precautions,
which include wearing a gown and gloves when entering the room. Although using an alcohol-
based hand sanitizer is acceptable for many situations, hand sanitizer does not kill the C.
diff pathogen. Therefore, the UAP must wash their hands with soap and water after being in
contact with the client. The other actions are appropriate and do not require immediate
interventions by the nurse.
Concepts tested

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Question 3950
The nurse is assigned to care for a client with end-stage liver failure and portal hypertension.
Which clinical manifestations would the nurse expect to see with these conditions? Select all
that apply.
A Shortness of breath
B Diminished pedal pulses
C Increased abdominal girth
D Elevated serum albumin level
E Increased weight gain

Question Explanation
Correct Answer is A, C, E
Rationale: The clinical manifestations, common with end-stage liver disease, include yellowing
of the skin (jaundice), ascites, dependent edema, bleeding and loss of appetite. The client will
have an increased abdominal girth due to the ascites and weight gain related to fluid retention.
With ascites, the client may experience shortness of breath. Having diminished pedal pulses is
not a common with liver failure. Clients with liver failure will have decreased, not elevated,
serum albumin levels.
Concepts tested

Question 3951
The nurse in the primary care office is following up with a client who has been experiencing
frequent constipation. Which statement by the client about using psyllium (Metamucil) indicates
that additional teaching is needed?
A "I will take it together with my other medications."
B "I will take it in the morning with lots of water."
C "I may notice some bloating while I am taking it."
D "I will only take it until my constipation is relieved."

Question Explanation
Correct Answer is A
Rationale: When using psyllium to manage constipation, it needs to be taken with at least 240
mL of water. The client may experience abdominal discomfort or bloating while taking psyllium.
When using psyllium to treat constipation, it should not be used long-term and be discontinued
when the constipation has resolved. Bulk laxatives can interfere with the absorption of some
medications, so it should be taken two hours before or two hours after other medications. The
client's statement about taking the psyllium with other medications requires additional teaching.
Concepts tested

Question 3952
A client is being admitted to the hospital who reports experiencing bloody stools for several
days. Which interventions should the nurse expect to be prescribed for this client? Select all that
apply.
A Surgical consult for a bowel resection
B Collection of a stool sample for occult blood testing

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C Administration of enoxaparin
D Discontinuation of all NSAID medications
E Administration of pantoprazole

Question Explanation
Correct Answer is B, D, E
Rationale: Peptic ulcer disease (PUD) can affect the gastric, duodenal or esophageal areas of the
gastrointestinal (GI) tract. Peptic ulcers cause erosions in the lining of the GI tract and can
causing bleeding. PUD may be caused by increase gastric acid, intake of NSAID medications or
other irritating agents. The nurse should anticipate the client being started on a proton-pump
inhibitor, such as pantoprazole, to decrease the gastric acid levels. All NSAID medications
should be discontinued to prevent further disruption of the GI mucosa. To validate the client's
claim of bloody stools, the nurse would expect to obtain a stool sample. The nurse should not
expect to administer enoxaparin, an anticoagulane often prescribed for venous thromboembolism
(VTE) prophylaxis, since that would aggrevate the bleeding in the GI tract. A surgical consult
would be premature at this time.
Concepts tested

Question 3953
A male client who is diagnosed with gonococcal urethritis tells the nurse he had recent sexual
contact with a woman who did not appear to have any disease. What is the best response by the
nurse?
A "Women might not have the disease but can be a carrier and infect others."
B "Women might not realize that they have gonorrhea because they are often asymptomatic."
C "Gonorrhea in women only affects the ovaries and not the genital organs."
D "Men are at a much greater risk than women for acquiring gonorrhea."

Question Explanation
Correct Answer is B
Rationale: Men and women who are sexually active are equally at risk for contracting
gonorrhea. Many women with gonorrhea are asymptomatic or have minor symptoms that are
easily overlooked. The disease may affect both the genitals and the other reproductive organs
and cause complications such as pelvic inflammatory disease. Only persons with an active
infection of gonorrhea can transmit the disease. A person does not become a carrier of
gonorrhea.
Concepts tested

Question 3954
The nurse is teaching a client about genital herpes. Which statement by the client indicates that
the teaching was effective?
A “My infection must be reported to the health department.”
B “My infection will be cured after I take all antibiotics.”
C “I can only get the disease from someone with visible lesions.”
D “I need to inform my sexual partner of my infection.”

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Question Explanation
Correct Answer is D
Rationale: It is critical for the nurse to make sure the client understands that informing their
partners of the disease is important to help stop the spread of the infection. Genital herpes is
transmittable even when lesions are not visible. Genital herpes is an incurable, life-long
infection. Although not a cure, antiviral medications are often used to shorten healing time of
lesions and reduce the frequency of outbreaks. Herpes simplex virus (HSV) is typically not
required to be reported. However, gonorrhea and syphilis are required to be reported to public
health authorities throughout the U.S. In some states, chlamydia infections must also be reported.
Concepts tested

Question 3955
To evaluate the effectiveness of antiretroviral therapy for a client infected with human
immunodeficiency virus (HIV), which laboratory test result will the nurse plan to review?
A Nucleic acid amplification test
B Rapid HIV antibody test
C Viral load test
D Western blot test

Question Explanation
Correct Answer is C
Rationale: Viral load refers to the amount of HIV circulating in the blood. The effectiveness of
antiretroviral therapy (ART) is measured by the decrease in the amount of HIV virus, i.e., viral
load, detectable in the blood. The goal is for the viral load to be so low that it is deemed
undetectable. An undetectable viral load does not mean that the client is cured or can no longer
transmit the disease. The other tests are used to detect HIV antibodies, which remain positive
even with effective ART. A nucleic acid amplification test (NAAT) is commonly used to
diagnose a gonorrhea infection.
Concepts tested

Question 3956
The nurse is reviewing the plan of care for a client with acute adrenocortical insufficiency.
Which intervention should be a priority for this client?
A Administration of insulin
B Administration of potassium supplements
C Implementation of a low-sodium diet
D Electrocardiogram monitoring

Question Explanation
Correct Answer is D
Rationale: Adrenocortical insufficiency is caused by an insufficiency of both cortisol and
aldosterone. Reduced aldosterone secretion causes a reduction in potassium excretion and an
increase in sodium and fluid excretion, ultimately resulting in hyperkalemia and subsequent
hyponatremia. Hyperkalemia can result in cardiac arrhythmias which can be fatal. Therefore, the
priority intervention is to complete electrocardiogram monitoring to assess for the presence of
dangerous arrhythmias. Additionally, the other interventions are clearly inappropriate.
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Implementation of sodium restriction is inappropriate, as patients may be experiencing
hyponatremia. Additionally, administration of potassium supplements is also inappropriate, as
patients with adrenocortical insufficiency are likely to experience hyperkalemia. Some patients
with adrenocortical insufficiency present with hypoglycemia, so the administration of insulin
may worsen their condition.
Concepts tested

Question 3957
The nurse understands that the prescribed levothyroxine is effective when the client with
hypothyroidism makes which statement?
A "I still feel lethargic and fatigued."
B "I was reprimanded at work after becoming angry with my boss."
C "I have been having daily, formed bowel movements."
D "I have to change my sheets in the morning because I sweat a lot at night."

Question Explanation
Correct Answer is C
Rationale: Levothyroxine sodium is utilized to treat hypothyroidism. The nurse must first
understand signs and symptoms of hypothyroidism, such as fatigue, lethargy, constipation,
hypotension, anorexia and weight gain. In doing so, the nurse can identify that reports of having
regular bowel movements is indicative of the levothyroxine working as intended, as constipation
is a common symptom of hypothyroidism.

Additionally, the nurse must also recognize symptoms of hyperthyroidism, as some clients on
levothyroxine sodium may be receiving too high a dose, resulting in excess thyroid hormone and
symptoms of hyperthyroidism, such as diaphoresis, irritability, heart palpitations, weight loss and
diarrhea. The nurse should recognize that a client who sweats through the night or who is
irritable and angry at work may be displaying symptoms of hyperthyroidism.
Concepts tested

Question 3958
A nurse is assessing a client with a deep vein thrombosis. Which finding should the nurse
anticipate?
A Swelling of one lower extremity
B Rapid respirations
C Chest pain
D Bilateral ankle edema

Question Explanation
Correct Answer is A
Rationale: The most common signs of deep vein thrombosis are pain in the region of the
thrombus and unilateral swelling of the extremity distal to the site. Bilateral pedal edema is
usually associated with fluid overload in right heart failure or venous insufficiency. Chest pain
and tachypnea that occurs suddenly in the client with DVT are signs of possible pulmonary
embolism, a serious complication of DVT.
Concepts tested
Page | 1260
Question 3959
The nurse is working on a medical-surgical floor and is making initial safety rounds on the
clients. Which statement made by a client would require immediate action by the nurse?
A "When I take in a deep breath, it stabs like a knife."
B "The pain came on after dinner. That soup seemed very spicy."
C "I feel pressure in the middle of my chest like an elephant is sitting on my chest."
D "When I turn in bed to reach the remote for the TV, my chest hurts."

Question Explanation
Correct Answer is C
Rationale: This is a classic description of chest pain in men caused by myocardial ischemia,
requiring immediate assessment and intervention to prevent possible damage to the heart muscle.
Pain after spicy food is often the result of irritation and gastric indigestion. The pain with a deep
breath is typically from an inflammation of the pleural covering of the lung, called pleurisy. Pain
with movement of the chest, such as turning in bed, is typically caused by costochondritis, which
is inflammation of the cartilage between the ribs and the sternum, and can be reproduced by
palpation of the painful area.
Concepts tested

Question 3960
The home health nurse is visiting a 3-year-old client when the child begins to have a generalized
seizure. Which intervention should the nurse implement first?
A Place the child on their side
B Restrain the child
C Place an oral airway in the mouth
D Give the prescribed anticonvulsant

Question Explanation
Correct Answer is A
Rationale: Protecting the airway is the priority during a seizure, and the first action should be to
roll the client on their side to open the airway and prevent aspiration in case of vomiting.
Nothing should be placed in the mouth when the client is having a seizure and the client should
not be restrained. Administration of the prescribed anticonvulsant would be appropriate after the
seizure has ended.
Concepts tested

Question 3961
The nurse in the preoperative clinic is caring for a client with breast cancer and providing
preoperative teaching a week before surgery. The client expresses an interest in complementary
and integrative health therapies. Which of the following statements is the most appropriate
response by the nurse?
A "I will set up a time before the surgery is scheduled for you to talk to your health care
providers about complementary and integrative health therapies."

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B "You may want to do some Internet research on the different nutritional therapies that are
recommended for your type of cancer."
C "You may use any complementary or alternative therapies that you wish to after you recover
from surgery."
D "Complementary and integrative health therapies are not recommended and you should focus
on the upcoming surgery."

Question Explanation
Correct Answer is A
Rationale: The intent of complementary and integrative therapies is to help the body to heal
itself. It is important for the nurse to be nonjudgmental and provide the client the opportunity to
explore appropriate complementary therapies. The nurse should not recommend a specific
therapy. While the client may want to explore nutritional options, this response avoids the
question the client asked.
Concepts tested

Question 3962
A nurse is performing chest compressions on an adult client in cardiac arrest. Another nurse
enters the room in response to the call for help. What should happen next?
A The second nurse will maintain an open airway and perform ventilations while the first nurse
continues chest compressions.
B The second nurse will leave to get personal protective devices (PPD) and oxygen.
C The first nurse will now perform 15 chest compressions and then wait while the second nurse
performs 2 ventilations.
D The second nurse will take 10 seconds to check the pulse and "look, listen and feel" for
breathing.

Question Explanation
Correct Answer is A
Rationale: In two-rescuer CPR, the first rescuer performs chest compressions and the second
rescuer performs (bag-mask) ventilation. Rescuers should switch roles after five cycles (about
every two minutes). The compressing rescuer should give (30) continuous chest compressions at
a rate of at least 100 per minute without pauses for ventilation; the rescuer will provide a breath
every six to eight seconds. Rescuers should all have quick access to personal protective devices
(PPD) prior to any intervention.
Concepts tested

Question 3963
A postpartum client admits to frequent alcohol use throughout the pregnancy. Which newborn
assessment finding does the nurse associate with fetal alcohol syndrome (FAS)?
A High birth weight.
B Craniofacial abnormalities.
C Organ dysfunction.
D Poor muscle tone.

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Question Explanation
Correct Answer is B
Rationale: Characteristic facial abnormalities are seen in the newborn with FAS, including small
head circumference, smaller eye openings, flattened cheekbones and indistinct philtrum.
Newborns often have a low birth weight (not high birth weight). Other irreversible effects of
alcohol exposure during pregnancy include mental retardation and delayed development; heart
defects and vision difficulties or hearing problems; learning disorders; and behavior problems.
The newborn with FAS may be irritable. The newborn with FAS will have a low birth weight
and have a below average height (length). The organs are not affected in FAS.
Concepts tested

Question 3964
The labor and delivery nurse is providing care to a client in active labor who just received
epidural anesthesia. Which intervention should the nurse implement following this procedure?
A Monitor the fetal heart rate for possible tachycardia
B Monitor maternal pulse for possible bradycardia
C Monitor maternal blood pressure for possible hypotension
D Reduce the intravenous fluid infusion to a keep vein open rate

Question Explanation
Correct Answer is C
Rationale: Epidural anesthesia can cause transient hypotension. Therefore, the nurse should
frequently monitor the maternal blood pressure for signs of hypotension. After an epidural in the
laboring client, IV fluids would be increased, not decreased, to prevent hypotension. The nurse
would observe for signs of fetal bradycardia (not tachycardia) following an epidural and monitor
for signs of maternal tachycardia, not bradycardia, secondary to a decrease in maternal blood
pressure.
Concepts tested

Question 3965
The nurse is caring for a 75-year-old client with peripheral artery disease of the lower
extremities. Which intervention should be included in the plan of care to reduce leg pain?
A Apply cold compresses.
B Follow activity restrictions.
C Elevate the legs above the heart.
D Support smoking cessation efforts.

Question Explanation
Correct Answer is D
Rationale: Peripheral artery disease (PAD) is caused by atherosclerosis to the lower extremities.
The client with PAD has intermittent claudication resulting in pain, heaviness, or numbness in
the extremity when walking. The primary management is through lifestyle changes, such as
quitting smoking. The nurse should support any smoking cessation efforts. Another lifestyle
change to improve pain in PAD is regular exercise, so a restriction is not necessary. Cold
compresses or limb elevation have not proven to improve pain in this situation.
Concepts tested
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Question 3966
The school nurse is performing an assessment on a 15-year-old client who sustained a mild
traumatic brain injury without loss of consciousness during a football game, one week earlier.
The nurse suspects post-concussion syndrome. Which findings would support this
diagnosis? Select all that apply.
A Delayed pupillary response
B Short-term memory loss
C Nausea and vomiting
D Insomnia
E Learning difficulties
F Positive Romberg sign

Question Explanation
Correct Answer is B, D, E
Rationale: The client with a traumatic brain injury (TBI) may have a variety of signs and
symptoms depending on the severity of injury and the resulting increase in intracranial pressure
(ICP). A mild TBI is characterized by a blow to the head with transient confusion or feeling
dazed or disoriented and loss of memory of events immediately before or after the accident.
Symptoms of a mild brain injury, often called a concussion, can include disturbances in sleep;
affect, enjoyment of daily activities, work performance, mood, memory, and ability to learn new
material; and can cause changes in personality. Nausea & vomiting, a slowed pupillary response
and positive Romberg sign are not typically seen with a mild TBI, i.e., concussion; they tend to
be seen with cerebellar involvement or a more severe TBI that involves an increased ICP.
Concepts tested

Question 3967
A nurse is performing an assessment on a client with pneumococcal pneumonia. Which finding
should the nurse anticipate?
A Bronchial breath sounds in the outer lung fields.
B Hacking, nonproductive cough.
C Decreased tactile fremitus.
D Hyper-resonance of areas of consolidation.

Question Explanation
Correct Answer is A
Rationale: Pneumococcal pneumonia is a bacterial infection in the lungs. This can lead to
consolidated lung tissue containing the exudate from the infection. This consolidation transmits
the bronchial breath sounds to the outer lung sounds. The client will have a productive cough,
increased tactile fremitus and the nurse will percuss a dull sound over areas of consolidation.
Concepts tested

Question 3968
The home health nurse is reviewing the medical record of a client with closed-angle glaucoma in
both eyes. Which statement by the client would support this diagnosis?

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A "I have constant blurred vision."
B "I have specks floating in my eyes."
C "I have to turn my head to see around the room."
D "I can't see out of my left eye."

Question Explanation
Correct Answer is C
Rationale: As intraocular pressure rises in glaucoma, there is a slow, progressive loss of the
peripheral visual field in the affected eye(s). If untreated or uncontrolled, it eventually can lead
to blindness. The client's statement that they have to turn their head to be able to see indicates a
loss of peripheral vision. Tiny, painless particles floating inside the eye are called floaters that
can be harmless or signal retinal detachment. Blurred vision can have many causes, including
refractive errors, chronic dry eyes, cataracts and macular degeneration. Complete, unilateral loss
of vision is typically seen with a stroke or other intracerebral process.
Concepts tested

Question 3969
A client has been on antibiotics for 72 hours to treat cystitis. Which findings reported by the
client require priority attention by the nurse?
A Nausea and anorexia
B Elevated temperature
C Smelly urine
D Burning on urination

Question Explanation
Correct Answer is B
Rationale: Elevated temperature after 72 hours on an antibiotic indicates that the antibiotic has
not been effective in eradicating the offending organism. The health care provider should be
informed immediately so that an appropriate medication can be prescribed and complications,
such as pyelonephritis, are prevented. The smelly urine and burning are expected with cystitis
and during initial treatment. Gastrointestinal findings may be related to the antibiotics as a side
effect and should also be reported. However, they are a lower priority and may resolve if the
antibiotic is changed.
Concepts tested

Question 3970
A client is diagnosed with mitral regurgitation. The nurse would expect to encounter which
finding?
A Crushing chest pain
B Platelet count
C Low red blood cell count
D Exertional dyspnea

Question Explanation
Correct Answer is D

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Rationale: Mitral regurgitation is the backflow of blood from the left ventricle into the left
atrium. The clinical manifestations include exertional dyspnea, fatigue, orthopnea and pulmonary
edema. The client with mitral regurgitation may experience palpitations but not crushing chest
pain. The red blood cells and the platelet count are not impacted by mitral regurgitation
Concepts tested

Question 3971
The nurse is assessing an infant with developmental dysplasia of the hip. Which finding should a
nurse anticipate?
A Unequal leg length
B Diminished femoral pulses
C Symmetrical gluteal folds
D Unlimited hip abduction

Question Explanation
Correct Answer is A
Rationale: Shortening of the affected leg is a sign of developmental dysplasia of the hip. Other
signs of hip dysplasia in an older infant include limited hip abduction and asymmetric gluteal
skin folds. An ultrasound examination is typically used to confirm developmental dysplasia of
the hip in the young infant; x-rays are used when the infant is older than 3 months.
Concepts tested

Question 3972
The nurse is caring for a client with acute pancreatitis. After pain management, which
intervention should be included in the plan of care?
A Institute seizure precautions.
B Encourage the client to cough and deep breathe every two hours.
C Provide a diet high in protein.
D Place the client in contact isolation.

Question Explanation
Correct Answer is B
Rationale: Pancreatitis is inflammation of the pancreas in which the digestive enzymes digest the
pancreas. One of the complications of pancreatitis is respiratory infections due to the fluid in the
retro-peritoneum pushing up against the diaphragm, causing shallow respirations. Coughing and
deep breathing every two hours will reduce the chances of respiratory infection. The client will
be NPO so a diet high in protein is inappropriate. There is no need for contact isolation or seizure
precautions for pancreatitis.
Concepts tested

Question 3973
The nurse is performing a neurological assessment on a client who suffered a right hemispheric
stroke. Which finding requires immediate attention?
A Emotional lability
B Loss of bladder control

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C Decrease in level of consciousness
D Visual spatial deficits

Question Explanation
Correct Answer is C
Rationale: A stroke is caused by an interruption of tissue perfusion or blood flow to any part of
the brain. Any interruption that lasts for more than a few minutes will cause cerebral tissue to die
(infarction). Brain metabolism and blood flow after a stroke can be affected around the infarction
and in the contralateral (opposite side) hemisphere. Regardless of the location of the stroke, the
nurse should follow the airway-breathing-circulation (ABC) approach to prioritize. A client with
a decrease in level of consciousness (LOC) may be unable to maintain an open airway; therefore,
this assessment finding could be life-threatening and requires immediate attention.
Concepts tested

Question 3974
The nurse in a long-term care facility is reviewing the plan of care for a female client diagnosed
with a urinary tract infection. To reduce the risk of recurrence, which interventions should the
nurse include in the plan of care? Select all that apply.
A Have the client void every 2 to 3 hours.
B Bathe the client rather than have her shower.
C Provide the client with at least 1 liter of water a day.
D Discourage the client from drinking coffee or black tea.
E Assist the client with wiping the perineum front to back.

Question Explanation
Correct Answer is A, D, E
Rationale: Appropriate interventions include having the client void every 2 to 3 hours during the
day to prevent retention and ensure frequent emptying of the bladder. Drinking caffeinate
beverages can cause irritation to the bladder, increasing the risk for an infection. To help reduce
pathogens from entering the urethral opening, the nurse should assist the client in wiping the
perineum from front to back. The client should take a shower, rather than bathe, as the bacteria in
the tub water may enter the urethra. The client should drink at least 2 to 3 liters of water a day, if
not contraindicated, to help flush out bacteria in the urinary tract.
Concepts tested

Question 3975
A client with benign prostatic hypertrophy has been prescribed tamsulosin. Which statement by
the nurse correctly describes how this medication works?
A "This drug will eliminate your nocturia."
B "Your libido will increase with this medication."
C "This medication will shrink your enlarged prostate gland."
D "This medication will improve the flow of urine."

Question Explanation
Correct Answer is D

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Rationale: Tamsulosin is an alpha-adrenergic blocker that is prescribed to promote bladder and
prostate gland relaxation for clients with benign prostatic hypertropy or hyperplasia (BPH).
Common clinical manifestations of BPH include urine obstruction, urinary retention, decrease
urine flow, hesitancy and nocturia. Tamsulosin will relax the smooth muscle of the bladder neck
and prostate, allowing urine to flow more easily and decreasing bladder neck contractions that
can cause hesitancy. Tamsulosin does not shrink the prostate, nor does it increase libido or
sexual desire. Finasteride, an androgen inhibitor also commonly prescribed for BPH, reduces the
prostate size, thus helping to alleviate the urinary symptoms of BPH. Although tamsulosin may
reduce episodes of having to void during the night (nocturia), it might not eliminate them.
Concepts tested

Question 3976
A 68-year-old, postmenopausal female client has been prescribed tamoxifen for breast cancer
with bone metastases. The nurse should teach the client about which potential adverse drug
effect?
A Insomnia
B Symptoms of hypocalcemia
C Stroke-like symptoms
D Seizures

Question Explanation
Correct Answer is C
Rationale: Tamoxifen is an antineoplastic drug, commonly prescribed for clients with breast
cancer or for clients who are at high risk for developing breast cancer. The most common
adverse drug effects (ADEs) are hot flashes, fluid retention, vaginal discharge, nausea, vomiting
and menstrual irregularities. In women with bone metastases, tamoxifen may cause
transient hypercalcemia. Because of its estrogen agonist actions, tamoxifen poses a small risk of
thromboembolic events, including deep vein thrombosis, pulmonary embolism and stroke.
Insomnia and seizures are not known ADEs of tamoxifen.
Concepts tested

Question 3977
The nurse is teaching a client with liver cirrhosis about the management of hepatic
encephalopathy. Which statement by the client indicates that additional teaching is needed?
A "I will eat enough protein and calories to stay healthy."
B "I will stop taking ibuprofen for my knee and back pain."
C "I will stop taking my lactulose when I have more than one loose stool."
D "I will brush my teeth with a soft toothbrush to avoid bleeding gums."

Question Explanation
Correct Answer is C
Rationale: Hepatic encephalopathy is a life-threatening complication of liver failure. The
functions of the liver include generating proteins for clotting, preventing bleeding, metabolizing
waste products such as ammonia and producing albumin to maintain oncotic pressure. Lactulose
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is a common medication prescribed to a client with hepatic encephalopathy. Lactulose will bind
to ammonia and is excreted from the body by stool. Without this medication, the ammonia level
will build because the damaged liver is unable to metabolize it, increasing the severity of the
disease. While taking lactulose the client may have loose bowel movements, but this should not
stop them from taking the medication. The client needs to ensure they are eating enough protein
to meet their body's energy demands. With a higher risk of bleeding, clients should use a soft
toothbrush and avoid any type of NSAID medications.
Concepts tested

Question 3978
Which discharge instruction should the nurse make sure to include for a client with chronic
pancreatitis?
A "Make sure to eat a low-fat, high-fiber diet."
B "Take the prescribed pancreatic enzymes on an empty stomach."
C "Limit alcohol intake to one drink a day."
D "Try to reduce smoking cigarettes to half a pack per day."

Question Explanation
Correct Answer is A
Rationale: Chronic pancreatitis is a progressive, destructive disease of the pancreas that has
remissions and exacerbations (i.e., flare-ups). Inflammation and fibrosis of the tissue contribute
to pancreatic insufficiency and diminished function of the organ. Acute episodes can be lessened
by dietary management and lifestyle changes. These include eating bland, low-fat, frequent
meals and avoiding rich, fatty foods. Alcohol consumption should be avoided completely as
alcohol can precipitate an acute episode. The client should avoid nicotine. The pancreatic
enzymes should be taken with food to replace enzymes lacking due to the pancreatitis and aid in
digestion.
Concepts tested

Question 3979
The nurse is speaking at a senior citizen community center on how to prevent constipation. What
information should the nurse include? Select all that apply.
A Take a daily laxative.
B Eat foods high in fiber, such as fresh fruit and whole grains.
C Increase your intake of dairy products.
D Exercise regularly such as walking for 30 minutes 3 to 5 times a week.
E Drink 2 to 3 liters of fluids per day.
F Take iron supplements regularly.

Question Explanation
Correct Answer is B, D, E
Rationale: Constipation is hardened, formed stool in the bowel and can cause the client to be
uncomfortable and have difficulty passing stool. To prevent constipation, it is important to
consume at least 2 liters of fluid a day, eat a diet high in fiber and whole grains, and be active,
which will help with peristalsis. Taking a daily laxative will cause the body to rely on the

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laxative and will actually increase the likelihood of constipation. Taking iron supplements or
increasing the intake of dairy products will not help prevent constipation.
Concepts tested

Question 3980
The nurse is reviewing the medical record of a client with diabetes who was admitted for a
surgical site infection. Which findings should the nurse report to the health care provider? Select
all that apply.
Complete metabolic panel:
 Glucose, serum: 220 mg/dL
 BUN: 16 mg/dL
 Creatinine: 1.06 mg/dL
 Potassium, serum 4.4g/dL
 AST (SGOT) 31 IU/L
 ALT (SGPT) 30 IU/L
 Hemoglobin A1C 8%
A Hemoglobin A1C of 8%
B ALT 30 IU/L
C Urine pH 7.3
D Serum glucose level of 220 mg/dL
E Negative protein in the urine
F Positive glucose in the urine
G BUN of 16 mg/dL

Question Explanation
Correct Answer is A, D, F
Rationale: In reviewing the lab values, the nurse should notify the HCP of the positive glucose
in urine (normally, glucose is not seen in urine), A1C of 8% (desired range for a client with
diabetes is 7% or less), and the serum glucose level of 220 mg/dL, which is higher than the
normal range of 70 to 110 mg/dL. These abnormal lab results indicate that the client's diabetes is
not managed well and most likely contributed to the client developing an infection. The BUN,
ALT and urine pH listed are considered within normal limits.
Concepts tested

Question 3981
The nurse is caring for a client who presents with polyuria, polydipsia and a urine specific
gravity of 1.002. The nurse suspects that the client is experiencing diabetes insipidus. Which risk
factors would support this diagnosis? Select all that apply.
A Current use of lithium
B History of radiation treatment
C Recent neurologic injury
D Recent neurologic injury
E History of pulmonary disease

Question Explanation

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Correct Answer is A, B, C, D
Rationale: Diabetes insipidus is a pathological condition caused by a deficient volume of
antidiuretic hormone or an inability of the kidneys to respond to antidiuretic hormone. This
results in the excretion of large volumes of dilute urine, accompanied by thirst to maintain
homeostasis in the light of dehydration. The nurse should be able to identify that polydipsia and
a low urine specific gravity may be indicative of diabetes insipidus, and should be able to assess
for the presence of risk factors. A history of recent surgery, radiation treatment or neurologic
injury may predispose an individual to poor antidiuretic hormone secretion if the posterior
pituitary gland, where antidiuretic hormone is excreted from, was injured. Lithium use can be
nephrotoxic and can result in the kidney's failure to respond to antidiuretic hormone. A client's
history of pulmonary disease is a risk factor for the development of syndrome of inappropriate
antidiuretic hormone (SIADH), a condition that results from excess antidiuretic hormone.
Concepts tested

Question 3982
The nurse is caring for a client who has hearing loss. Which actions should the nurse implement
to facilitate communication with this client? Select all that apply.
A Speak at a slower rate than usual.
B Speak to the client at eye level.
C Use short sentences.
D Know basic sign language techniques.
E Speak in a loud voice toward the client's ear.

Question Explanation
Correct Answer is B, C
Rationale: Important actions to improve communication between the nurse and a client with
hearing loss is for the nurse to be sure they speak to the client at eye level and use short
sentences. It is not necessary to speak at a slower rate or speak loudly. Not all clients with
hearing loss understand sign language and nurses are not required to learn it.
Concepts tested

Question 3983
The nurse is reviewing the plan of care for a 30-year-old client newly diagnosed with multiple
sclerosis. Which interventions should the nurse include for this client? Select all that apply.
A Instruct the client on how to self-catheterize as needed.
B Encourage participation in vocational rehabilitation.
C Encourage participation in physical and occupational therapy.
D Encourage independence in personal care and bathing.
E Review methods to prevent and treat constipation.

Question Explanation
Correct Answer is B, C, D, E
Rationale: Multiple sclerosis (MS) is a debilitating disorder affecting the myelin sheaths of the
nervous system. Symptoms will vary depending on the extent and area of damage. Clients with
MS are encouraged to maintain as high a level as possible of independence. They are encouraged

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to participate in physical and occupational therapy (PT/OT), as well as exercise therapies. They
should be taught about methods to prevent and treat constipation. They should be taught how to
manage cases of bladder incontinence, but it is not necessary to self-catheterize. The client
should be encouraged to maintain independence in personal care. Depending on the level and
severity of the disease, the client may need to participate in vocational rehabilitation (VR). VR is
a federal-state program that helps people who have physical disabilities maintain or return to
employment.
Concepts tested

Question 3984
The nurse is providing discharge teaching for a client after cataract surgery of the left eye. Which
statements by the client indicate an understanding of the teaching? Select all that apply.
A "I will call the surgeon if my eye is bloodshot."
B "I will not rub, press on or scratch my eye."
C "I will follow the instructions for the eye drops."
D "I will call the surgeon if the pain is intense."
E "I will drive very carefully today."

Question Explanation
Correct Answer is B, C, D
Rationale: Cataract surgery is generally done in an outpatient environment, with the client being
discharged within a few hours of the procedure. There is generally little to no pain, and what
pain the client has can be relieved with mild analgesics. The client should not press on, scratch or
rub the eye. They will likely be prescribed eye drops with varying instructions and should follow
these directions. Intense pain may indicate an increase in intraocular pressure or hemorrhage and
the surgeon should be notified immediately. Eyes that are bloodshot or bruised is an expected
occurrence and should be resolved within a week. The client should not drive until instructed by
the surgeon, generally for 48 hours.
Concepts tested

Question 3985
The nurse in the 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?
A "You should avoid becoming pregnant while taking this medication."
B "Call the office immediately if you feel like hurting or killing yourself."
C "You should stay away from large crowds and sick children."
D "You might experience irregular menses and intermittent bleeding."

Question Explanation
Correct Answer is B
Rationale: Levetiracetam is an anti-convulsant medication used to prevent seizures. One of the
significant side effects is behavioral changes and suicidal ideations. It is important to notify the
provider office immediately if the client experiences these thoughts. The other instructions do
not apply to this particular medication.

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Concepts tested

Question 3986
A client is diagnosed with amyotrophic lateral sclerosis (ALS). Which nursing action will help
prevent the complications of atelectasis and pneumonia in this client?
A Active and passive range of motion exercises twice a day
B Repositioning every two hours around the clock
C Use of the incentive spirometer every two hours while awake
D Chest physiotherapy twice a day

Question Explanation
Correct Answer is D
Rationale: ALS is a progressive neurodegenerative disease. Early symptoms include increasing
muscle weakness, especially involving the arms and legs, speech, swallowing or breathing;
eventually there is total paralysis. As the chest muscles and diaphragm become weaker, it will be
more difficult to cough and clear secretions. This will predispose clients to develop recurrent
pulmonary infections. Chest physiotherapy and airway clearance devices will help prevent and/or
treat these secondary infections. Deep breathing and coughing exercises may not be realistic for
this client. Repositioning is targeted to circulation issues and is not specific for prevention of
complications associated with the lung.
Concepts tested

Question 3987
An infant has just returned from surgery for placement of a gastrostomy tube as an initial
treatment for a diagnosis of tracheoesophageal fistula (TEF). The mother asks, "When can the
tube be used for feeding?" Which is the most appropriate response by the nurse?
A "The stomach contents and air must be drained first."
B "The feeding tube can be used immediately."
C "Healing of the anastomosis must be complete before feeding."
D "Feedings can begin in five to seven days."

Question Explanation
Correct Answer is A
Rationale: Tracheoesophageal fistula (TEF) is an abnormal opening between the esophagus and
trachea. After insertion of a gastrostomy tube for TEF, feeding will not begin for about 24 hours,
and the tube will be connected to a drainage bag to empty the stomach contents and air. Giving
tube feeding through a gastronomy tube is independent of healing of the esophageal anastomosis.
Concepts tested

Question 3988
A 14-year-old with a history of sickle cell disease is admitted to the hospital with a diagnosis of
vaso-occlusive crisis. Which statement by the client would most likely indicate the cause of this
crisis?
A "I really enjoyed my fishing trip yesterday. I caught two fish."

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B "I used cold medicine last week and I have gotten worse."
C "I knew this would happen. I've been eating too much red meat lately."
D "I have really been working hard practicing with the debate team at school."

Question Explanation
Correct Answer is B
Rationale: Any condition that increases the body's need for oxygen or alters the transport of
oxygen, including infection, dehydration or even cold weather (due to vasospasm) may result in
a sickle cell crisis. Sickle cell crisis is also called vaso-occlusive crisis and pain is the most
distinguishing clinical feature. Clients should recognize the earliest signs of a vaso-occlusive
crisis and seek help, treat all febrile illness promptly and identify environmental hazards that
may precipitate a crisis.
Concepts tested

Question 3989
The nurse is caring for a client with asthma. During the initial assessment the nurse notes low-
pitched wheezes in the final half of exhalation. One hour later, the nurse notes the wheezes are
higher-pitched and last throughout exhalation. What should this change in assessment indicate to
the nurse?
A The client is hyperventilating.
B The client requires more oxygen.
C The client needs to be suctioned.
D The airway obstruction has increased.

Question Explanation
Correct Answer is D
Rationale: The higher pitched a sound is, the more narrow the airway. Therefore, the airway
obstruction has increased or worsened, necessitating urgent intervention to promote
bronchodilation or a change in interventions that are not be effective. Other signs of worsening
asthma and the development of respiratory distress would include restlessness, anxiety, increased
pulse and blood pressure and increased respiratory rate with the use of accessory muscles of
breathing. Although secretions may be thick and tenacious during an acute asthmatic attack,
there is no data to support the need for suctioning in this question. There is no data provided to
support adding oxygen or hyperventilating the client.
Concepts tested

Question 3990
An older adult client admitted with hypoglycemia has an order for a continuous IV infusion of
1000 mL of dextrose 5% in water (D5W) at 83 mL per hour. When the nurse assesses the client,
she discovers that the client mistakenly received 800 mL over the past two hours. What is
the priority nursing action at this time?
A Check the vital signs and compare to baseline readings.
B Place the client in a mid- to high-Fowler's position.
C Auscultate the lungs bilaterally at the bases.
D Obtain a blood glucose level.

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Question Explanation
Correct Answer is C
Rationale: The nurse should follow the A-B-C prioritization approach. Clients can quickly
develop hypervolemia following rapid infusion of isotonic IV fluids. Findings of fluid overload
include increased blood pressure, tachycardia, shortness of breath, crackles heard in the lungs
and distended neck veins. Therefore, the priority nursing action at this time is to auscultate the
lungs to assess for pulmonary congestion.
Concepts tested

Question 3991
The nurse is reviewing the chart of a client who was recently diagnosed with coronary artery
disease due to atherosclerosis. Which factors most likely contributed to the development of this
disease? Select all that apply.
A Follows the D.A.S.H. diet
B Low-density lipoprotein (LDL) level of 149 mg/dL
C Mother died of a myocardial infarction
D History of diabetes mellitus
E Used to smoke 40 packs per year until one year ago
F Drinks one glass of red wine 3 to 4 days per week

Question Explanation
Correct Answer is B, C, D, E
Rationale: Atherosclerosis arises when plaque (fat, cholesterol and other substances)
accumulates inside arterial walls. The plaque limits blood flow through arteries and can
eventually lead to tissue and organ ischemia. Atherosclerosis can develop in any artery in the
body. Smoking contributes to the development of atherosclerosis by damaging artery walls and
triggering vasoconstriction. A family history of heart disease (mother) is a risk factor for the
development of atherosclerosis. Diabetes and elevated low-density lipoprotein (LDL) cholesterol
levels are closely tied to the development of atherosclerosis. The target LDL level for a client is
less than 100 mg/dL. The client's current alcohol consumption is within current daily
recommendations of no more than 1 to 2 drinks per day. The D.A.S.H. diet is rich in fruits,
vegetables, whole grains and legumes, which can reduce the development and progression of
atherosclerosis.
Concepts tested

Question 3992
A client is admitted to the hospital with endocarditis. The nurse understands that which risk
factors can lead to the development of endocarditis? Select all that apply.
A Treatment of substance use disorder with methadone
B Placement of a central venous access device
C Atrial fibrillation with use of warfarin
D Oral abscess with tooth extraction
E Placement of an arteriovenous fistula for hemodialysis
F History of aortic valve replacement

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Question Explanation
Correct Answer is B, D, E, F
Rationale: Infective endocarditis (IE) is an infection of the inner layer of the heart wall and
muscle. The infection is commonly caused by bacteria such as Staphylococcus aureus. The
endocardium can become infected when bacteria are carried through the heart by blood flow. IE
can occur in individuals with existing cardiac disease or with no cardiac disease. Clients who
have poor oral hygiene and a history of dental procedures (i.e., tooth extraction) are at risk for
developing IE. Invasive devices (i.e., indwelling catheters, venous access devices, pacemakers
and arteriovenous fistulas) and heart valve replacement place clients at risks for IE. One
complication of endocarditis includes arrhythmias, but arrhythmias (i.e., atrial fibrillation) do not
place the client at risk for developing IE. Individuals who engage in intravenous drug use are at
risk for IE. However, individuals who take methadone by mouth for a substance use disorder are
not at risk for IE.
Concepts tested

Question 3993
A client is admitted to the telemetry unit with syncope due to sinus bradycardia. Which
intervention should the nurse include in the client's plan of care?
A Maintain the client on bedrest.
B Implement seizure precautions.
C Discuss the client's wishes for organ donation.
D Administer a stool softener daily.

Question Explanation
Correct Answer is D
Rationale: Sinus bradycardia is defined as a heart rate of less than 60 beats per minutes with a
regular rhythm that originates from the sinoatrial (SA) node. Typically, clients who develop
sinus bradycardia are asymptomatic. If a client develops symptomatic bradycardia, they can
present with hypotension, shortness of breath, chest pain, syncope or syncopal episodes and
altered mentation. To avoid a vasovagal response (i.e., the slowing of the heart rate caused by
bearing down when trying to defecate) and the risk for another syncopal episode, it is important
to ensure that the client's bowel movements are soft and easily expelled. The client should also
be instructed to avoid holding their breath or bearing down (Valsalva maneuver). The other
interventions are not appropriate or required for this client.
Concepts tested

Question 3994
The nurse is teaching a client who is in the third trimester of pregnancy. Which factor should the
nurse include that can increase the neonate's risk for development of sepsis?
A Maternal gestational diabetes
B Precipitous vaginal birth
C Cesarean delivery
D Premature rupture of membranes

Question Explanation
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Correct Answer is D
Rationale: Premature rupture of the membranes (PROM) means the spontaneous rupture of the
amniotic sac and leakage of amniotic fluid before the onset of labor. PROM can lead to
intrauterine infection and neonatal sepsis, especially if the PROM occurred at an early
gestational age. Typically, the mother is prescribed a 7-day course of a broad-spectrum antibiotic
to reduce the risk for infection. The other factors are not typically associated with an increased
risk for neonatal sepsis.
Concepts tested

Question 3995
The nurse is developing a plan of care for a client admitted with an acute asthma attack. The
client has audible wheezes and a pulse oximeter reading of 88%. Which nursing problem is
the priority?
A Impaired gas exchange
B Risk for infection
C Anxiety
D Spiritual distress

Question Explanation
Correct Answer is A
Rationale: The low pulse oximetry reading indicates poor gas exchange. This is the result of
bronchoconstriction and mucosal edema that occurs during an acute asthma attack. Maintaining
an open airway and correcting the impaired gas exchange is therefore the priority. Treatment
includes administration of oxygen, administration of bronchodilators via nebulizer and the use of
corticosteroids. While the other problems may also apply to the client, they are not the priority at
this time.
Concepts tested

Question 3996
The nurse is providing education to a client diagnosed with iron-deficiency anemia who reports
fatigue and dizziness. The nurse explains the cause of the client's symptoms are from which
condition?
A Reduced oxygen saturation
B Destruction of red blood cells (RBCs)
C Decreased cardiac output
D Tissue hypoxia

Question Explanation
Correct Answer is D
Rationale: Iron-deficiency anemia is when the RBCs are unusually small and pale (due to their
low hemoglobin content.) Tissue hypoxia is the result of not having enough functioning
hemoglobin in the blood to oxygenate the tissues; tissue hypoxia is responsible for symptoms
such as fatigue, leg cramps and chewing ice. It's possible the client could have a normal
SpO2 because the small amount of hemoglobin that's in the blood may be well saturated with
oxygen. Anemia does not decrease cardiac output. Destruction of RBCs is associated with
hemolytic anemia, not iron-deficiency anemia.
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Concepts tested

Question 3997
The nurse is caring for a client in renal failure who has a subclavian vascular access port for
hemodialysis. Which finding requires immediate action by the nurse?
A Pruritus
B Fatigue
C Anuria
D Fever

Question Explanation
Correct Answer is D
Rationale: Clients with chronic medical conditions and a central venous access device or line
that is intermittently being accessed are at a high risk for developing an infection. A fever in this
client could indicate a possible central line-associated blood stream infection. Therefore, a fever
should be immediately reported to the client's health care provider. The other findings would be
expected in a client with renal failure that requires hemodialysis.
Concepts tested

Question 3998
A child with Tetralogy of fallot visits the clinic several weeks before a scheduled surgery. The
nurse should give priority attention to which focus?
Question 8 Answer Choices
A Observation for developmental delays
B Assessment of oxygenation
C Maintenance of adequate nutrition
D Prevention of infection

Question Explanation
Correct Answer is B
Rationale: All of the responses would be important for a child diagnosed with tetralogy of
Fallot. However, persistent hypoxemia causes acidosis, which further decreases pulmonary blood
flow. Additionally, low oxygenation leads to development of polycythemia and may result in
neurological complications.
Concepts tested

Question 3999
The nurse is providing education to a client with asthma who is allergic to house-dust mites.
Which information about the prevention of an asthma attack would be the most important for the
nurse to include during teaching?
A Choose 100% cotton linens with a low thread count.
B Open the curtains to let the sunlight in each morning
C Wash and rinse the bed linens in hot water
D Change the pillow covers every month

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Question Explanation
Correct Answer is C

Question 4000
The nurse is assessing a 6 year-old child for the first time in the clinic and finds that the child has
deformities of the joints, limbs and fingers; a thinned upper lip; and small teeth with poor
enamel. The mother states: "My child struggles with counting and color recognition." Based on
this data, the nurse suspects that the child is most likely displaying the effects of which problem?
A Lead poisoning
B Congenital abnormalities
C Chronic toxoplasmosis
D Fetal alcohol syndrome (FAS)

Question Explanation
Correct Answer is D
Rationale: Major features of fetal alcohol syndrome (FAS) are facial and other malformed
physical features, such as small head circumference and brain size (microcephaly), small eyelid
openings, a sunken nasal bridge, an exceptionally thin upper lip, a short, upturned nose and a
smooth skin surface between the nose and upper lip. Vision difficulties include nearsightedness
(myopia). Other findings are mental retardation, delayed development, abnormal behavior such
as short attention span, hyperactivity, poor impulse control, extreme nervousness and anxiety.
Behavioral problems, cognitive impairment and psychosocial deficits are also associated with
this syndrome.
Concepts tested

Question 4001
The nurse is caring for a client who has gastroesophageal reflux disease (GERD). The primary
health care provider's orders include omeprazole twice a day, Maalox prior to meals, elevation of
the head of the bed, an acid-reflux diet, and no alcohol. Which order should the nurse question?
A Bed position
B Schedule for antacid
C Prescribed diet
D Schedule for the proton-pump inhibitor

Question Explanation
Correct Answer is B
Rationale: All of the options listed are potential recommendations but the schedule for antacids
should be one to three hours after eating and at bedtime as needed.
Concepts tested

Question 4002
The nurse is providing discharge education to a client diagnosed with fibromyalgia syndrome
(FMS). Which statement by the client indicates that additional teaching is needed?
A "I will avoid caffeine, sugar, and alcohol before bedtime."
B "I should take the duloxetine once a day, every day."

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C "If my pain stays the same, I will take an extra dose of the pregabalin."
D "I will take an exercise class – maybe I'll sign up for a yoga class."

Question Explanation
Correct Answer is C
Rationale: Fibromyalgia Syndrome (FMS) or fibromyalgia is a chronic pain syndrome,
characterized by pain in the lower back, neck, or head that can be triggered by pressure, noxious
stimuli, or stress. The client will often complain of sleep cycle disturbance and moderate to
severe fatigue. Treatment for fibromyalgia is varied, but medications such as duloxetine and
pregabalin are FDA-approved for the treatment of FMS. Pregabalin [Lyrica] reduces GABA
neurotransmitter release, helping to relieve neuropathic pain seen with FMS. Pregabalin has the
potential for abuse and physical dependence and is classified as a Schedule V controlled
substance. The client should be instructed not to take additional doses if pain is not relieved and
to notify their health care provider instead.
Concepts tested

Question 4003
The nurse is auscultating the heart of a client who has dilated cardiomyopathy. Which finding
should the nurse expect to hear?
A Diastolic murmur
B Ventricular gallop of S3
C Apical click
D Split S2

Question Explanation
Correct Answer is B
Rationale: A ventricular gallop, S3 is caused by blood flowing rapidly into a distended
noncompliant ventricle. This is the most common sound with left-sided heart failure. Increased
left heart pressures may cause dilation of the mitral valve in the client with heart failure resulting
in a systolic murmur.
Concepts tested

Question 4004
The nurse is providing postoperative care for a client following a laparoscopic cholecystectomy.
Which assessment finding should be of highest concern?
A Client reports shoulder discomfort.
B Client has absent bowel sounds.
C Client reports right upper quadrant pain.
D Client is drowsy.

Question Explanation
Correct Answer is C
Rationale: Shoulder pain or discomfort is a common complaint following laparoscopic surgery
due to the effects of carbon dioxide gas used during the procedure. Postoperative drowsiness is
expected. The absence of bowel sounds immediately after surgery is not a cause for alarm. Right

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upper quadrant pain could be from a retained gallstone or bile duct injury; therefore
postoperative pain in the right upper quadrant should be of highest concern.
Concepts tested

Question 4005
The community health nurse is developing a plan of care for a
female adolescent with a body mass index greater than 40. The
nurse should recognize that the client has the highest risk for which
problem?
A Learning difficulties
B Social isolation
C Sexually transmitted infection
D Developmental delays

Question Explanation
Correct Answer is B
Rationale: A body mass index (BMI) greater than 40 indicates morbid obesity. During
adolescence, individuals go through rapid physical and psychological
changes which can affect their body image. In addition, adolescents living in Western,
industrialized cultures such as the United States tend to experience a significant amount of peer,
cultural and social pressure to maintain a certain
desired physical appearance. Most often this desired appearance is being thin and physically fit.
A morbidly obese adolescent is at risk for bullying, peer pressure, a
poor body image and low self-esteem which can put them at a high risk to distance themselves
from others, i.e., socially isolate.
Concepts tested

Question 4006
A 76-year-old client who smokes one pack of cigarettes per day is diagnosed with chronic
obstructive pulmonary disease (COPD). The nurse is teaching the client and family members
about the use of oxygen by nasal cannula in the home. Which information is most important for
the nurse to include in the discharge instructions?
A The client should not smoke while wearing oxygen
B Adjust the liter flow to 5 L as needed for shortness of breath
C Turn the oxygen off during every meal
D The client will need to make arrangements for portable oxygen when traveling

Question Explanation
Correct Answer is D
Rationale: Because oxygen supports combustion, there is a risk of fire if anyone smokes near the
oxygen equipment. The client should take off the oxygen, turn off the flow meter and go to
another part of the home or outside to smoke. Smoking cessation should be encouraged and
supported in ways that are appropriate for the client's readiness to quit. The most important
teaching point at discharge is to stress not smoking while wearing oxygen for the client's safety.
Concepts tested

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Question 4007
The nurse is caring for a client who has decreased adrenal function. Which intervention should
the nurse include in the client's plan of care?
A Prevent constipation
B Encourage physical activity
C Limit the number of visitors
D Place the client in reverse isolation

Question Explanation
Correct Answer is C
Rationale: Any stress, either physical or emotional, places additional stress on the adrenal
glands, which could precipitate an Addisonian crisis in this client. The plan of care should
protect the client from stress by avoiding the emotional stress of (too many) visitors and by
reducing physical activity until the client's condition stabilizes.
Concepts tested

Question 4008
The nurse is caring for a client who was in a motor vehicle accident. Which finding should be
the highest priority if newly identified by the nurse?
A Reduced sensory responses
B Pupils fixed and dilated
C Diminished spinal reflexes
D Flaccid paralysis

Question Explanation
Correct Answer is B
Rationale: Pupils that are fixed and dilated indicate overwhelming injury and intrinsic damage to
the upper brain stem, and would be the highest priority as it is a poor prognostic sign. The other
findings are more consistent with partial dysfunction of the brain or spinal cord.
Concepts tested

Question 4009
The nurse is caring for a client admitted to the hospital with severe left-sided flank pain and
hematuria. Diagnostic tests indicate a kidney stone partially obstructing the left ureter. Which
outcome is the most important for this client?
A Pain controlled with medication
B Adequate urinary elimination is maintained
C Verbalizes understanding of the disease process
D Tolerates diet without nausea and vomiting

Question Explanation
Correct Answer is B
Rationale: While all options are appropriate to the care of this client, urinary elimination is the
nursing priority. A stone that completely obstructs the ureter can cause hydronephrosis and

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potential kidney damage. Remember Maslow - physiologic needs are more important than
nutritional needs. Pain control and teaching are lower priorities
Concepts tested

Question 4010
A client is seen at the primary care clinic for allergic rhinitis. Which clinical manifestations
should the nurse expect with this diagnosis? Select all that apply
A Watery, itchy, reddened eyes
B Alteration in sense of smell
C Purulent, green nasal discharge
D Increase in serum eosinophil count
E Worsening of symptoms during spring and fall season

Question Explanation
Correct Answer is A, B, D, E
Rationale: Common symptoms of allergic rhinitis are due primarily to the release of immune
mediators such as histamine, prostaglandins, eosinophils and cytokines. This leads to sneezing,
runny nose with clear discharge, nasal congestion and an increased eosinophil counts. Symptoms
may appear similar to a cold. Due to drainage, the client's sense of smell can be altered.
However, purulent green nasal discharge is not consistent with this diagnosis and would be more
expected in the case of a sinus infection. Exposure to mold, pets, dust and pollens, especially
during spring and fall, can exacerbate allergic rhinitis.
Concepts tested

Question 4011
The nurse is planning care for a client admitted to the hospital with influenza. Which
interventions should the nurse include in the client's plan of care? Select all that apply.
A Administer the prescribed oseltamivir.
B Maintain droplet precautions.
C Limit visitors who show signs of a respiratory infection.
D Administer the influenza vaccine.
E Instruct the client on proper cough etiquette.

Question Explanation
Correct Answer is A, B, C, E
Rationale: Antiviral agents, such as oseltamivir, are used to shorten the course and reduce
symptoms of the flu. Droplet transmission-based precautions are indicated to prevent the spread
of the flu. To avoid further transmission of the illness, visitors with signs/symptoms of a
respiratory illness should not be permitted on the unit. It is important to ensure that clients
understand how to prevent transmission of infections such as the flu through proper hand
hygiene and cough etiquette. The flu vaccine should not be given while the client is acutely ill.
Concepts tested

Question 4012

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The nurse is teaching a client about asthma. What information is important for the nurse to
include? Select all that apply.
A Action and purpose of medications
B Use of peak flow monitoring
C When to seek medical assistance
D Avoiding triggers for asthma attacks
E Eating fewer but larger meals
F Limiting fluid intake

Question Explanation
Correct Answer is A, B, C, D
Rationale: Clients must understand the use of medications including quick-relief (rescue) and
long-acting (maintenance) therapies. Clients use the peak flow meter to assess effectiveness of
medication or breathing status. An acute attack can be a medical emergency and knowing where
and how to seek medical care is important. Certain conditions (triggers) can exacerbate an attack
and should be avoided. Consumption of large meals can distend the abdomen, which can add to
respiratory distress. Smaller, frequent meals are better tolerated. Clients should increase, not
limit, fluid intake to help liquefy secretions for easier expectoration.
Concepts tested

Question 4013
A client has been diagnosed with emphysema. Which intervention should the nurse implement
when caring for this client?
A Reassure the client that the lung damage is usually reversible.
B Schedule a lung cancer screening for the client.
C Assist the client with enrolling in a smoking cessation program.
D Inquire if the client has a power of attorney for health care.

Question Explanation
Correct Answer is C
Rationale: By the time the client is diagnosed with emphysema, lung damage is usually
permanent and a common cause of disability. Smoking is the most common risk factor for
developing emphysema and the client should stop smoking. Participating in a structured program
increases the client's chance for successful smoking cessation. Scheduling a lung cancer
screening and asking about a power of attorney are not appropriate interventions for the client at
this time.
Concepts tested

Question 4014
A client with a history of asthma is admitted for a minor surgical procedure. Preoperatively, the
peak flow is measured at 480 liters/minute. Postoperatively, the client reports chest tightness and
the peak flow is now 200 liters/minute. What should the nurse do first?
A Notify both the surgeon and primary care provider
B Apply oxygen at two liters per nasal cannula
C Administer the PRN dose of albuterol

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D Repeat the peak flow reading in 30 minutes

Question Explanation
Correct Answer is C
Rationale: Peak flow monitoring during exacerbations of asthma is recommended for clients with
moderate-to-severe persistent asthma to determine the severity of the exacerbation and to guide
the treatment. A peak flow reading of less than 50% of the client's baseline reading is a medical
alert condition and a short-acting beta agonist must be taken immediately. Notifying the health
care provider is important, but that is not what would be done first. First, the client needs
assistance. Oxygen administration will not be effective if the airway constriction is not relieved
with the albuterol. Leaving the client and returning in 30 minutes will do nothing to help a client
in acute distress.
Concepts tested

Question 4015
A client diagnosed with hypoparathyroidism would be most likely to display which of the
following symptoms?
A Pruritus
B Decreased reflexes
C Polydipsia
D Flank pain

Question Explanation
Correct Answer is A
Rationale: A client with hypoparathyroidism can present with the following laboratory
anomalies: hypocalcemia, hyperphosphatemia and hypomagnesemia. Therefore, the nurse should
identify signs and symptoms associated with these laboratory changes. Pruritus is often
associated with increased levels of serum phosphorous and is common in patients with
hypoparathyroidism. Kidney stones and associated flank pain are sometimes seen in clients
with hypercalcemia, which is not traditionally seen in clients with hypoparathyroidism. In fact,
clients with hypoparathyroidism often have low levels of serum calcium. Clients with
hypermagnesemia can present with decreased reflexes. However, serum magnesium is often low
in clients with hypoparathyroidism. Polydipsia is often seen in clients with diabetes mellitus
secondary to hyperglycemia, and glucose levels are not typically impacted by
hypoparathyroidism.
Concepts tested

Question 4016
The nurse in the long-term care facility is reviewing the plan of care for a client with Parkinson's
disease. Which interventions should the nurse make sure to include for this client? Select all that
apply.
A Set-up a bladder training program for the client.
B Encourage participation in speech therapy.
C Use cognitive strategies to enhance the client's memory.
D Promote independence by letting client wander throughout the facility.

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E Provide assistance with ambulation.

Question Explanation
Correct Answer is A, B, C, E
Rationale: Parkinson's disease is a neurological disease that primarily affects movement and can
impact cognitive function such as memory. All of the interventions are appropriate for this client
with the exception of allowing the client to wander throughout the facility. Clients with
Parkinson's disease often suffer from postural instability and are at great risk for falls and injury.
The client should have someone with them if they wish to walk throughout the facility. There are
other ways to promote the client's independence and the client's safety must come first.
Concepts tested

Question 4017
The clinic nurse is following up with a client who was seen a few days ago for trigeminal
neuralgia. Which action by the client indicates an understanding of how to manage the
condition?
A Keeps the environment at a moderate temperature and free from drafts.
B Eats a bowl of hot, steaming soup every day for lunch.
C Takes an analgesic after performing household chores.
D Performs vigorous brushing of teeth twice per day.

Question Explanation
Correct Answer is A
Rationale: Trigeminal neuralgia is a disruption in the cranial nerve and causes sudden, severe,
brief stabbing pain. Keeping the environment at a moderate temperature and free from drafts can
reduce the risk of triggering an acute attack. The client will often avoid oral care because of the
potential for pain, but should be instructed to use a soft-bristles toothbrush and gently brush their
teeth. Meals should be warm-to-cool, not hot, to avoid pain exacerbation. Analgesics should be
taken before performing activities that can increase feelings of discomfort.
Concepts tested

Question 4018
The nurse is providing care for a 40-year-old client suspected of having Guillain-Barré
syndrome. Which intervention should the nurse plan for?
A Implementation of airborne precautions
B Administration of immunoglobulins
C A bone marrow biopsy
D Genetic testing of the client's children

Question Explanation
Correct Answer is B
Rationale: Guillain-Barré Is a syndrome with an unknown etiology occurring after a bacterial or
viral infection. It is characterized by muscle weakness and paralysis that occurs in an ascending
manner. It may result in paralysis of the respiratory muscles requiring mechanical ventilation for
the client. Intravenous immunoglobulins (IV Ig) are used to treat Guillain-Barré in the early

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phase. They are believed to interfere with antigen presentation and help to modulate the body's
immune response. The other interventions are not appropriate or necessary for this condition.
Concepts tested

Question 4019
The nurse is caring for a client who was admitted for hyperglycemic hyperosmolar state (HHS).
Which clinical finding would support this diagnosis?
A Blood sugar > 600 mg/dL
B Positive urine ketones
C Serum pH level < 7.35
D Deep, rapid breathing pattern

Question Explanation
Correct Answer is A
Rationale: Clients who suffer from type 2 diabetes mellitus are at risk for having hyperglycemic
hyperosmolar state (HHS). HHS has a gradual onset with precipitating factors including poor
fluid intake, infections or stress. While these are similar etiologies to diabetic ketoacidosis
(DKA), there are some differences. Blood sugar levels with HHS are generally much higher (>
600 mg/dL) when compared to DKA (> 300 mg/dL). A deep, rapid breathing pattern (i.e.,
Kussmaul's) is associated with DKA. The serum pH for HHS is usually normal, since there is an
absence of ketones and acidosis.
Concepts tested

Question 4020
The nurse is caring for a client with diabetes who was admitted for intractable vomiting. The
nurse notes that the client's skin is cool to the touch, and the fingerstick blood sugar result is 55
mg/dL. What intervention should the nurse implement first?
A Administer glucagon.
B Recheck the blood sugar in 15 minutes.
C Administer an antiemetic.
D Offer the client a warm blanket.

Question Explanation
Correct Answer is A
Rationale: A client with diabetes receiving anti-hyperglycemic agents or insulin who is unable
to eat or digest food is at risk for hypoglycemia (blood sugar level less than 70 mg/dL). Cool,
clammy skin and a decreased level of consciousness are additional signs of hypoglycemia. To
treat the hypoglycemia, the client requires glucose in the form of glucagon or another
carbohydrate to increase the blood glucose to an acceptable level, typically greater than 70
mg/dL. After addressing the hypoglycemia first, the nurse should implement the other
interventions.
Concepts tested

Question 4021

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The nurse is reviewing the electronic medical record of a client diagnosed with endometriosis.
The nurse should expect which findings with this diagnosis? Select all that apply.
A Dyspareunia
B Amenorrhea
C Infertility
D Urinary tract infection
E Dysmenorrhea

Question Explanation
Correct Answer is A, C, E
Rationale: The following findings that would indicate the client has endometriosis are pain with
menstruation (dysmenorrhea), pain with intercourse (dyspareunia), excessive bleeding, and
infertility. The client may also complain of pelvic and/or back pain, along with pain during
bowel movements. The endometrial tissue that implants outside the uterus may cause mild to
severe pain, fluctuations in menstrual cycles and fibroids that can cause infertility. Endometriosis
often times is mistaken for pelvic inflammatory disease (PID), which causes inflammation of the
pelvis, irritable bowel syndrome (IBS) or ovarian cysts. A urinary tract infection and amenorrhea
(absence of menstruation) are not usually seen with endometriosis.
Concepts tested

Question 4022
The nurse in the outpatient clinic is admitting a client scheduled for a prostatectomy this
morning. Which statement by the client should be of greatest concern to the nurse?
A "I have had an allergic reaction to an antibiotic before."
B "I have not had to urinate since yesterday evening."
C "I have not had anything to eat since 9:00 pm last night."
D "I am feeling nervous about the procedure."

Question Explanation
Correct Answer is B
Rationale: The client's statement about not having urinated in over 12 hours should be the
greatest concern to the nurse. Urinary retention is a complication of an enlarged prostate gland
and the nurse will need to further evaluate the client. The client may require a bladder ultrasound
(bladder scan) to determine the amount of urine retained and the insertion of a catheter to drain
the bladder may be indicated. The health care provider should also be notified. The nurse will
then follow up on the client's other statements.
Concepts tested

Question 4023
A nurse working in a nursing home is caring for an older adult client who has been diagnosed
with a urinary tract infection. Which finding should be of greatest concern to the nurse?
A Low blood pressure
B Cloudy urine
C Suprapubic pain
D Confusion

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Question Explanation
Correct Answer is A
Rationale: Having a low blood pressure should be the greatest concern to the nurse. Clients
with a urinary tract infection (UTI) are at risk of developing urosepsis, an infection of the blood,
which can quickly lead to septic shock. Low blood pressure can be a sign of urosepsis and the
beginning stage of shock. Confusion, suprapubic pain and cloudy urine are expected signs and
symptoms of a UTI.
Concepts tested

Question 4024
The nurse is developing a plan of care for a client with benign prostatic hyperplasia. Which
nursing interventions should the nurse include for this client? Select all that apply.
A Monitor for bladder distention.
B Calculate accurate intake and output.
C Catheterize as needed for post-void residual urine.
D Limit caffeinated and alcoholic beverages.
E Void every 1 to 2 hours to empty the bladder.

Question Explanation
Correct Answer is A, C, D
Rationale: Benign prostatic hyperplasia (BPH) is a benign enlargement of the prostate gland.
This is common among aging men and can cause urinary difficulties including obstruction,
retention, infection and incontinence. Nursing management includes assessing/monitoring for
bladder distention. With urinary retention, this can cause pain and increased risk of an acute
kidney injury. If the client is retaining urine, the nurse might need to perform straight
catheterization to empty the bladder. The client should attempt to void every 4 to 6 hours to
prevent retention. The client should avoid or limit the use of caffeinated and alcoholic beverages
as these can cause irritation to the bladder and worsen symptoms. Monitoring intake and output
would be appropriate to evaluate a client’s fluid balance and kidney function, not BPH.
Concepts tested

Question 4025
The nurse is performing an assessment on a college student who comes to the health clinic with
symptoms of meningitis. The student lives in the school dormitory on campus with hundreds of
other students. What is the priority action the nurse should take?
A Alert the college's administration and dormitory staff.
B Administer acetaminophen for the headache.
C Perform a focused neurological assessment.
D Obtain the client's immunization history.

Question Explanation
Correct Answer is A

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Rationale: Although all of the actions are appropriate for this client, the priority is to notify
school officials and the dormitory staff. If the client turns out to have bacterial meningitis, it is
important to identify other students who might have been exposed.
Concepts tested

Question 4026
The nurse is reviewing discharge instructions with a client with a new diagnosis of a seizure
disorder. Which statements indicate that the client understood the instructions? Select all that
apply.
A "I will make sure to wear a medical alert bracelet."
B "My family will hold me down tightly during a seizure."
C "My family has developed a plan for when I have a seizure."
D "I will withdraw from my college classes just in case."
E "I will keep a diary of any seizure activity."
F "I will not miss a dose of my seizure medication."

Question Explanation
Correct Answer is A, C, E, F
Rationale: Seizures may involve sudden jerky movements accompanied by a loss of
consciousness. Once a seizure has occurred it is important for a client and their family members
to be prepared and try to prevent recurrence. It is important to take anticonvulsant medication as
ordered. Diaries of seizure activity help to determine if there is a trigger. Wearing a medical alert
bracelet and having a plan for the family, such as when to call an ambulance, is a proactive plan
to manage the disease. The client does not have to stop attending college and should continue
with their normal life and activities. A client experiencing a seizure should not be restrained or
held down during the seizure as that can cause injury to the client or family member.
Concepts tested

Question 4027
An adolescent client is hospitalized with hemarthrosis from a hemophilia A bleeding episode.
Which order from the provider should the nurse question?
A Desmopressin acetate 0.3 mcg/kg IV infused over 30 minutes.
B Ibuprofen 400 mg as needed for pain.
C Immobilization of the joint in a splint.
D Passive range of motion every shift.

Question Explanation
Correct Answer is B
Rationale: Aspirin and NSAIDs such as ibuprofen could increase the risk of additional bleeding
in this client due to the potential effects on platelet aggregation; therefore, the nurse should
contact the provider to clarify the order for pain relief. Hemophilia A results from a deficiency of
clotting factor VIII. Desmopressin acetate promotes the release of von Willebrand's antigen from
the platelets, which carries factor VIII, helping to control bleeding associated with factor VIII
deficiency. Muscle strengthening and range of motion exercises are always indicated. Splinting
of joints may provide pain relief.

Page | 1290
Concepts tested

Question 4028
The nurse is teaching a 27-year-old client with asthma about the therapeutic regimen. Which
statement by the client indicates further teaching is needed?
A "I should monitor my peak flow every day."
B "I should contact the clinic if I am using my medication more often."
C "I should learn stress reduction and relaxation techniques."
D “I need to limit my exercise, especially activities such as walking and running."

Question Explanation
Correct Answer is D
Rationale: Limiting physical activity in an otherwise healthy, young client should not be
necessary. If exercise intolerance exists, the asthma management plan should include specific
medications to treat the problem such as using an inhaled beta-agonist five minutes before
exercise. The goal is always to return to a normal lifestyle. It is appropriate for the client to learn
to relax. The asthmatic client should monitor their peak flow every day and medications may
need to be adjusted if the reading is in the yellow or red-zone. If the client is using their rescue
inhaler more often, a medication adjustment may be needed.
Concepts tested

Question 4029
A nurse is caring for a client recently diagnosed with Addison's disease. While the nurse is
reinforcing education, which statement by the client indicates the need for additional teaching?
A "I will take my methylprednisolone when I start to feel sick."
B "I will wash my hands often to prevent infections."
C "I will eat six small meals a day instead of three."
D "I may experience changes in my mood."

Question Explanation
Correct Answer is A
Rationale: A person with Addison's disease suffers from low levels of circulating cortisol. The
client will be required to take exogenous corticosteroids. A commonly prescribed medication is
methylprednisolone, which the client should take every day, not only when they feel sick. This
medication suppresses the immune system, so the client should wash their hands often to prevent
infection. As their condition progresses, clients may experience anorexia, nausea, vomiting and
diarrhea. To ease gastrointenstinal discomfort, the client should eat small meals throughout the
day and drink sufficient amounts of fluids. Low-dose, long-term therapy with steroids can cause
depression or other psychologic disturbances. The client should be educated about potential
psychologic reactions and when to notify their health care provider.
Concepts tested

Question 4030
The nurse on the surgical unit is caring for a client who underwent a thyroidectomy eight hours
ago. Which finding requires immediate action?

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A Respiratory rate of 24
B Voice hoarseness
C Diaphoresis
D Wheezing

Question Explanation
Correct Answer is D
Rationale: Following a thyroidectomy, it is critical that the nurse monitors the client closely for
hemorrhage or airway obstruction, such as tracheal compression, which can lead to respiratory
arrest. Signs of hemorrhage or tracheal compression include wheezing, frequent swallowing or
choking and bleeding noted from the incision site. The elevated respiratory rate is related to the
tracheal compression/airway obstruction and should return to normal once the compression has
been addressed. Voice hoarseness frequently occurs following a thyroidectomy due to edema at
the site of incision and diaphoresis may be a symptom of hyperthyroidism. Both should be
monitored, but do not require immediate action.
Concepts tested

Question 4031
The nurse is evaluating a client who was admitted for a small bowel obstruction and dehydration.
Which observation by the nurse would indicate that the dehydration is improving?
A The client reports the passing of flatus.
B The client denies any nausea or vomiting.
C The client has normoactive bowel sounds
D The client voided 300 mL of urine in the past two hours.

Question Explanation
Correct Answer is D
Rationale: Treatment for dehydration typically includes rehydration by increasing oral fluid
intake and/or administering intravenous fluids. During dehydration, urine output usually
decreases as the kidneys attempt to restore fluid volume by increasing water reabsorption. The
fact that the client voided 300 mL in two hours indicates that fluid volume has been restored, the
dehydration is resolved and the kidneys are eliminating excess water. The other findings pertain
more to functioning of the client's bowel not the client's fluid balance.
Concepts tested

Question 4032
The nurse suspects cardiac tamponade in a client who has acute pericarditis. How should the
nurse determine the presence of pulsus paradoxus?
A Subtract the diastolic blood pressure from the systolic blood pressure.
B Listen for a pericardial friction rub when the client is instructed to hold their breath.
C Check the electrocardiogram for dysrhythmias during the respiratory cycle.
D Note when Korotkoff sounds are auscultated during inspiration and expiration.

Question Explanation

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Correct Answer is D
Rationale: Pulsus paradoxus is a decrease in systolic blood pressure (SBP) during inspiration
that is exaggerated in cardiac tamponade. Pulsus paradoxus exists when there is a difference
greater than 10 mm Hg between when Korotkoff sounds are heard during expiration and when
they are heard throughout the respiratory cycle. The other methods described would not be useful
in determining the presence of pulsus paradoxus.
Concepts tested

Question 4033
The nurse is collecting data about a client admitted with cardiomyopathy. How should the nurse
document the low pitch, blowing sound the nurse heard when auscultating near the apex of the
heart?
A Stridor
B Murmur
C Wheeze
D Pulsus paradoxus

Question Explanation
Correct Answer is B
Rationale: Murmurs reflect turbulent blood flow through normal or abnormal heart valves. They
are classified according to their timing in the cardiac cycle: systolic murmurs (e.g., aortic
stenosis and mitral regurgitation) occur between S1 and S2, whereas diastolic murmurs (e.g.,
mitral stenosis and aortic regurgitation) occur between S2 and S1. They are also graded by the
provider according to their intensity. The quality of murmurs can be further characterized as
harsh, blowing, whistling, rumbling or squeaking. They are also described by pitch, which is
usually high or low. An auscultatable murmur near the apex of the heart or the left fifth
intercostal space is most likely related to mitral valve problems that could have led to
cardiomyopathy. Stridor and wheeze are abnormal sounds found with auscultation of the lungs
and are airway-related. Pulsus paradoxus is obtained during a blood pressure measurement and
is indicative of cardiac tamponade.
Concepts tested

Question 4034
The nurse is caring for a client with Legionnaire's disease. Which finding would require the
nurse's immediate attention?
A Decreased chest wall expansion
B Pleuritic pain on inspiration
C A decrease in respiratory rate from 34 to 24
D Dry mucous membranes in the mouth

Question Explanation
Correct Answer is A
Rationale: The respiratory status of a client with this acute bacterial pneumonia known as
Legionnaires' disease is critical. Note that all of these findings would be of concern, but a
decrease in chest wall expansion is the priority because it reflects a possible decrease in the depth
and effort of respirations. Further findings of restlessness, including low oxygen saturation,
Page | 1293
would indicate hypoxemia. The client may need to have oxygen titrated to maintain adequate
O2 saturation. Mechanical ventilation may be needed for signs of respiratory failure.
Concepts tested

Question 4035
The nurse admits a 50-year-old client with a three-day history of swelling of the face, hands and
feet; foamy brown urine; fever and malaise. Which information obtained in the admission
interview alerts the nurse that these findings may reflect a diagnosis of acute glomerulonephritis?
A Type 1 diabetes since age 15
B Travel to a foreign country
C Sore throat two weeks ago
D History of mild hypertension

Question Explanation
Correct Answer is C
Rationale: Glomerulonephritis commonly presents with proteinuria (foamy urine) that is rusty or
brownish in appearance and swelling due to the systemic protein loss. In the majority of cases of
acute glomerulonephritis, there is a history of an untreated streptococcal throat infection
preceding the onset of symptoms by two to three weeks. The other options are not directly
related to the development of acute glomerulonephritis.
Concepts tested

Question 4036
The nurse admits a 3-week-old infant to the special care nursery with a diagnosis of
bronchopulmonary dysplasia. As the nurse reviews the birth history, which data would
be most consistent with this diagnosis?
A Meconium was cleared from the airway at delivery
B Phototherapy was used to treat Rh incompatibility
C The infant received mechanical ventilation for two weeks
D Gestational age assessment suggested growth retardation

Question Explanation
Correct Answer is C
Rationale: Bronchopulmonary dysplasia (BPD) is an iatrogenic disease caused by mechanical
ventilation. When the prematurely born infant is treated with mechanical ventilation, over time
the pressure from the ventilation and excess oxygen can injure the infant's lungs, causing BPD.
Concepts tested

Question 4037
A 72-year-old client reports having discomfort immediately after a below-the-knee amputation.
Which initial action by the nurse is most appropriate?
A Wrap the stump snugly in an elastic bandage
B Administer opioid narcotics as ordered
C Ensure that the stump is elevated
D Conduct guided imagery or distraction

Page | 1294
Question Explanation
Correct Answer is C
Rationale: Elevating the stump is the priority intervention for the first 24 hours after surgery.
This will help prevent pressure due to postoperative swelling, which will minimize pain or
discomfort. Without this action, a firm elastic bandage, opioid narcotics, or guided imagery will
have little effect. Analgesics appropriate to the level of pain should be administered as needed in
the postoperative period to promote client comfort. After the first day, the residual limb should
be flat on the bed.
Concepts tested

Question 4038
The nurse in the emergency room is admitting a client with acute coronary syndrome. Which
intervention should the nurse implement first?
A Insert a peripheral venous access device
B Obtain a 12-lead ECG
C Place on continuous ECG monitoring
D Administer oxygen via nasal cannula

Question Explanation
Correct Answer is D
Rationale: It is extremely important to quickly diagnose and treat a patient with acute coronary
syndrome (ACS) to preserve heart muscle. Initial management of the patient with chest pain
most often occurs in the ER. The nurse should first administer supplemental oxygen to keep
O2 saturation above 93% and help with myocardial tissue perfusion. A 12-lead ECG should be
obtained and the client should be placed on continuous ECG monitoring. Next, the nurse should
establish IV access.
Concepts tested

Question 4039
The nurse is evaluating the growth and development of a toddler who has acquired
immunodeficiency syndrome (AIDS). The nurse should anticipate which finding in this child?
A Accelerated development of fine motor skills
B Delay in achievement of most developmental milestones
C Achieve developmental milestones at an erratic rate
D Difficulty with color recognition

Question Explanation
Correct Answer is B
Rationale: Developmental delays are common in children with AIDS, and after achievement of
normal development, there may be loss of milestones. The majority of children with AIDS have
neurological involvement. There is decreased brain growth as evidenced by microcephaly and
abnormal neurologic findings.
Concepts tested

Question 4040
Page | 1295
The nurse in a pediatric clinic is caring for a 10-year-old child with suspected COVID-19
respiratory infection. Which assessment finding requires immediate intervention by the nurse?
A Rapid, bounding pulse
B Profuse diaphoresis
C Temperature of 101.3°F (38.5°C)
D Slow, irregular respirations

Question Explanation
Correct Answer is D
Rationale: A slow and irregular respiratory rate is a sign of respiratory fatigue and impending
acute respiratory failure in the child. Respiratory failure can rapidly lead to respiratory and
cardiac arrest. Immediate interventions are required, such as supplemental oxygen, intubation
and mechanical ventilation to support the child's respiratory status.
Concepts tested

Question 4041
The nurse in the urgent care clinic is assessing an older male adult client who hit his head during
a fall. Which finding should immediately be reported to the health care provider?
A Chronic tremors
B A 4 x 4 cm hematoma at the base of the skull
C Clear drainage from the ears
D Severe headache

Question Explanation
Correct Answer is C
Rationale: Drainage from the nose and ear in a client with head trauma may be caused by
leakage of cerebrospinal fluid (CSF) due to a basilar skull fracture. This finding should
be immediately reported to the health care provider. The other findings are unrelated or
expected after a fall with head injury and are not as urgent as the possible leakage of CSF fluid.
Concepts tested

Question 4042
The nurse is teaching the parents of a client diagnosed with sickle cell anemia. Which statement
made by the nurse accurately explains their child's diagnosis?
A "There is a reduced number of red blood cells due to inadequate iron in the diet."
B "Red blood cells are abnormally shaped, preventing adequate oxygen delivery to the tissue."
C "Sickle-shaped red blood cells carry carbon dioxide to the tissues instead of oxygen."
D "There is a depression of the platelets and also the red and white blood cells."

Question Explanation
Correct Answer is B
Rationale: Sickle cell anemia is caused by an abnormal type of hemoglobin, which changes the
shape of red blood cells from a round to a sickle shape. These fragile abnormal blood cells carry
less hemoglobin and can get stuck in the smaller blood vessels, depriving the tissue of oxygen

Page | 1296
and causing severe pain and tissue damage. Inadequate dietary iron causes iron-deficiency
anemia. Platelets, red blood cells and white blood cells are all depressed in pancytopenia.
Concepts tested

Question 4043
A 3-year-old child is being treated in the emergency department after ingestion of one ounce of a
liquid narcotic. Which action should the nurse perform first?
A Assess airway, breathing, circulation and level of consciousness
B Start the ordered intravenous fluids
C Obtain blood and urine samples
D Prepare for gastric lavage

Question Explanation
Correct Answer is A
Rationale: The first step in treatment of a toxic exposure or ingestion is to assess the airway,
breathing and circulation (ABCs), particularly when the substance is known to cause CNS
depression, such as a narcotic. The level of consciousness will also be an important indicator of
the CNS-depressant effects of the medication. The other actions are correct and also important,
but they are not the first priority.
Concepts tested

Question 4044
The nurse is caring for a client newly diagnosed with atrial fibrillation. The atrial heart rate is
250 and the ventricular rate is controlled at 75. Which finding is a cause for the most concern?
A Tachypnea with movement
B Difficulty speaking
C Loss of appetite
D Diminished bowel sounds

Question Explanation
Correct Answer is B
Rationale: Anticoagulant therapy is usually given to patients with atrial fibrillation to prevent
blood clots and stroke. A new finding of difficulty speaking may indicate that the client has
suffered a stroke. The nurse should assess for any other cognitive changes, assess lung function,
and immediately contact the provider and possibly the stroke team. The atrial rate of 250 is
normal for atrial fibrillation and is of no concern; the ventricular rate of 75 indicates that the
cardiac rate is well-controlled (a ventricular rate above 100 would not be adequately controlled,
necessitating additional rate control medications such as a beta blocker, calcium channel blocker
or digoxin).
Concepts tested

Question 4045
The nurse is caring for a client recently diagnosed with hypothyroidism. Which client statement
indicates that additional teaching is needed?
A "Once I feel better, I won't need to take this medication every day."

Page | 1297
B "Within the next few weeks, I should likely feel less fatigued."
C "I will have to have blood tests done regularly."
D "I might experience anxiety or problems with sleeping."

Question Explanation
Correct Answer is A
Rationale: Clients with hypothyroidism often need lifelong thyroid hormone replacement
therapy (HRT). Therefore, a client who plans on stopping medications once symptoms have
improved is likely to have a re-emergence of symptoms, demonstrating the need for additional
teaching. Clients can expect symptoms of hypothyroidism to improve within a few weeks after
starting HRT. HRT with such drugs as levothyroxine may cause such side effects as anxiety,
nervousness or insomnia. The client should be taught that these are often temporary but to notify
their health care provider (HCP) if they worsen. Clients on HRT will have their thyroid
stimulating hormone (TSH) levels checked regularly to monitor the effectiveness of their
medication therapy.
Concepts tested

Question 4046
The nurse is caring for a client with late-stage liver cirrhosis. The nurse should monitor the client
for which clinical manifestations? Select all that apply.
A Fluid volume deficit
B Spider angiomas
C Ascites
D Encephalopathy
E Pulmonary hypertension
F Splenomegaly
G Increased albumin level

Question Explanation
Correct Answer is B, C, D, F
Rationale: Late clinical manifestations related to cirrhosis are the result of portal hypertension
and the inability of the liver to maintain normal functions such as detoxification, blood clotting,
bile production, blood filtration and carbohydrate, protein and fat metabolism. Common findings
include low serum albumin levels, leading to edema and fluid volume excess, spider angiomas
(i.e., telangiectasia or spider nevi), encephalopathy and increased venous pressure in the portal
circulation, leading to ascites and an enlarged spleen. Pulmonary hypertension is not a typical
finding with cirrhosis of the liver.
Concepts tested

Question 4047
A client who was admitted with viral hepatitis is being discharged home. Which of the following
statements by the client indicate an understanding of the discharge instructions? Select all that
apply.
A "I will call my doctor if my skin turns yellow."
B "I will avoid drinking alcoholic beverages."

Page | 1298
C "I will take acetaminophen for pain."
D "I will call my doctor if my belly gets bigger."
E "I will avoid too much salt in my diet."

Question Explanation
Correct Answer is A, B, D, E
Rationale: Hepatitis is an inflammation in the liver that leads to liver cell damage. Clients with
hepatitis should avoid drinking alcohol and taking drugs metabolized in the liver, such as
acetaminophen. A yellow discoloration of the sclera of the eyes and the skin on the rest of the
body is called jaundice. Jaundice is an indication of worsening hepatic function. Clients with
impaired hepatic function should also avoid high levels of salt in their diets to prevent fluid
retention. Abdominal distention (i.e., the client's belly getting bigger) could be ascites, a
condition which occurs as a result of low serum albumin levels that can lead to fluid
accumulation in the abdominal cavity. Clients should report these findings to their health care
provider.
Concepts tested

Question 4048
The nurse is caring for a client with end-stage renal disease (ESRD). Which manifestations
would the nurse expect to see with this client? Select all that apply.
A Conjunctivitis
B Pruritus
C HbA1c of 5.9%
D Blood pressure of 119/78
E Frequent fractures

Question Explanation
Correct Answer is A, B, E
Rationale: Clients with chronic kidney disease (CKD) and ESRD will present with calcium and
phosphorous imbalance, low calcium levels and high phosphorous levels. Bone mineral loss as a
result of low calcium levels can result in frequent fractures. Additionally, excessive
phosphorous, called metastatic calcifications, can become deposited in various body tissues and
systems, including the optic area, which can result in conjunctivitis. Pruritus is a common side
effect of excessive serum phosphate. Both diabetes mellitus and hypertension are risk factors for
CKD/ESRD, but a HbA1c of 5.9% shows that the diabetes is well-controlled, so does the blood
pressure of 119/78 for hypertension.
Concepts tested

Question 4049
The nursing care plan for a client in the diuresis stage of acute kidney injury (AKI) should
include monitoring for which complication?
A Urinary retention
B Electrolyte imbalance
C Excess fluid volume
D Acute pain

Page | 1299
Question Explanation
Correct Answer is B
Rationale: During the diuresis stage of AKI, the client will be losing an excessive amount of
urine (3 to 6 liters per day) and will be at risk for fluid volume deficit and electrolyte imbalances.
Therefore, the nurse must monitor the client's electrolyte levels closely, especially potassium
(hypokalemia). The other conditions are not complications typically seen during the diuretic
phase of AKI.
Concepts tested

Question 4050
The nurse should monitor which clients who may be at-risk for the development of acute kidney
injury? Select all that apply.
A A client with a history of syndrome of inappropriate diuretic hormone
B A client with a history of cirrhosis
C A client admitted with an acute myocardial infarction
D A client who received multiple blood transfusions
E A client recovering from septic shock

Question Explanation
Correct Answer is C, D, E
Rationale: Reduced renal perfusion is a risk factor for acute kidney injury (AKI). A client with
significant blood or fluid loss, such as one who was recently in a motor vehicle accident would
be at-risk for the development of AKI due to poor perfusion. Myocardial infarction is another
risk factor for AKI due to reduced cardiac output and subsequent hypoperfusion. Finally, septic
shock is associated with significant hypotension, which can cause poor blood flow and
hypoperfusion to the kidneys. All of these factors predispose a client to developing AKI. Clients
with a history of syndrome of inappropriate antidiuretic hormone secretion (SIADH) or cirrhosis,
on the other hand, may present with volume overload, and thus are not at increased risk for the
development of AKI.
Concepts tested

Question 4051
The‌‌home‌‌health‌‌nurse‌‌is‌‌visiting‌‌a‌‌client‌‌with‌‌sickle‌‌cell‌‌disease.‌‌What‌‌are‌
‌the ‌priority‌interventions‌‌for‌‌this‌‌client? ‌Select‌‌all‌‌that‌‌apply.‌
A Minimizing end-organ damage.
B Receiving annual influenza vaccination.
C Preventing opioid abuse.
D Finding a bone marrow donor.
E Preventing sickle cell crisis.
F Managing pain effectively.
G Maintaining fluid intake of 2 to 3 liters per day.

Question Explanation
Correct Answer is A, B, E, F, G

Page | 1300
Rationale: Care for the client with sickle cell disease (SCD) focuses on prevention of crises and
sequelae from the disease. Because an acute infection can precipitate a sickle cell crisis, the
client should receive the influenza vaccine annually. Increased intake of fluids is recommended
to reduce blood viscosity and maintain renal function. SCD is a genetic disease and currently
incurable. SCD can be very painful, especially during a crisis. Clients will require increasing
doses of analgesics in order to achieve pain control. Morphine and hydromorphone are the drugs
of choice.
Concepts tested

Question 4052
A client is admitted to the cardiology unit for treatment for recurrent supraventricular
tachycardia. Which observation by the nurse would best indicate that the client's condition can
be considered hemodynamically stable?
Question 2 Answer Choices
A The client's blood pressure is 88/40 mm Hg.
B The client denies any chest pain and capillary refill is less than three seconds.
C The client's pulse oximeter reads 91% on three liters nasal cannula.
D The client's cardiac monitor shows a heart rate of 170 beats per minute.

Question Explanation
Correct Answer is B
Rationale: Supraventricular tachycardia (SVT) is an arrhythmia that originates above the
atrioventricular (AV) node. Clients with SVT can have a heart rate between 160-250 beats per
minute (BPM). Causes of SVT include electrolyte imbalances, cardiac disease, hypoxia and
medications. Clients with SVT typically present with palpitations, chest pain and shortness of
breath. They can also develop cardiogenic shock if the rhythm goes untreated. Treatment for
SVT includes vagal maneuvers, medications (i.e., adenosine) and synchronized cardioversion.
Based on the client's blood pressure and heart rate, the client is hemodynamically unstable.
Although the client's oxygenation status is within acceptable limits, it is not a good indicator of
hemodynamic status. The absence of chest pain and good capillary refill indicate that the client is
maintaining an adequate cardiac output and are, therefore, the best indicators that the client is
hemodynamically stable.
Concepts tested

Question 4053
The nurse is planning care for a client newly diagnosed with essential hypertension. Which
interventions should the nurse include in the client's plan of care? Select all that apply.
A Evaluate the client's understanding of a low-sodium diet.
B Evaluate the client's ability to take their own blood pressure.
C Encourage the client to limit smoking to one pack of cigarettes per day.
D Instruct the client to abstain from drinking any alcohol.
E Encourage the client to take daily, 30-minute walks.
F Explain the negative effects of hypertension on the body.

Question Explanation

Page | 1301
Correct Answer is A, B, E, F
Rationale: Hypertension can occur when the resistance to blood pumping through the arteries
increases. Risk factors for the development of hypertension include older age, smoking, salt
intake, family history and ethnicity. The client should be advised on the negative effects of
hypertension on the body, such as kidney failure and cardiovascular disease. The client should
know how to correctly check their blood pressure at home. Clients with hypertension should not
only limit smoking, but should not smoke at all due to the vasoconstrictive effects of nicotine.
Clients should understand what foods are appropriate for a reduced- or low-sodium diet and how
engaging in regular physical activity can help manage their disease. Complete abstinence from
alcohol is not required.
Concepts tested

Question 4054
A client diagnosed with renal calculi is admitted to the medical surgical unit. Which intervention
should the nurse implement first?
Question 4 Answer Choices
A Monitor the client's urinary output.
B Assess the client's pain.
C Review appropriate diet choices with client.
D Increase the client's oral fluid intake.

Question Explanation
Correct Answer is B
Rationale: The nurse should use the nursing process to prioritize and plan which intervention to
implement first. The first step in the process is assessment/data collection and should be taken
before formulating a plan of care and implementing interventions. All of the interventions in the
scenario are appropriate for a client with renal calculi, but asking the client about their pain level
should be done first. Based on the data obtained (i.e., the client’s pain level) the nurse should
then decide how to proceed.
Concepts tested

Question 4055
The nurse is caring for a client when the client begins to have a seizure. Which is the priority
action for the nurse to take?
A Maintain the client's airway.
B Apply restraints to prevent injury.
C Administer an antiepileptic.
D Insert an oral airway device or bite block.

Question Explanation
Correct Answer is A
Rationale: During a seizure, the client may not be able to maintain an open airway and is at risk
for aspirating their own secretions. In order to maintain an open airway, the nurse should turn the
client to their side and have suction equipment available. During a seizure, restricting the client's
movements and/or inserting an object into the client's mouth is contraindicated and can cause

Page | 1302
injury or further airway obstruction. After addressing the client's airway and breathing needs, the
nurse should administer any prescribed antiepileptics.
Concepts tested

Question 4056
A client is admitted to the nursing unit for respiratory distress due to a myasthenia gravis crisis.
Which recent treatment may have been a contributing factor to the client's condition?
Question 6 Answer Choices
A The administration of intravenous immunoglobulin for immune support
B The administration of morphine sulfate for acute pain management
C The administration of corticosteroids for immunosuppression
D The plasmapheresis exchange procedure performed for antibody removal

Question Explanation
Correct Answer is B
Rationale: Myasthenia gravis is a chronic autoimmune disease characterized by fatigue and
weakness, primarily in muscles innervated by the cranial nerves, as well as in skeletal and
respiratory muscles. As a result, nerve impulses are not transmitted to the skeletal muscle at the
neuromuscular junction. The priority for nursing management of the client in myasthenic crisis is
maintaining adequate respiratory function. Since this is an autoimmune disease, corticosteroids
may be used for immunosuppression as well as intravenous immunoglobulin (IVIg) therapy.
Plasmapheresis exchange is performed to remove antibodies from the blood. Drugs containing
magnesium and morphine should be avoided because they may increase the client's weakness
and respiratory suppression.
Concepts tested

Question 4057
The nurse is working with a client who is diagnosed with multiple sclerosis on how to reduce
muscle spasticity. Which statement by the client indicates the need for further teaching?
A "If I exercise daily, it can help with relieving spasticity."
B "Taking a long hot bath may relieve the muscle spasms."
C "My stretching routine can help with the muscle spasms."
D "Taking the prescribed muscle relaxant will relieve painful spasms."

Question Explanation
Correct Answer is B
Rationale: The client with multiple sclerosis (MS) should not use hot water for a bath because of
the risk of thermal injury (e.g., burns) due to sensory deficits with MS. Instead, warm
compresses may be used to relieve muscle spasms. The other actions can help with muscle
spasms or spasticity and are appropriate for the client to use.
Concepts tested

Question 4058
The nurse is caring for a client with meningitis. Which observation by the nurse would indicate
that the client's condition is worsening?

Page | 1303
A Complaints of a headache
B Decreased level of consciousness
C A temperature of 101.3° F. (38.5° C)
D Complaints of light sensitivity

Question Explanation
Correct Answer is B
Rationale: Meningitis is an inflammation of the arachnoid and pia matter of the brain and spinal
cord. Expected findings for a client with meningitis include photophobia, headache, fever and
chills. The most important nursing intervention for clients with meningitis is the accurate
monitoring and recording of their neurologic status, vital signs and vascular assessment.
Increased Intracranial Pressure (ICP) is a life-threatening complication of meningitis. A decrease
in the client's level of consciousness is typically the first sign of an increasing ICP.
Concepts tested

Question 4059
The nurse is caring for a client who was admitted to the hospital for syndrome of inappropriate
antidiuretic hormone. Which interventions are appropriate for this client's plan of care? Select
all that apply.
A Increase the client's fluid intake to 5,000 milliliters per day.
B Monitor the client for pulmonary edema and orthopnea.
C Document the client's weight daily.
D Monitor the client's serum sodium level.
E Administer five units of vasopressin every six hours, intramuscularly.
F Keep a padded tongue blade at the bedside.
G Document changes in the client's neurologic status.

Question Explanation
Correct Answer is B, C, D, G
Rationale: Syndrome of inappropriate antidiuretic hormone (SIADH) is caused by excessive
antidiuretic hormone leading to fluid volume overload and dilutional hyponatremia. Associated
clinical manifestations are related to fluid overload (pulmonary edema, orthopnea and
crackles/rales in the lungs) and dilutional hyponatremia (confusion, headache, decreased muscle
strength and decreased neuromuscular excitability). Appropriate interventions include
monitoring the response to treatment, preventing complications, maintaining a safe environment
and reinforcing education regarding fluid restriction. Vasopressin, an antidiuretic analogue, is
contraindicated in clients with SIADH. While this client is at increased risk for seizures, padded
tongue blades are not appropriate seizure precautions. Monitoring and documenting sodium
levels, daily weight, pulmonary status and neurologic status are appropriate for this client.
Concepts tested

Question 4060
The nurse is planning the care for a client who was admitted with complications related to
chronic diabetes insipidus. Which interventions are a priority for this client? Select all that
apply.

Page | 1304
A Monitor fluid intake and output.
B Measure blood glucose levels before meals.
C Restrict fluid intake to 1000 mL per day.
D Weigh the client every morning.
E Monitor urinary specific gravity.
F Evaluate the moisture level of mucous membranes.
G Measure blood pressure and heart rate.

Question Explanation
Correct Answer is A, D, E, F, G
Rationale: Chronic diabetes insipidus is a disorder associated with an inadequate level of
antidiuretic hormone or the decreased ability for the renal tubules to respond to antidiuretic
hormone. Clinical manifestations of this disorder are related to dehydration due to the large
amounts of diluted urine being excreted. For clients with diabetes insipidus, priority
interventions within the plan of care should focus on fluid balance, including blood pressure and
heart rate, fluid intake and output, inspecting the mucous membranes, weighing the client daily
and monitoring urinary specific gravity. Fluid restrictions are contraindicated for this client and
could lead to severe dehydration. Additionally, diabetes insipidus is not associated with blood
glucose imbalance.
Concepts tested

Question 4061
The nurse is caring for a 30-year-old female client scheduled for a hypophysectomy due to a
pituitary tumor. The client asks how removal of the pituitary gland will affect her Which is the
best response by the nurse?
A "Because of the surgery, you will be at an increased risk for seizures."
B "You will be immunocompromised and need to stay away from large crowds."
C "You will be required to monitor your blood sugar levels and take insulin."
D "After the procedure, you might have difficulties getting pregnant."

Question Explanation
Correct Answer is D
Rationale: Surgical removal of the pituitary gland, or hypophysectomy, is a common treatment
strategy for patients with pituitary tumors. Unfortunately, because the pituitary gland is
responsible for fertility-related hormones such as luteinizing hormone (LH) and follicle-
stimulating hormone (FSH), complications of this surgery include problems with fertility and the
cessation of menses in women of childbearing age. Removal of the pituitary gland will not affect
glucose metabolism and the immune system or create a risk for seizures.
Concepts tested

Question 4062

Page | 1305
The client who was admitted with exacerbation of ulcerative colitis has developed
hyperglycemia. Which medication that the client was prescribed most likely caused this adverse
drug effect?
A Diphenoxylate/atropine
B Dicyclomine
C Prednisone
D Acetaminophen

Question Explanation
Correct Answer is C
Rationale: Prednisone is a corticosteroid, specifically a glucocorticoid. Corticosteroid therapy
may be prescribed during exacerbations of ulcerative colitis to decrease inflammation. Common
adverse effects include hyperglycemia, osteoporosis, peptic ulcer disease and an increased risk
for infection. The nurse should monitor clients who are receiving prednisone for hyperglycemia.
Dicyclomine hydrochloride and diphenoxylate with atropine are cholinergic blocking drugs
prescribed for gas (flatus) and diarrhea, commonly seen with ulcerative colitis. Acetaminophen is
a non-narcotic analgesic given for mild-to-moderate pain. None of those drugs are known to
cause an elevated blood sugar.
Concepts tested

Question 4063
The nurse is caring for a postoperative client following an appendectomy. The client has a
nasogastric tube connected to low, continuous suction. Twice during the shift, the nurse irrigated
the nasogastric tube with 50 mL of sterile water each time. At the end of the shift, the nurse
empties a total of 450 mL from the drainage container. How much actual gastric drainage did the
client have for the nurse's shift?
A 350
B 450
C 400
D 300

Question Explanation
Correct answer is A
After surgery, a nasogastric (NG) tube is placed to decompress the stomach and prevent
abdominal distension. The nurse should carefully monitor and record the amounts of gastric
drainage from the NG tube.

Drainage Container Total - Irrigation Volume Total = Shift Total

Total drainage was 450 mL
Irrigation was 50 mL x 2 occurrences = 100 mL
Concepts tested

Question 4064
The home health nurse is assisting a client who is scheduled for a chemotherapy infusion the
next day. The client's medical record indicates frequent episodes of nausea and vomiting after

Page | 1306
previous chemotherapy treatments. Which action would be most helpful in preventing nausea
and vomiting in this client?
A Reinforce teaching to the client about the side effects of chemotherapy.
B Keep the client on only ice chips for 24 hours after the infusion.
C Administrate metoclopramide prior to start of the infusion.
D Administrate ondansetron immediately after the infusion.

Question Explanation
Correct Answer is C
Rationale: Chemotherapy-induced nausea and vomiting (CINV) arises from a variety of local
and central nervous system mechanisms. Most chemotherapy drugs are emetogenic to some
degree. The most helpful way to prevent CINV is by premedicating the client with an antiemetic
drug, such as metoclopramide, before the infusion. The client may need to take antiemetics for a
couple days after the infusion, but the need for them can be decreased if the client has been
premedicated with antiemetics. Although education is important, it will not prevent CINV.
Concepts tested

Question 4065
The home health nurse is caring for a client who underwent a partial gastrectomy due to gastric
cancer several months ago. Which finding would indicate that the client is suffering from
pernicious anemia? Select all that apply.
A The client is exhibiting alopecia.
B The client is experiencing urinary retention.
C The client's sclerae are icteric.
D The client's tongue is shiny and beefy-red.
E The client reports numbness and tingling in the feet.

Question Explanation
Correct Answer is C, D, E
Rationale: Pernicious anemia or B12 deficiency are expected in this client due to the removal of
a portion of the stomach. With the absence of intrinsic factor, B12 absorption cannot occur and,
if left untreated, will lead to pernicious anemia. Typical symptoms include a smooth, beefy-red
tongue (glossitis), fatigue, weight loss and jaundice (yellowing of the skin and sclerae). B12 also
plays a key role in nerve function and, when absent, can cause paresthesia in the hands and feet.
Urinary retention and alopecia (hair loss) are not usually seen with pernicious anemia.
Concepts tested

Question 4066
The nurse is caring for a client receiving chemotherapy for breast cancer. Which client statement
indicates that additional teaching is required?
A "I feel nauseous every day after receiving my medications."
B "My neighbor is bringing me fresh flowers from her garden."
C "I've been careful to drink water in small sips throughout the day."
D "I have been waking up throughout the night, feeling restless."

Page | 1307
Question Explanation
Correct Answer is B
Rationale: Clients receiving chemotherapeutic treatment are at-risk for neutropenia and
associated infections. Chemotherapy can suppress, or weaken, the immune system, otherwise
known as immunosuppression. Fresh flowers and plants introduce the potential for the client to
be exposed to fungi or bacteria, and thus should be avoided in immunosuppressed patients on
chemotherapeutic agents. Nausea and impaired sleep are common side effects of chemotherapy,
and although they should be addressed by the nurse, they are not a priority concern. Clients who
drink water throughout the day are likely to stay hydrated despite potential nausea and vomiting,
so this is also not a concerning statement.
Concepts tested

Question 4067
The nurse is caring for a client who is taking leuprolide for endometriosis. The nurse should
monitor the client for which side effects? Select all that apply.
A Increased fertility
B Anorexia
C Amenorrhea
D Hot flashes
E Emotional lability
F Vaginal dryness

Question Explanation
Correct Answer is C, D, E, F
Rationale: Endometriosis is a benign gynecologic condition in which endometrial tissue grows
outside of the uterus. It can be controlled, but not cured, by drug therapy. Drugs commonly used
include oral contraceptives and GnRH agonists such leuprolide and nafarelin. GnRH drugs result
in amenorrhea (absence of menstruation) and other symptoms that mimic menopause such as hot
flashes, vaginal dryness and emotional lability. Anorexia (lack of appetite) is not a side effect
usually seen with leuprolide. Leuprolide does not increase fertility.
Concepts tested

Question 4068
A 50-year-old male client with a family history of prostatic hyperplasia asks the nurse how the
health care provider will screen him for the disease. Which is the best response by the nurse?
A A prostate-specific antigen test
B A digital rectal exam
C A prostate biopsy
D A history of symptoms

Question Explanation
Correct Answer is B
Rationale: A digital rectal exam is the most effective way to determine if the prostate gland is
enlarged. The prostate-specific antigen (PSA) test is a blood test used primarily to screen for
prostate cancer, not benign prostatic hyperplasia (BPH). A history of symptoms will also be

Page | 1308
completed, however many symptoms of BPH are similar to other conditions. A biopsy is usually
done to determine the presence of cancer.
Concepts tested

Question 4069
The nurse is caring for a client who was recently diagnosed with hypopituitarism. Which client
statements would indicate additional teaching is needed? Select all that apply.
A "I should feel less fatigued within the next few weeks."
B "I will need to take calcium and vitamin D supplements."
C "I should let my health care provider know if there are changes in my urinary patterns."
D "I should expect breast swelling or tenderness."
E "I should expect to feel more thirsty throughout the day."

Question Explanation
Correct Answer is D, E
Rationale: Clients with hypopituitarism are at-risk for diabetes insipidus, in addition to increased
levels of prolactin and subsequent breast tenderness, swelling and leakage. Both of these findings
are abnormal and should be evaluated by a health care provider (HCP). Thus, additional teaching
is required for a client who states that breast swelling or tenderness is expected or that increased
thirst is expected. For the same reason, changes in frequency of urination may indicate diabetes
insipidus and should be reported to a HCP. Clients with hypopituitarism should expect to see an
improvement in symptoms within a few weeks. Additionally, clients are at-risk for osteoporosis
and may need calcium and vitamin D supplements.
Concepts tested

Question 4070
The nurse is caring for a client with adrenal insufficiency. The nurse understands that the
hormone cortisol is controlled by a cascade of events in specific organs. Beginning with the
organ that responds first to low cortisol levels, place the following events in the correct order.
1. Adrenal cortex is stimulated.
2. Hypothalamus is stimulated
3. Cortisol level returns to adequate range
4. Anterior pituitary is stimulated
5. Adrenocorticotropic hormone is released
6. Cortisol is released
7. Cortisol releasing hormone is released
A 2, 7, 4, 5, 1, 6, 3
B 1, 2, 4, 6, 5, 7, 3
C 2, 1, 6, 4, 3, 5, 7
D 7, 1, 2, 4, 5, 6, 3

Question Explanation
Correct Answer is A

Page | 1309
Rationale: Adrenal insufficiency (Addison's disease) is caused by a decrease in adrenocortical
hormones, such as cortisol and aldosterone. Adrenal insufficiency is characterized by muscle
weakness, fatigue, hypotension and electrolyte imbalances. This hormone cascade is controlled
by the hypothalamic-pituitary axis. In this negative feedback loop, the hypothalamus is
stimulated by low cortisol levels, which causes a release of cortisol releasing hormone (CRH).
CRH stimulates the anterior pituitary to release adrenocorticotropic hormone (ACTH). ACTH
stimulates the adrenal cortex to release cortisol. Finally, adequate levels of cortisol cause the
hypothalamus to stop releasing CRH.
Concepts tested

Question 4071
The nurse is caring for a client with severe iron deficiency anemia. Which interventions should
the nurse include in the client's plan of care? Select all that apply.
A Monitor the client's stool for color, consistency, and frequency
B Review the client's medical record for NSAID use
C Encourage the client to eat more green leafy vegetables and beans
D Administer the client's prescribed iron supplements with milk
E Instruct assistive personnel to allow the client to rest during care activities
F Prepare the client for a packed red blood cells transfusion
G Monitor the client for palpitations and orthostatic hypotension

Question Explanation
Correct Answer is A, B, C, E, G
Rationale: Iron deficiency anemia is the most common type of anemia. Lower levels of iron in
the body fail to produce red blood cells (RBCs). Without sufficient RBCs, the client's body and
tissues will not receive enough oxygen. Risk factors for iron deficiency anemia include
pregnancy, gastric bypass, blood loss, gastric ulcer, gastrectomy, and menstruation. Because iron
deficiency anemia can be caused by gastrointestinal (GI) bleeding, it is recommended to check
the color of the client's stool. Dark, tarry stools could indicate upper GI bleeding. Manifestations
of anemia include palpitations, tachycardia, hypotension, pallor, and shortness of breath. Clients
should take iron on an empty stomach for better absorption. Taking iron with milk will block the
medication's absorption. Clients should be encouraged to eat foods that contain iron, such as
green leafy vegetables, beans, legumes, and muscle meats. NSAID use has the potential to cause
gastric ulcer development and GI bleeding. Clients with anemia will be fatigued and tire easily
and should be allowed to rest during care activities. The scenario does not indicate that the client
needs a blood transfusion at this time.
Concepts tested

Question 4072
The nurse is caring for a client with a diagnosis of pericarditis. The unlicensed assistive person
reports to the nurse that the client's last set of vital signs were blood pressure of 84/40 mm Hg,
respiratory rate of 28 breaths/minute, heart rate of 112 bpm, and the client seemed short of
breath. The nurse examines the client and also notes the presence of jugular vein distention.
What should the nurse do next?
A Obtain a 12-lead electrocardiogram

Page | 1310
B Place the client on nothing by mouth status
C Administer the prescribed metoprolol
D Notify the health care provider

Question Explanation
Correct Answer is D
Rationale: Clients with pericarditis are at risk for developing cardiac tamponade. Cardiac
tamponade means fluid builds up within the pericardial sac, compressing the heart and making it
difficult to pump, thus reducing cardiac output. The client is showing signs and symptoms of
cardiac tamponade and reduced cardiac output: hypotension, tachycardia, tachypnea, shortness of
breath, and jugular vein distention. The nurse should immediately notify the health care provider
(HCP) because cardiac tamponade is a life-threatening emergency that requires immediate
intervention. The nurse should not give the metoprolol, a beta-blocker, since the drug will further
lower the client's blood pressure and may cause the client to go into shock. The other
interventions should be performed after the HCP has been notified.
Concepts tested

Question 4073
The nurse in the outpatient clinic is reviewing the medical record of a client diagnosed with
Raynaud's disease. What information from the client's health history would support this
diagnosis? Select all that apply.
A The client smokes two packs of cigarettes per day.
B The client reports brittle fingernails that break easily.
C Fingers become cyanotic when exposed to cold objects.
D The client works in an office setting as a typist.
E Warfarin is listed on the medication reconciliation form.

Question Explanation
Correct Answer is A, B, C, D
Rationale: Raynaud's disease is considered a vasospastic disorder that affects the small arteries of
the fingers and toes. Raynaud's occurs due to an imbalance between vasodilation and
vasoconstriction. Cases of Raynaud's are considered either idiopathic or pathologic. Risk factors
include occupation-related factors, such as repetitive hand motions (typing, industrial
equipment), or hyperhomocysteinemia. Clients with Raynaud's disease may complain of their
fingers or toes becoming cyanotic or pale when they come in contact with cold objects or a cold
environment. When this occurs, clients may complain of numbness or tingling in the affected
digits. Exposure to tobacco, emotions, and caffeine have been known to trigger a vasospastic
event. Medications that can be used for Raynaud's include statins, calcium channel blockers, and
vasodilators. Anticoagulants are not indicated for the treatment or prevention of Raynaud's
disease. A construction worker who operates a jackhammer would be at risk for Raynaud's due to
the vibrating equipment. Clients who suffer from frequent vasospastic attacks can develop brittle
nails.
Concepts tested

Question 4074

Page | 1311
The hospital nurse is teaching a client who is being discharged home about their new diagnosis
of type 2 diabetes mellitus. Which statement by the client would require clarification from the
nurse?
A “When I administer my insulin, I will rotate injection sites.”
B "I will make sure to have an eye exam every five years.”
C “It is important to increase my physical activity gradually.”
D “At home, I should check my blood sugar before meals and at bedtime.”

Question Explanation
Correct Answer is B
Rationale: For diabetic clients, it is imperative they protect and monitor the function of their eyes
and kidneys due to the vascular damage associated with diabetes mellitus. Eye exams should be
performed annually for diabetic clients due to the risk of diabetic retinopathy. Clients should
increase physical activity slowly to prevent injury. Additionally, before meals and at bedtime is
an appropriate time for checking blood sugar. Rotating injection sites helps prevent
lipodystrophy and increase the absorption of insulin.
Concepts tested

Question 4075
The nurse prepares to care for a 4-year-old child newly admitted with rhabdomyosarcoma.
Which area and function of the child's body should the nurse alert the staff to pay attention to?
Question 5 Answer Choices
A The kidneys
B The leg bones
C The cerebellum
D The muscles

Question Explanation
Correct Answer is D
Rationale: Rhabdomyosarcoma (RMS) is a malignant tumor that develops from normal skeletal
muscle cells. Because skeletal muscle cells are found in every site of the body, RMS can develop
in any part of the body. RMS is the most common children's soft tissue sarcoma. It originates in
striated (skeletal) muscles and can be found anywhere in the body. The clue is in the middle of
the word "myo," which typically means muscle. The most common locations for these tumors
are in the structures of the head and neck, the male or female genitourinary tract (e.g. bladder,
prostate, etc.), and the extremities. Although the tumors originate in the muscle, they can
metastasize to the bone. Kidney and brain tissue are not composed of striated skeletal muscle;
therefore, tumors would not develop in these locations. Clients would complain of a lump or
swelling in the body, which may be painful.
Concepts tested

Question 4076
The nurse is assessing a client with myasthenia gravis who has a dose of pyridostigmine ordered
for 7 am. Prior to giving the medication, the nurse observes and notes diplopia, dysphagia, and a
weak cough. The client has ordered breakfast for 8 am. Which action is the priority?
Page | 1312
A Assess for lower extremity weakness
B Give the client edrophonium chloride
C Administer the pryidostigmine as soon as possible
D Hold the medication and notify the health care provider

Question Explanation
Correct Answer is C
Rationale: Myasthenia gravis is a chronic, progressive autoimmune disorder that is characterized
by periods of remission and exacerbation. Auto-antibodies attack the neuromuscular junction of
skeletal muscles, thus leading to weakness of skeletal muscle groups. The condition worsens
with activity and improves with rest and progresses to more severe weakness over weeks to
months. Edrophonium chloride is typically administered for diagnostic purposes, not for
treatment. The findings indicate that the priority is for pyridostigmine to be administered
promptly to decrease symptoms of muscle weakness and facilitate the client's ability to eat
breakfast. Lower extremity weakness is expected in this diagnosis and is not relevant to the
situation. Holding the medication would only be an option if a cholinergic crisis is suspected.
Concepts tested

Question 4077
The nurse is teaching the parents of a 2-week-old infant with tetralogy of Fallot. Which finding
should the nurse instruct the parents to immediately report to the health care provider?
A Feeding problems
B Changes in level of consciousness
C Poor weight gain
D Fatigue with crying

Question Explanation
Correct Answer is B
Rationale: Tetralogy of Fallot (TOF) is a congenital heart defect that is characterized by four
structural abnormalities: right ventricular hypertrophy, aortic displacement, pulmonary stenosis,
and a ventricular septal defect. While parents should report any of these findings, they
should immediately notify the health care provider or call 911 if the level of consciousness
(LOC) decreases, or the infant becomes unresponsive. A decreased LOC indicates brain anoxia,
which may lead to death, and is a medical emergency. The other findings (e.g., feeding
problems, poor weight gain, and fatigue with crying) can indicate the development of heart
failure in an infant.
Concepts tested

Question 4078
The nurse assesses several postpartum women. Which of these women is at the highest risk for a
puerperal infection?
A Five days postpartum, temperature is 99.6°F (37.6°C) since undergoing cesarean section
B Twelve hours postpartum, temperature is 100°F (37.7°C) following vaginal delivery
C Three days postpartum, temperature is 100.8°F (38.2°C) for two days after undergoing
cesarean section

Page | 1313
D Seven days postpartum, temperature is 99°F (37.2°C) since vaginal delivery

Question Explanation
Correct Answer is C
Rationale: A temperature of 100.4°F (38°C) or higher on two successive days (not counting the
first 24 hours after birth) indicates a postpartum infection. Puerperal infections can be due to
endometritis, wound, and other infections; the risk of endometritis increases after cesarean
delivery. The other women are not at risk for infection because their temperatures are within the
expected normal findings for the time period.
Concepts tested

Question 4079
The nurse is assessing a 2-year-old toddler with a possible diagnosis of congenital heart disease.
Which of the following findings will the nurse most likely see with this diagnosis?
A Several otitis media episodes in the last year
B Takes frequent breaks while playing
C Changing food preferences and dislikes
D Weight and height in the tenth percentile since birth

Question Explanation
Correct Answer is B
Rationale: Children with heart disease tend to have exercise intolerance. The child self-limits
activity, which is consistent with manifestations of congenital heart disease in children.
Concepts tested

Question 4080
The nurse is caring for a female, long-distance runner who is diagnosed with anorexia nervosa.
Which of the following concerns should the nurse determine to be the priority when planning the
client's care
A Electrolyte imbalance
B Blood disorders
C Digestive problems
D Amenorrhea

Question Explanation
Correct Answer is D
Rationale: Anorexia nervosa is considered an eating disorder that is characterized by low body
weight, a fear of gaining weight, and distorted reality of weight. Clients with anorexia nervosa
control their weight through caloric restriction and starvation. Anorexia nervosa affects the
whole body. However, female athletes with this condition can experience a decrease in
hormones, which causes irregular periods or even amenorrhea. Low estrogen levels and poor
nutrition, especially low calcium intake, can lead to premenopausal osteoporosis. Young women
athletes are at high risk of stress fractures and other bone pathology. The three conditions (eating
disorder, amenorrhea, and osteoporosis) are sometimes referred to as the female athlete triad.
Clients who suffer from anorexia are at risk for malnutrition, digestive problems, and blood

Page | 1314
disorders. However, the question pertains to a female, long-distance runner. The nurse's priority
would be to focus on the client's periods.
Concepts tested

Question 4081
The nurse is caring for a client at the community clinic who requires treatment for recurrent
pelvic inflammatory disease (PID). The nurse knows that this condition most frequently follows
which type of infection?
A Trichomoniasis
B Syphillis
C Chlamydia
D Herpes simplex 2

Question Explanation
Correct Answer is C
Rationale: Pelvic Inflammatory Disease (PID) is an infection of the female upper reproductive
tract. Treatment is broad-spectrum antibiotics. Chlamydia and gonorrhea infections are the most
frequent cause of PID. These sexually transmitted infections often have subtle findings;
therefore, they are often not diagnosed early in their course before more widespread infection
and complications occur. This also prevents appropriate detection and treatment before
transmission to others during sexual activity. A complication of recurrent infection is the
obstruction and scarring of the fallopian tubes resulting in infertility.
Concepts tested

Question 4082
The home health nurse is teaching a client with reduced mobility after a stroke about how to
prevent pressure injuries or ulcers. Which statement from the client indicates that additional
teaching is needed?
A "I should monitor my skin for redness or warmth."
B "I should shift my body weight frequently throughout the day."
C "I should walk with my walker when I can."
D "I should massage areas of my skin that are red."

Question Explanation
Correct Answer is D
Rationale: Pressure ulcers occur in areas of soft tissue when pressure applied over time exceeds
normal capillary closure pressure resulting in tissue necrosis. For this reason, a critical
intervention is the relief of pressure. Thus, clients should understand that it is important to shift
their body weight and reposition throughout the day and to maximize mobility by ambulating
when they are physically able and with assistive devices. Additionally, clients should monitor for
early signs of pressure-related tissue damage, such as skin redness or warmth. The client's
statement about massaging any reddened areas is incorrect and requires additional teaching.
Clients should avoid massaging areas of tissue damage, as this can lead to capillary damage and
deep tissue injury.
Concepts tested

Page | 1315
Question 4083
The nurse is caring for an 80-year-old client in an assisted living facility, who has a temperature
of 100.6°F (38.1°C). This is a sudden change from the client's usual temperature. Which of the
following assessments should the nurse perform first?
A Lung sounds
B Urine output
C Level of alertness
D Appetite

Question Explanation
Correct Answer is C
Rationale: Older adults have atypical signs and symptoms of infection. This may make it
challenging to identify changes in an older client's condition. Anorexia is considered a symptom
of infection. However, it is a vague finding that could be applicable to anything. It is not the
most important finding. Confusion and decreased level of consciousness are commonly seen in
older adults with an infection. They are often the first sign of infection even in the absence of
fever. If the client is alert and responds to questions appropriately, then the temperature should
be rechecked. Assessing the client's level of consciousness will help the nurse determine the
severity of the temperature elevation and the possibility that this represents an infection. The
urine and lungs should be assessed for findings of infection because urinary tract infections and
pneumonia are common causes of fever in older adults. However, the client's level of
consciousness should be assessed first.
Concepts tested

Question 4084
The nurse is caring for a client in the emergency room with a fractured lower right leg, who
receives morphine IV for the pain. One hour later, the client reports that "the pain is getting
worse." The nurse should recognize that the client may be developing which of the following
complications?
A Fatty embolism
B Thromboembolic complications
C Osteomyelitis
D Acute compartment syndrome

Question Explanation
Correct Answer is D
Rationale: Pain is one of the most common complaints of a client who suffers a fracture. It is not
uncommon for clients to receive intravenous (IV) pain medications in the initial setting after a
fracture. Thromboembolic complications, such as deep vein thrombosis and pulmonary
embolism, are not characterized by increased pain at the site of injury. Increasing pain that is not
relieved by narcotic analgesics is a possible sign of compartment syndrome. This condition
occurs when the perfusion in the leg decreases due to ongoing swelling at the site. It requires
immediate action by the nurse to prevent permanent muscle damage. A fat embolism is
associated with sudden changes in respiratory status, petechial hemorrhages, and chest pain. This
condition does not increase pain at the site of injury. Osteomyelitis is a bone infection that could
occur sometime after the initial injury typically around 48 to 72 hours later.
Page | 1316
Concepts tested

Question 4085
The nurse is developing a plan of care for a postoperative client following the surgical creation
of an ileostomy. Which intervention should the nurse implement first?
A Providing emotional support
B Assessing the appearance of the stoma
C Teaching the management of the pouch
D Addressing concerns with body image

Question Explanation
Correct Answer is B
Rationale: Following the nursing process, assessing the appearance of the stoma is the
intervention that should be implemented first. The nurse needs to monitor for stoma health and
possible complications. Examples of complications include bleeding, infection, or lack of blood
flow to the stoma. As the stoma starts to function, the nurse would explain the care of the stoma
to the client. Providing emotional support, teaching how to care for the ostomy, and addressing
body image concerns are important but should be implemented after assessing the ostomy.
Concepts tested

Question 4086
The nurse is caring for a 6-year-old child with edema and hypertension associated with acute
glomerulonephritis (AGN). Which of the following interventions should be the highest
priority for the nurse?
A Establish seizure precautions
B Administer prescribed antibiotics
C Relieve boredom through physical activity
D Encourage protein-rich foods

Question Explanation
Correct Answer is A
Rationale: Acute glomerulonephritis (AGN) is the inflammation of the nephrons and glomeruli
caused by a previous streptococcal infection. In AGN, there is a leakage of red blood cells and
protein from the inflamed glomeruli. Dietary restrictions should include fluids, sodium, protein,
and potassium due to the edema and low urine output. A child with edema and severe
hypertension may be at risk for complications such as hypertensive encephalopathy. This
complication occurs due to decreased kidney function and low urine output. Findings with this
complication include headache, confusion, and vomiting. Seizure precautions should be
instituted in this client. Although antibiotics may be indicated if a bacterial infection is still
present, this is not the priority action. The child should be on bed rest during the acute phase
until they start to recover.
Concepts tested

Question 4087

Page | 1317
The nurse is caring for a client diagnosed with multiple sclerosis who plans to begin an exercise
program. Which of the following information should the nurse be sure to emphasize when
discussing this topic with the client?
A Dress warmly
B Avoid dehydration
C Avoid aerobic exercise
D Focus on strength training

Question Explanation
Correct Answer is B
Rationale: Multiple sclerosis (MS) is an autoimmune disease in which the body's immune system
attacks and damages the myelin sheath, the insulating material that surrounds the nerve fibers of
the brain and spinal cord. When the myelin sheath becomes damaged, nerve impulses to and
from the brain are interrupted. As a result, clients with MS experience muscle weakness, poor
balance and coordination, muscle spasticity, and paralysis that may be temporary or permanent.
Clients with MS who participate in regular aerobic exercise have better cardiovascular fitness,
greater strength, better bowel and bladder function, and less fatigue. The client must take in
adequate fluids before and during exercise periods to prevent dehydration. It is recommended
that clients with MS exercise when it is colder and perform exercise earlier in the day to avoid
fatigue.
Concepts tested

Question 4088
The nurse is admitting a client with a diagnosis of acute bacterial endocarditis. Which of the
following findings would alert the nurse to a complication of this condition?
Question 18 Answer Choices
A Macular rash
B Pain and pallor in one foot
C Heart murmur
D Hemorrhage

Question Explanation
Correct Answer is B
Rationale: Endocarditis is an inflammation of the endocardium layer of the heart secondary to an
infection. Acute endocarditis occurs very quickly and the symptoms are severe. Vegetations
grow on the heart valves in bacterial endocarditis. These vegetations may break off and travel
through the bloodstream, lodge in small vessels, and result in necrosis of the tissue distal to the
embolus. Although clients with endocarditis can manifest with lesions and petechiae, the
presence of a rash is not commonly found with this condition. Pain and pallor are findings in an
embolic arterial occlusion of an extremity. Other findings would include pulselessness,
paresthesia, paralysis, and poikilothermia (coldness), known as the 6 Ps of ischemia.
Hemorrhage or bleeding is not a typical manifestation of a complication of endocarditis. Heart
murmurs are a common finding in endocarditis, and clients with murmurs caused by valve
damage are at the highest risk of developing endocarditis.
Concepts tested

Page | 1318
Question 4089
The nurse is counseling a 6-year-old child who was recently diagnosed with nocturnal enuresis.
Which of the following must the nurse understand about the pathophysiology of this disorder
prior to counseling the child?
A Enuresis has a definite genetic link.
B Enuresis may be associated with sleep phobia.
C Enuresis is a sign of willful misbehavior.
D Enuresis often has no clear etiology.

Question Explanation
Correct Answer is D
Rationale: Nocturnal enuresis (NE) occurs in a child over the age of five who does not have any
other physical or mental conditions contributing to the problem. A urinalysis (UA) is indicated to
rule out other reasons (i.e. medical and mental disorders) for the nighttime bed-wetting. An
individualized treatment plan is indicated for the client. Although there are many predisposing
factors associated with NE, no clear etiology has been determined for the condition. NE is not
the fault of the child nor is it caused by willful misbehavior. Often children are asleep when the
bed-wetting occurs. It is not done on purpose. There is no evidence that supports that NE is
associated with sleep phobia. Although NE is commonly associated with a family history of the
condition, no genetic link has been definitely confirmed.
Concepts tested

Question 4090
The nurse is admitting a client to the emergency department (ED) who reports chest pain. Which
of the intervention(s) does the nurse expect to be implemented within the first 10 minutes of the
client's arrival in the ED? Select all that apply.
A Blood draw for cardiac troponin
B Supplemental oxygen
C Problem-focused cardiovascular assessment
D 12-lead ECG
E Intravenous thrombolysis
F Intravenous access

Question Explanation
Correct Answer is A, C, D, F
Rationale: Chest pain can be associated with a blockage in a coronary artery. All clients
reporting chest pain should be treated as if the pain is cardiac and ischemic in nature. Treatment
will depend on whether the chest pain is due to a myocardial infarction (MI) and the type of MI.
IV (intravenous) thrombolysis should be used if an ST-elevated myocardial infarction (STEMI)
is confirmed, and the client is unable to be transported to the cardiac catheterization lab within
90 minutes. Supplemental oxygen should only be used to maintain oxygen saturation greater than
90%. Supplemental oxygen may harm nonhypoxic clients with STEMI. Treatment in the
emergency department (ED) begins with a problem-focused cardiovascular assessment due to
assess history and risk factors. IV access should be established, and labs drawn for cardiac

Page | 1319
markers (i.e. troponin). A 12-lead ECG should be performed to help confirm if the chest pain is
an MI.
Concepts tested

Question 4091
The nurse is caring for a client with a dry chest tube drainage system due to a left tension
pneumothorax. Two hours ago, the health care provider (HCP) changed the chest tube
prescription to water seal only. When entering the client's room, the nurse finds the client to be
short of breath, tachypneic, and with an oxygen saturation of 84%. On auscultation, the nurse
notes absent breath sounds to the left upper lobe. What action should the nurse take first?
A Apply oxygen via nasal cannula
B Request a chest x-ray
C Document all interventions in the client's medical record
D Notify the appropriate HCP

Question Explanation
Correct Answer is A
Rationale: A chest tube system is usually changed from wall suction to water seal only when the
pleural space has re-expanded after a pneumothorax and in preparation for removing the chest
tube. Shortness of breath, tachypnea, absent breath sounds, and hypoxemia indicate a recurrence
of the pneumothorax. This is a life-threatening medical emergency that requires the nurse to
prioritize. Using the Airway-Breathing-Circulation (ABC) decision-making strategy, the nurse
should first provide the client with supplemental oxygen and then immediately notify the HCP.
A chest x-ray will be required to determine the cause of the client's change in condition. After the
client's urgent needs have been addressed, the nurse should then document all interventions
implemented in the client's medical record.
Concepts tested

Question 4092
A nurse is caring for a client after a tonsillectomy. The nurse observes the client swallowing
frequently between sips of water. The nurse understands that this could be a sign of which
complication?
A Bleeding
B Postnasal drip
C Aspiration
D Anxiety

Question Explanation
Correct Answer is A
Rationale: After a tonsillectomy, bleeding from the surgical site is a potential complication.
Clients who are bleeding from that area tend to "swallow" the blood. Postnasal drip may also
cause frequent swallowing, but unless the client also had an adenoidectomy performed, a
postnasal drip should not be present. Anxiety symptoms typically don't include frequent
swallowing. Frequent swallowing is not a sign of aspiration.
Concepts tested

Page | 1320
Question 4093
A client who is receiving continuous oxygen therapy by nasal cannula for an acute respiratory
problem is becoming increasingly confused. What should the nurse do first?
A Raise the head of the bed
B Obtain a pulse oximeter reading
C Notify the health care provider
D Administer a bronchodilator

Question Explanation
Correct Answer is B
Rationale: Cerebral hypoxia can be a cause of confusion and is an indicator that the client
requires more oxygen. By following the nursing process, the nurse should first determine the
client's current oxygen saturation. The nurse should then notify the health care provider of the
change in the client's condition and implement the other interventions if appropriate.
Concepts tested

Question 4094
The nurse is caring for a client with bronchiolitis. What is the priority nursing intervention?
A Administering 100% oxygen
B Maintaining a soft diet
C Maintaining a patent airway
D Administering antiviral medications

Question Explanation
Correct Answer is C
Rationale: Bronchiolitis (tracheobronchitis) is the swelling and mucus buildup in the bronchioles,
usually due to a viral infection. Using the Airway-Breathing-Circulation decision-making
approach, the priority is to ensure a patent airway for this client. The scenario does not provide
data that administering 100% oxygen is required. Antiviral medications are indicated but would
be used as supportive care. A soft diet might be helpful, but that is not the priority.
Concepts tested

Question 4095
A client who has been hospitalized for pneumonia is ready to be discharged home. Which
statement indicates that the client understood the discharge instructions given by the nurse?
A "I will schedule an appointment for the influenza vaccine."
B "I will call the doctor if I still feel tired after a week."
C "I will need to use home oxygen therapy for one month."
D "I will continue deep breathing and coughing exercises at home."

Question Explanation
Correct Answer is D
Rationale: Clients should continue to cough and perform deep breathing exercises after discharge
to promote alveolar expansion and clearing of the airways. Fatigue is expected for several weeks.

Page | 1321
Home oxygen therapy is not needed with successful treatment of pneumonia. The influenza
vaccine does not protect against pneumonia.
Concepts tested

Question 4096
The nurse is interviewing a client who was recently exposed to pulmonary tuberculosis (TB).
Which finding(s) would the nurse most likely see with this client?
A Hemoptysis and respiratory failure
B A rash to the trunk and back
C A positive Mantoux skin test
D A fever requiring hospitalization

Question Explanation
Correct Answer is C
Rationale: After exposure to TB, the most likely finding would be a positive skin (Mantoux) test.
The other findings would more likely be seen with an acute respiratory infection or advanced
TB. A rash is not a typical finding with TB.
Concepts tested

Question 4097
When planning care for a client on a mechanical ventilator, the nurse understands that the
application of positive end-expiratory pressure (PEEP) to the ventilator settings has which
therapeutic effect?
A Prevention of ventilator-associated pneumonia
B Prevention of alveolar collapse during expiration
C Increased inflation of the lungs
D Decreased need for suctioning

Question Explanation
Correct Answer is B
Rationale: Positive end-expiratory pressure (PEEP) is positive pressure that is applied to the
airway during exhalation. This positive pressure prevents the alveoli from collapsing, improving
oxygenation and enabling a reduced fraction of inspired oxygen (FIO2) requirement. The other
answers are incorrect.
Concepts tested

Question 4098
The nurse in a pediatric clinic is caring for a 10-year-old child with a suspected COVID-19
respiratory infection. Which assessment finding requires immediate intervention by the nurse?
A Slow, irregular respirations
B Temperature of 101.3°F (38.5°C)
C Profuse diaphoresis
D Rapid, bounding pulse

Question Explanation

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Correct Answer is A
Rationale: A slow and irregular respiratory rate is a sign of respiratory fatigue and impending
acute respiratory failure in the child. Respiratory failure can rapidly lead to respiratory and
cardiac arrest. Immediate interventions are required, such as supplemental oxygen, intubation,
and mechanical ventilation to support the child's respiratory status.
Concepts tested

Question 4099
The psychiatric nurse is caring for a client admitted with psychogenic polydipsia. Which finding
indicates that the client might be experiencing a complication of the condition?
A Muscle spasms
B Lethargy
C Urinary retention
D Polyuria

Question Explanation
Correct Answer is B
Rationale: Polydipsia is excessive or abnormal thirst accompanied by the intake of excessive
quantities of water or fluid. Psychogenic polydipsia (PPD), or primary polydipsia, is
characterized by excessive volitional water intake and is often seen in patients with severe
mental illness and/or developmental disability. There may be no physical effects, but
hyponatremia can occur. Neuropsychiatric manifestations of hyponatremia include headache,
nausea, cramping, hyporeflexia, dysarthric speech, lethargy, confusion, seizures, and delirium.
Coma and even sudden death can ensue as sodium status worsens. It is critical that the nurse
monitors the client closely for symptoms of hyponatremia. The other findings are either expected
with polydipsia (polyuria) or unrelated to hyponatremia.
Concepts tested

Question 4100
The nurse is caring for a client admitted to the acute care setting with a diagnosis of Guillain-
Barré syndrome. While reviewing the client's chart, which of the following orders would the
nurse question?
A Physical therapy and occupational therapy consults
B Schedule surgery for a tracheostomy
C Administer pyridostigmine
D Obtain vital signs prior to plasmapheresis

Question Explanation
Correct Answer is C
Rationale: Guillain-Barré syndrome is an autoimmune condition where the immune system
attacks the peripheral nervous system and cranial nerves. More specifically, the immune system
attacks the myelin sheath of the nerves. As the myelin sheath starts to break down, nerve
transmission slows down. Manifestations of this syndrome include paraesthesias, paralysis, loss
of reflexes, and loss of muscle tone. The syndrome is temporary, and most clients typically make
a full recovery. During the acute phase of the condition, the client may be totally paralyzed and
may need to be placed on a mechanical ventilator. Pyridostigmine is a cholinesterase inhibitor
Page | 1323
medication that is used to treat myasthenia gravis, not Guillain-Barre syndrome. Once recovery
begins, physical and occupational therapy is ordered. Plasmapheresis is a blood purification
procedure used to treat autoimmune conditions; it reduces the severity and duration of the
Guillain-Barre episode. The procedure can cause hypotension and arrhythmias.
Concepts tested

Question 4101
The nurse is caring for an 8-month-old infant who has prenatally acquired human
immunodeficiency virus (HIV) infection. Which clinical manifestations should the nurse monitor
the infant for? Select all that apply.
A Kaposi sarcoma
B Recurrent diarrhea
C Autism
D Failure to thrive
E Developmental delays
F Hepatomegaly

Question Explanation
Correct Answer is A, B, D, F
Rationale: The majority of infants with perinatally acquired HIV infection are clinically normal
at birth. Common clinical manifestations of HIV infection in children vary and include such
signs as lymphadenopathy, hepatosplenomegaly, and unexplained diarrhea. Diarrhea may be the
result of pathogens or of HIV itself, due to malabsorption of carbohydrates, protein, and fat.
HIV-infected children often do not grow normally. They may be proportionally smaller in both
length and weight for their age. Kaposi sarcoma, one of the hallmarks of adult-acquired
immunodeficiency syndrome (AIDS), is found in less than 1% of affected children. Autism or
developmental delays are not conditions associated with HIV or AIDS.
Concepts tested

Question 4102
The emergency room nurse is caring for a client admitted with a cervical spinal cord injury.
Which assessment is the priority?
A Blood pressure
B Muscle weakness
C Ability to urinate
D Respiratory function

Question Explanation
Correct Answer is D
Rationale: A spinal injury at the cervical level can result in quadriplegia with impairment of the
phrenic nerve. As a result, the client is at high risk for respiratory insufficiency and failure;
therefore, assessing and close monitoring of respiratory function is the priority.
Concepts tested

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Question 4103
The nurse is caring for a client with portal hypertension and esophageal varices caused by liver
failure. Which nursing problem is the priority?
A Risk for impaired skin integrity
B Risk for bleeding
C Risk for malnutrition
D Risk for falls

Question Explanation
Correct Answer is B
Rationale: Clients with liver failure are at risk for developing portal hypertension secondary to
the fibrous changes that occur with liver failure. Esophageal varices are dilated and tortuous
vessels of the esophagus that are at risk for rupture if the portal circulation pressure rises.
Bleeding from the varices could lead to shock and death; therefore, risk for bleeding is
the priority nursing problem.
Concepts tested

Question 4104
The nurse is caring for a child who has just returned from surgery following a tonsillectomy and
adenoidectomy. Which action by the nurse is most appropriate?
A Allow the child to drink through a straw
B Place the child in a supine position
C Offer ice cream every two hours
D Observe swallowing patterns

Question Explanation
Correct Answer is D
Rationale: Tonsillectomies and adenoidectomies are the removals of a client's tonsils and
adenoids. These procedures are routinely performed when a client suffers from frequent bouts of
tonsillitis or resistant forms of tonsillitis. Complications of these procedures include bleeding,
infection, and dehydration. In the postoperative area, clients should be positioned at a 45° angle.
This position allows the client to maintain a patent airway. It also can prevent aspiration in the
event that the client begins to hemorrhage. One manifestation of bleeding includes frequent
swallowing. It is imperative that the nurse monitors the client's swallowing patterns. In the
postoperative area, clients should drink from a glass, not a straw. Straws could disrupt the suture
lines from the procedure. After a tonsillectomy, clients should gradually introduce fluids back
into their diet. The literature suggests starting with clear fluids, not full liquids. Starting full
liquids may cause nausea, vomiting, and frequent coughing.
Concepts tested

Question 4105
The nurse walks into a client's room and finds the client lying on the floor. What should the
nurse do next?
A Call for help and activate the code team

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B Assess if the client's airway is patent
C Determine if anyone witnessed the client fall
D Establish if the client is unresponsive

Question Explanation
Correct Answer is D
Rationale: The first step in cardiopulmonary resuscitation (CPR) is to establish the client's
responsiveness. The nurse would then call for help, activate the code team, and check the client's
pulse. A pulse check should occur for at least five seconds but no longer than ten seconds. If the
client has no pulse, the nurse should immediately start chest compressions. Once the first thirty
chest compressions have been completed, the nurse should then open the client's airway and
perform two rescue breaths.
Concepts tested

Question 4106
The nurse is planning care for a client with a myocardial infarction. The client has a nursing
problem of pain related to cardiac ischemia. Which of the following interventions would
be essential for the nurse to include in the client's plan of care?
A Administer anti-platelet therapy as soon as possible
B Obtain a chest x-ray as soon as possible
C Administer a stool softener to prevent constipation
D Monitor the client's temperature every four hours

Question Explanation
Correct Answer is A
Rationale: The pain that occurs with a myocardial infarction (MI) is related to ischemia of the
heart muscle. The majority of clients who suffer an MI develop a thrombus inside a coronary
artery. It is these blockages that cause ischemia, which in turn lead to chest pain. Although the
use of stool softeners is recommended in this scenario, it is not the highest priority intervention
to be added to the client's plan of care. After an MI, clients may develop a low-grade fever due to
an inflammatory response. Although assessing a client's temperature is appropriate in this
scenario, it is not the highest priority intervention to be added to the client's plan of care.
Administering an anti-platelet agent as soon as possible would be essential in this scenario.
Evidence suggests that aspirin reduces the platelet aggregation of a thrombus. Obtaining a chest
radiography after an MI is not the highest priority intervention to be added to this client's plan of
care. A chest radiography is not a specific test performed to evaluate the occurrence of an MI.
Concepts tested

Question 4107
The nurse is caring for a 10-month-old infant diagnosed with iron-deficiency anemia. Based on
this diagnosis, which of these findings should the nurse anticipate?
A Pale mucosa of the eyelids and lips
B Heart rate of 120 bpm
C Increased appetite
D Hemoglobin level of 12 g/dL

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Question Explanation
Correct Answer is A
Rationale: Iron-deficiency anemia commonly occurs in infants 9–24 months old. Although
infants are born with iron stores available, because they grow very rapidly, they need to absorb
iron every day. Breast milk or formula provides enough daily iron for infants. However, in the
event that an infant does not absorb enough iron, they may become iron-deficient anemic.
Common manifestations of anemia include irritability, fatigue, brittle nails, and cyanosis. An
infant with iron-deficiency anemia would suffer from a poor appetite and not an increased
appetite. A hemoglobin level of 12 g/dL is considered normal in an infant. The normal
hemoglobin range for an infant is 11 to 13 g/dL. A heart rate of 120 bpm is considered normal in
an infant. The normal heart rate range for an infant is 120 to 180 bpm. Pale mucosa of the eyelids
and lips would be the anticipated finding in this client.
Concepts tested

Question 4108
The nurse is admitting a 3-year-old child with manifestations of sudden onset of irritability,
croaking on inspiration, and skin temperature that's hot to the touch. The child is currently
leaning forward with suprasternal retractions, a protruded tongue, and excessive drooling. What
should the nurse do first?
A Collect a sputum specimen for culture
B Prepare the child for an x-ray of the upper airways
C Notify the health care provider of the child's status
D Examine the child's throat for redness

Question Explanation
Correct Answer is C
Rationale: The child's manifestations suggest epiglottitis, which is the inflammation of the
epiglottis. Although rare, the condition is more commonly found in children and is usually
caused by Haemophilus influenza B. Epiglottitis can lead to airway obstruction and thus is
considered a medical emergency. Manifestations of epiglottitis include dysphagia, difficulty
talking, apprehension, retractions, stridor on inspiration, and an elevated temperature. The nurse
would first want to notify the health care provider. The child's condition is worsening as
indicated by them leaning forward and having suprasternal retractions. Although a sputum
specimen may be warranted in this situation, it is not the first action that should be implemented.
In a client with epiglottitis, one should never insert anything into the client's mouth or throat, as
this could lead to a spasm of the airway. Radiographic films would not be indicated in the
diagnosis of epiglottitis.
Concepts tested

Question 4109
The nurse in the outpatient clinic is following up on a client with a fractured arm. The client's
arm was placed in a cast four hours ago. The client states, "my fingers are tingling and feel cold."
Which action should the nurse take first?
A Notify the health care provider
B Elevate the client's arm above the level of the heart

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C Apply an ice pack to the cast to reduce swelling
D Check the capillary refill in the client's fingers

Question Explanation
Correct Answer is D
Rationale: The client with a cast on an extremity is at risk for the development of compartment
syndrome. Compartment syndrome occurs when the swelling underneath the cast becomes so
great that it will decrease circulation and tissue perfusion to the extremity distal to the cast. This
is a medical emergency. Using the nursing process, the nurse should first collect more data by
checking the client's capillary refill, which can support the possibility of compartment syndrome.
After obtaining the additional information, the nurse can make the best decision about what to do
next.
Concepts tested

Question 4110
A client has received instructions for the management of osteoarthritis. Which statement by the
client would indicate a need for additional teaching?
A "Early surgical intervention is the preferred treatment."
B "Gradual weight loss may help my pain."
C "I will avoid driving after I have taken cyclobenzaprine."
D "It is important for me to balance my exercise and rest periods."

Question Explanation
Correct Answer is A
Rationale: Clients with osteoarthritis experience the erosion of cartilage in their joints, which
leads to pain and swelling of the joints. Weight loss has been shown to decrease pressure on the
joints, which can decrease pain. Balancing exercise and rest periods allow the client to be active
to help decrease joint stiffness while decreasing the likelihood of more inflammation in the joint.
Cyclobenzaprine is a muscle relaxant used to manage pain and muscle spasms in clients with
osteoarthritis. Cyclobenzaprine can cause drowsiness, fatigue, and dizziness. For safety reasons,
the client should not drive after taking cyclobenzaprine. Initial management of osteoarthritis
includes physical therapy, medications, and weight loss. Surgical management is typically not
considered until all medical interventions have failed
Concepts tested

Question 4111
The nurse in a pediatrician's office is completing a health history on an infant. The parent reports
that the infant vomits forcefully after almost every feeding, has hard infrequent stools and seems
very sleepy. The nurse suspects that the infant might be experiencing which condition?
A Sickle cell disease
B Pyloric stenosis
C Rotavirus
D Diphtheria

Question Explanation

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Correct Answer is B
Rationale: Pyloric stenosis is a condition where the pylorus increases in size causing a partial to
complete obstruction between the stomach and small intestine. Manifestations include projectile
vomiting, dehydration, weight loss, constipation and lethargy. The other disorders do not cause
the reported symptoms.
Concepts tested

Question 4112
The nurse in the postanesthesia unit is assessing a postoperative infant following a hypospadias
repair. The infant's legs are drawn up to his chest, he is crying, and urine is leaking around his
urinary catheter. What intervention is the priority?
A Administer the scheduled antibiotic
B Apply a cold compress
C Feed the infant
D Administer the prescribed oxybutynin

Question Explanation
Correct Answer is D
Rationale: Hypospadias is a congenital condition where the opening of the urethra is on the
underside of the penis. This condition is most often surgically corrected. The procedure involves
placement of a urinary stent to the bladder for drainage while the newly formed urethra heals.
One common side effect of this procedure is bladder spasms. Pediatric clients often present
during a bladder spasm with knees pulled up to the chest, back arched and urine leakage around
the catheter. Using Maslow's hierarchy of needs to prioritize, the priority is to manage the
infant's pain caused by the bladder spasm with an anticholinergic medication such as oxybutynin.
Concepts tested

Question 4113
The triage nurse in a pediatrician's office is speaking with the parent of a young child that has
been having frequent episodes of diarrhea. Which instruction is most important to provide to the
parent?
A "Call the office immediately if your child becomes difficult to arouse."
B "Use a barrier ointment to prevent a diaper rash."
C "Make sure to have the entire family wash their hands frequently."
D "Give your child extra bottles of water throughout the day."

Question Explanation
Correct Answer is A
Rationale: Dehydration occurs when the loss of fluids is greater than the intake. Diarrhea is a
common cause of dehydration in children. Rehydration and prevention of dehydration are the
primary goals of care. A decrease in level of consciousness such as lethargy and difficulties
arousing the child indicate severe cellular dehydration and should be reported immediately;
therefore, this instruction is most important to provide to the parent. The other instructions are
also appropriate to be given to the parent, but they are not as important.
Concepts tested

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Question 4114
The medical-surgical nurse is reviewing the postoperative orders for an adolescent following
spinal fusion surgery to correct scoliosis. Which prescribed intervention should the nurse
question?
A Continue patient-controlled analgesia
B Change dressing if it becomes saturated
C Assess sensation to lower extremities frequently
D Log-roll when changing position

Question Explanation
Correct Answer is B
Rationale: Scoliosis is a spinal deformity that sometimes is treated with spinal fusion surgery.
Spinal fusion surgery is a major surgery requiring close monitoring to prevent postoperative
complications. There is a risk of cerebral spinal fluid (CSF) leak postoperatively. A saturated
dressing that was applied in surgery should not be removed or changed by the nurse. Instead, the
nurse should notify the surgeon immediately to come and evaluate the client and dressing. The
other orders are appropriate. Clients should be log-rolled when changing position in order to
prevent flexion of the spine. Frequent neurovascular assessments to the lower extremities should
be performed to monitor for any neurosensory impairment. Considerable pain is common after
surgery and is most often managed with opioids via patient-controlled analgesia.
Concepts tested

Question 4115
The nurse in a neonatal intensive care unit is performing a physical assessment on a newborn
with a large ventricular septal defect (VSD). Which findings are consistent with this
diagnosis? Select all that apply.
A Wheezes
B Retractions
C Hypertension
D Tachycardia
E Heart murmur
F Cool extremities
G Increased urinary output

Question Explanation
Correct Answer is A, B, D, E, F
Rationale: A ventricular septal defect (VSD) is a congenial heart disorder that results in a hole in
the tissues that separate the left and right ventricles. This hole allows blood to abnormally shunt
between the right and left ventricle decreasing the hearts ability to pump effectively. Heart
murmurs are often the first clinical finding. Babies with large VSDs commonly experience
excess fluid in their lungs leading to congestive heart failure (CHF). Clinical findings of
congestive heart failure include impaired myocardial function, pulmonary congestion, and
systemic venous congestion. A heart murmur, tachycardia, retractions, cool extremities, and
wheezing are all assessment findings with VSD. Increased urinary output and hypertension are
not typical findings with VSD.

Page | 1330
Concepts tested

Question 4116
The nurse is reviewing the medical record of a client who has been diagnosed with systemic
lupus erythematosus. The nurse would expect which findings associated with this disease? Select
all that apply.
A A recent ten pound weight gain
B A red, raised rash on the face
C Polydipsia for the last month
D Reports of pain in the hands and knees
E A temperature of 100.6° F (38° C)
F Generalized weakness

Question Explanation
Correct Answer is B, D, E, F
Rationale: Systemic lupus erythematosus (SLE) is an autoimmune, inflammatory disorder of the
connective tissue. It can affect multiple organs. This disorder has remission periods and flare-
ups. A client who was recently diagnosed often presents during an exacerbation. Common
assessment findings during exacerbation include a red, raised, rash on the face, commonly
known as the "butterfly rash" and generalized weakness that can be associated with the fever and
joint inflammation that are also present. SLE most frequently affects small joints (such as the
hands) and the knees. Clients tend to experience anorexia which often leads to reports of weight
loss, not weight gain. Polydipsia (excessive thirst) is not associated with SLE.
Concepts tested

Question 4117
A client who has osteoarthritis, affecting both knees, is reporting constant pain at a level of 4 on
a 0 to 10 scale. Which nonpharmacological intervention should the nurse implement for this
client to help alleviate the pain?
A Collaborate with physical therapy for paraffin dips to the knees.
B Position the client with the knee joints in a flexed position.
C Place the client on strict bedrest with bathroom privileges only.
D Provide opportunity for the client to participate in hydrotherapy

Question Explanation
Correct Answer is D
Rationale: Osteoarthritis (OA) means the degeneration of cartilage in the joints, primarily the
weight-bearing joints. These degenerative changes lead to swelling and pain in the joint. To
prevent joint stiffness, it is important to encourage the client to balance activity and rest. Strict
bedrest would only increase joint stiffness and further decrease in joint mobility. Paraffin (a type
of wax) dips are helpful for clients with OA in the hands, but are not usually used for OA in the
knees. The joints should be placed in a neutral, not flexed, position to prevent contractures.
Soaking in a hot bathtub or doing hydrotherapy with physical therapy provides warmth that will
decrease pain. The buoyancy of the client's body in water decreases weight on the joints, which
will also decrease pain

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Concepts tested

Question 4118
The home health nurse is reviewing information with a client who is being treated for pulmonary
tuberculosis. Which statement by the nurse is correct?
A "You can stop the medications once your symptoms have resolved."
B "You should avoid public transportation and crowds in enclosed areas."
C "You should not leave your home until your cough is completely gone."
D "Your family members should get the tuberculosis vaccine."

Question Explanation
Correct Answer is B
Rationale: Tuberculosis (TB) is an infectious disease that usually involves the lungs but can
affect other organs. Treatment involves drug therapy and the prevention of transmission. Drug
therapy typically consists of several medications that must be taken for several months, even if
symptoms have subsided. Clients with pulmonary TB are not required to remain indoors, but
should avoid travel on public transportation and trips to public places. Currently, there is no
recommended vaccine for TB in the U.S.
Concepts tested

Question 4119
The nurse is planning care for a 3-month-old infant in the immediate postoperative period after
placement of a ventriculoperitoneal shunt for hydrocephalus. In anticipation of complications of
the procedure, the nurse should take which action?
A Pump the shunt at intervals to assess for proper function
B Maintain the infant in supine position
C Assess for abdominal distention or taut abdominal wall
D Begin formula feedings when infant is alert

Question Explanation
Correct Answer is C
Rationale: The nurse should observe for abdominal distention or a taunt abdominal wall because
cerebrospinal fluid could cause peritonitis or a postoperative ileus as a complication of distal
catheter placement. The child does not need to remain supine and can be placed in an upright
position. The infant would be started on clear liquids initially, not formula. The shunt will not be
pumped.
Concepts tested

Question 4120
The nurse is evaluating a client with status asthmaticus. Which finding best indicates that
interventions were effective?
A The client's wheezes have decreased in intensity.
B The client's respiratory rate is 20.
C The client's pulse oximeter reads 94%.
D The client denies shortness of breath.

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Question Explanation
Correct Answer is C
Rationale: Status asthmaticus means a severe, acute asthma exacerbation. Management of an
acute asthma exacerbation focuses on correcting hypoxemia and improving ventilation.
Supplemental oxygen is usually administered to achieve an O2 saturation of greater than 90%.
The client's reading of 94% is the best indicator that interventions were effective. Wheezing, the
respiratory rate and the client's subjective report are unreliable signs to gauge if the client's
oxygenation status is adequate.
Concepts tested

Question 4121
The nurse in the primary health care provider's office is reviewing the medical record of a client
with idiopathic pulmonary arterial hypertension. The nurse should expect which potential clinical
manifestations with this disease? Select all that apply.
A Abnormal heart sounds
B Elevated serum creatinine level
C Cor pulmonale
D Dyspnea on exertion
E Exertional chest pain

Question Explanation
Correct Answer is A, C, D, E
Rationale: Idiopathic pulmonary arterial hypertension (IPAH) has no apparent cause and is
characterized by an elevated pressure in the pulmonary arterial circulation. The disease is
incurable but drug therapy will greatly help. Classic symptoms include: exertional dyspnea and
chest pain, fatigue, right-sided heart failure (cor pulmonale) due to the increased workload of the
right ventricle and abnormal heart sounds, such as an S3. An elevated creatinine level would
indicate renal dysfunction, not pulmonary hypertension.
Concepts tested

Question 4122
A nurse is administering the influenza vaccine in an occupational health clinic. Within 10
minutes of giving the vaccine to a middle-aged adult male, the man reports having itchy and
watery eyes, feeling anxious and short of breath. What should the nurse do first?
A Administer SQ epinephrine.
B Apply oxygen.
C Maintain the airway.
D Take the client's vital signs.

Question Explanation
Correct Answer is A

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Rationale: The man is exhibiting signs and symptoms of an anaphylactic reaction. Although all
of the interventions are correct, the nurse should first administer epinephrine to stop the
bronchial constriction and airway obstruction that is occurring.
Concepts tested

Question 4123
The nurse in the outpatient clinic is reviewing discharge instructions with a client being treated
for recurring sinusitis. Which statement by the client indicates that additional teaching is
needed? Select all that apply.
A Use probiotics daily to reduce recurrence.
B Sleep in a flat position to decrease postnasal drip
C Control asthma symptoms with prescribed medications.
D Use nasal decongestant sprays several times daily.
E Wash hands and change clothing after outdoor activities.
F Restrict water intake to reduce copious nasal drainage.
G Reduce the use of smokeless tobacco and cigarettes.

Question Explanation
Correct Answer is A, C, E
Rationale: The use of nasal decongestant sprays for more than three days often leads to
increased rebound congestion when use is discontinued. Instead, the client may opt for saline
nasal sprays, which relieve congestion without rebound effects. Probiotics have shown to be
effective in reducing acute sinusitis and other upper respiratory tract infections. Sinusitis is much
more common in clients with asthma, with up to half of those with moderate-to-severe asthma
experiencing chronic sinus inflammation. Allergies often precipitate sinusitis, and handwashing
and removing allergens from clothing can reduce allergy symptoms and the risk of sinusitis.
Smoking is a risk factor for sinusitis and should be entirely avoided. The client should drink 6 to
8 glasses of water daily to thin secretions and reduce the risk of infection. The client should sleep
with the head upright, not flat, in order to allow sinus drainage.
Concepts tested

Question 4124
The nurse is caring for a client newly diagnosed with chronic obstructive pulmonary disease
(COPD). The nurse reviews the client's medical record and notes which risk factors? Select all
that apply.
A History of smoking tobacco products
B Seasonal allergic rhinitis
C Hyperlipidemia
D History of childhood asthma
E History of pulmonary embolus
F A family history of COPD

Question Explanation

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Correct Answer is A, D, F
Rationale: COPD is a pulmonary disease that is characterized by chronic airway inflammation,
mucus hypersecretion, bronchospasms, destruction of alveoli and airflow limitations, leading to
chronic carbon dioxide retention. It is primarily caused by cigarette smoking. Other risk factors
include genetics, asthma and exposure to occupational chemicals and air pollution.
Hyperlipidemia is a risk factor for cardiovascular diseases. Pulmonary embolism and allergic
rhinitis are not risk factors for COPD.
Concepts tested

Question 4125
The nurse is caring for a client who is receiving external beam radiation to the mediastinum for
treatment of bronchial cancer. Which problem should be addressed as a priority in planning
care?
A Fatigue
B Leukopenia
C Skin irritation
D Esophagitis

Question Explanation
Correct Answer is B
Rationale: Clients being treated by radiation over the sternum, which is a bone marrow
producing area, develop leukopenia due to the depressant effect of radiation therapy on the bone
marrow function. With the resultant low white counts, infection is a potential outcome. The other
options are possible complication outcomes of radiation therapy on this part of the body.
However, they are not the priority because leukopenia is a threat to the entire body and the other
options are more of a local problem.
Concepts tested

Question 4126
The nurse is planning care for a client with pneumonia. Which of the following interventions
would be the most effective by the nurse, in promoting the clearance of respiratory secretions?
A Increase fluid intake throughout the day
B Maintain bed rest with bathroom privileges
C Administer pain medications as needed
D Administration of cough suppressants

Question Explanation
Correct Answer is A
Rationale: Pneumonia is an infection of the lower respiratory system that affects the lungs and
alevoli. The lung fields and sacs can become inflamed and filled with fluid. Pneumonia can be
caused by a bacteria, virus or fungus. Manifestations of pneumonia include cough, pleuritic chest
pain, fever and shortness of breath. In clients who have pleuritic chest pain, coughing will often
exacerbate the client's chest discomfort. Pain medication may be indicated to help the client
cough more effectively and remove sputum. Clients need to be out of bed as frequently as
tolerated. Lying in bed causes pulmonary secretions to be stagnant in the lung fields. The client
should be encouraged to drink adequate fluids (i.e. 2-3 L) throughout the day. Secretion removal
Page | 1335
is enhanced with adequate hydration, which thins and liquefies secretions, making them easier to
cough out. The client should not be instructed to use cough suppressants. Suppressants don't
allow clients to cough, and remove secretions and sputum.
Concepts tested

Question 4127
The L&D nurse is caring for a pregnant client at 40-weeks gestation who was admitted with new
onset contractions at 8 am. At 10 am, the client is ready to give birth. Based on this abnormal
labor pattern, which potential complication should the nurse monitor the client for?
A Placenta previa
B Eclampsia
C Cesarean delivery
D Fetal hypoxia

Question Explanation
Correct Answer is D
Rationale: This labor pattern is considered "precipitous," which is defined as active labor lasting
less than three hours. Because the contractions are coming rapidly, with little time in between
contractions, there is a risk of fetal hypoxia. The other complications are not associated with
precipitous labor.
Concepts tested

Question 4128
The nurse is evaluating a stage III pressure ulcer. Which assessment finding would indicate that
the prescribed treatment is working?
A Soft yellow tissue seen in wound bed
B The periwound texture is moist and soft
C The edge of the wound appears rolled or curled under
D The size of the wound is decreasing

Question Explanation
Correct Answer is D
Rationale: A wound that is decreasing in size is healing. "Slough" is yellow, tan or green tissue
that is not healing. Soft and denuded tissue in the periwound area indicate tissue breakdown due
to excessive moisture from wound drainage. Curled or rolled wound edges (epibole) prevents
epithelial cells from migrating to close the wound, preventing the wound from healing.
Concepts tested

Question 4129
A client is admitted to an ambulatory surgery center and underwent a right inguinal orchiectomy.
Which goal is the priority before the client should be discharged home?
A The client's psychological counseling is scheduled.
B The client is able to tolerate a general diet.
C The client is able to ambulate in the hallway with assistance.
D The client's postoperative pain is well-managed.

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Question Explanation
Correct Answer is D
Rationale: An orchiectomy is the surgical removal of one or both testicles. It is usually
performed to treat cancer (testicular, prostate, or cancer of the male breast). Due to the location
of the incision, pain management is the priority. Most men will be able to eat regularly when
they get home. They should at least tolerate liquids before discharge. The client should be able to
walk without assistance prior to discharge. Psychological counseling may be needed as part of
long-term aftercare; however, this is not the priority prior to discharge.
Concepts tested

Question 4130
A woman who is 5 days postpartum and has a history of pregnancy-induced hypertension, calls
the hospital triage nurse hotline to ask for advice. She states, "I have had the worst pounding
headache for the past two days. Since this afternoon, everything I look at appears blurred.
Nothing I have taken helps." What action should the nurse take?
A Advise the client to have someone bring her to the obstetrician's as soon as possible.
B Ask the client to explain what exactly she has taken for the headache and how often.
C Explain to the client that changes in her hormones may be the problem.
D Instruct the client to call 911 to be brought to the nearest emergency room.

Question Explanation
Correct Answer is D
Rationale: The woman is describing symptoms related to pregnancy-induced hypertension (PIH)
that appears to be progressing to preeclampsia/eclampsia. PIH may progress to preeclampsia and
eclampsia prior to, during, or up to 10 days after delivery. This places the woman at risk for
seizure activity which is a medical emergency. The client should call 911 to be brought
immediately to the closest emergency room (ER).
Concepts tested

Question 4131
An emergency room nurse is assigned to the triage area of a nearby mass casualty event. Which
of these clients should the nurse tag as "Black" or "to be seen last"?
A A 7-month-old infant with closed fractures to both lower legs who is crying loudly
B A 14-year-old client with a small amount of bright red blood dripping from their nose
C A 45-year-old client with second and third degree burns over 90% of their body
D An 83-year-old client with an open fracture of the left arm

Question Explanation
Correct Answer is C
Rationale: Clients that are deemed least likely to survive are tagged "black" or "to be seen last."
This increases the ability to provide treatment to victims who have a greater chance of survival.
Fractures are treatable with splinting and immobilization. It is a positive sign that the infant is
alert and crying. The client with minor bleeding from the nose should be evaluated for head
trauma, but appears stable at this time. A client with burns over 90% of their body will

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experience massive fluid loss and the burn injuries will most likely be fatal. Therefore, this client
should receive a black tag or be seen last.
Concepts tested

Question 4132
The nurse in the postanesthesia care unit is caring for a client who is recovering from a left lower
lobectomy. The client has a chest tube in place. While repositioning the client during the first
post-op check, the nurse notices 75 mL of a dark red fluid flowing into the collection chamber of
the chest drainage system. What action should the nurse take?
A Check if the client had a type and crossmatch done.
B Turn the client back to the original position.
C Notify the surgeon immediately.
D Continue to monitor the rate of the drainage.

Question Explanation
Correct Answer is D
Rationale: Following a lobectomy, it is not unusual for blood to collect in the chest and be
released into the chest drainage system when the client changes positions. This is most common
in the immediate, post-operative phase. The dark color of the blood indicates it is likely old
blood and there is not active bleeding inside of the chest. Sanguineous drainage should be
expected within the initial 24 hours post-op, progressing to serosanguineous, and then to a serous
type. If the drainage exceeds approximately 100 mL in one hour, then the nurse should call the
surgeon. In this case, the nurse should continue to monitor the rate of the drainage.
Concepts tested

Question 4133
The nurse is examining a 2-year-old child with a tentative diagnosis of Wilm's tumor. Which
statement by the child's parent should the nurse follow-up on?
A "My child seems to be urinating less over the past 2 days."
B "All of my child's pants have become tight around the waist."
C "My child has lost 3 pounds in the last month."
D "My child prefers some salty foods more than others."

Question Explanation
Correct Answer is A
Rationale: Wilm's tumor is a malignant tumor of the kidney that can lead to kidney dysfunction.
A recent decrease in urinary output should be investigated further as it may be a sign of renal
dysfunction. Increasing abdominal girth is a common finding with a Wilm's tumor, but does not
require immediate intervention by the nurse.
Concepts tested

Question 4134
A client with a spinal cord injury at the T-2 level reports having a "pounding" headache. Further
assessment by the nurse reveals excessive sweating, rash, piloerection, facial flushing, congested
nasal passages and a heart rate of 50 bpm. What is the priority action?

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A Transfer the client to the bed and administer the ordered PRN analgesic.
B Measure the client's respirations, blood pressure, temperature and pupillary response.
C Assist the client with relaxation techniques.
D Check the client for bladder distention or kinking of the urinary catheter.

Question Explanation
Correct Answer is D
Rationale: The client is exhibiting manifestations of autonomic dysreflexia, also called
hyperreflexia, seen with a spinal cord injury (SCI), typically above the T6 level. It is most often
caused by a noxious stimulus below the level of the injury such as a full bladder, an enema or
bowel movement, fecal impaction, changing of an indwelling catheter and a vaginal or rectal
examination. The stimulus creates an exaggerated response of the sympathetic nervous system
that can be a life-threatening event. Therefore, the priority action is to identify and relieve the
cause of the response.
Concepts tested

Question 4135
A 67-year-old client is admitted to the telemetry unit with substernal chest pressure that radiates
to the jaw. The client's diagnosis is an acute myocardial infarction. To monitor the client, the
nurse should give priority to which assessment?
A Assess the client's activity tolerance.
B Assess the client's level of anxiety.
C Assess the client's pain level.
D Assess the client's cardiac output.

Question Explanation
Correct Answer is D
Rationale: In the immediate post- myocardial infarction (MI) period, altered cardiac output is a
potential problem. An area of myocardial tissue has been damaged by a lack of blood flow and
oxygenation, increasing the risk for decreased cardiac output, dysrhythmias and heart failure.
Findings would include low blood pressure, tachycardia, low urine output, unrelieved or
worsening chest pain, and shortness of breath. Nursing assessments and interventions should be
directed toward promoting myocardial tissue perfusion and oxygenation. The other assessments
are also relevant, but monitoring cardiac output is the priority.
Concepts tested

Question 4136
A client is transported to the emergency department after a motor vehicle accident. When
assessing the client 30 minutes after arrival, the nurse notes several physical changes. Which
finding requires immediate attention?
A Tracheal deviation
B Increased restlessness
C Tachycardia
D Tachypnea

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Question Explanation
Correct Answer is A
Rationale: Tracheal deviation is a sign that a mediastinal shift has occurred, most likely due to a
tension pneumothorax. Air escaping from the injured lung into the pleural cavity causes pressure
to build, collapsing the lung and shifting the mediastinum to the opposite side. This obstructs
venous return to the heart, leading to circulatory instability and may result in cardiac arrest. This
is a medical emergency, requiring emergency placement of a chest tube to remove air from the
pleural cavity relieving the pressure. The other findings are most likely related to the potential
pneumothorax.
Concepts tested

Question 4137
The nurse is caring for a client following a right lower lung lobectomy. During the assessment of
the chest drainage unit, the nurse notices bubbling in the water-seal chamber. What is
the first action the nurse should take?
A Position the client in a supine position.
B Call the primary health care provider immediately.
C Check for any increase in the amount of drainage.
D Assess the chest tube dressing, tubing and drainage system.

Question Explanation
Correct Answer is D
Rationale: The first action the nurse should take is to thoroughly check the dressing, tubing and
drainage system. Intermittent bubbling in the water seal chamber right after surgery usually
indicates an air leak from the pleural space. This is a common finding and should resolve as the
lung re-expands. Continuous bubbling usually means a leak in the chest drainage unit such as a
loose connection or a leak around the insertion site. Other nursing actions will include assessing
the color and amount of the drainage and auscultating the lungs. After the initial post-operative
period, the nurse will assist the client to change positions, cough and deep breathe to help re-
expand the lung and promote fluid drainage.
Concepts tested

Question 4138
The nurse on a telemetry unit is assessing orthostatic vital signs on a client with cardiomyopathy.
The client's systolic blood pressure decreased from 145 to 110 mmHg between the supine and
upright positions. The client's heart rate increased from 72 to 96 bpm during that time. The client
reports feeling lightheaded when standing up. Which action should the nurse implement?
A Increase the client's PO fluid intake for the next 2 hours.
B Instruct the client to empty their bladder and reassess their BP.
C Instruct the client to follow a high protein diet.
D Restrict the client's PO fluids for the next 4-6 hours.

Question Explanation
Correct Answer is A
Rationale: The client is experiencing postural hypotension. Postural hypotension is a decrease in
systolic blood pressure of at least 15 mmHg, accompanied by an increase in heart rate of 15 to 20
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beats above the baseline with a change of position from supine to upright. This is often
accompanied by lightheadedness. Fluid replacement is appropriate, and must be instituted very
cautiously. The client with cardiomyopathy will also be sensitive to changes in fluid status and
fluid overload may develop rapidly with aggressive rehydration. After the client increases fluid
intake for one to two hours, the client should be reassessed for resolution of the postural
hypotension.
Concepts tested

Question 4139
The nurse on an inpatient medical unit is caring for a client who is in the advanced stage of
multiple myeloma. Which intervention should the nurse include in the plan of care?
A Monitor the client for hypokalemia.
B Administer diuretics as ordered.
C Place the client in protective isolation.
D Use careful repositioning techniques.

Question Explanation
Correct Answer is D
Rationale: Multiple myeloma occurs when abnormal plasma cells (myeloma cells) collect in
several bones. This disease may also harm other tissues and organs, especially the kidneys. This
type of cancer causes hypercalcemia, renal failure, anemia, and bone damage. Because multiple
myeloma can cause erosion of bone mass and fractures, extra care should be taken when moving
or positioning a client due to the risk of pathological fractures.
Concepts tested

Question 4140
The nurse is caring for a client in the late stages of amyotrophic lateral sclerosis. Which finding
is consistent with this diagnosis?
A Confusion
B Shallow respirations
C Tonic-clonic seizures
D Loss of half of visual field

Question Explanation
Correct Answer is B
Rationale: Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disease that
affects nerve cells in the brain and spinal cord. In ALS, upper and lower motor neurons
degenerate and stop sending messages to muscles. All muscles eventually weaken and atrophy,
including the muscles needed to maintain effective respirations. People eventually lose their
ability to speak, eat, move and breathe. The other findings are not typically seen with ALS.
Concepts tested

Question 4141
During a yearly health screening, an older female client reports having perimenopausal
symptoms including irregular menstrual cycles, mood swings and hot flashes. She requests a
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more natural approach to manage the symptoms. Which non-pharmacological interventions
should the nurse include? Select all that apply.
A "1-2 glasses of red wine with dinner can help you manage stress."
B "Use deep breathing exercises when you start having a hot flash."
C "You should drink at least 8-10 glasses of water a day."
D "Incorporate more vegetables and legumes in your diet."
E "Try exercising just before bedtime to help you sleep more soundly."
F "Yoga may help you manage stress and relieve symptoms."

Question Explanation
Correct Answer is B, C, D, F
Rationale: Measures that have been found to be effective in helping manage symptoms of hot
flashes include exercise, stress reduction and getting enough sleep at night. Reducing the
temperature in the room at night and taking a warm bath or shower before bedtime can help
clients get a better night's sleep. Slow abdominal breathing (6-8 breaths per minute) at the onset
of hot flashes can help. Other measures that can lessen the number of and severity of hot flashes
include yoga, as well as avoiding alcohol, spicy foods and caffeine. Eating a more plant-based
diet can also help.
Concepts tested

Question 4142
The nurse is caring for a client diagnosed with chronic obstructive pulmonary disease. The client
reports persistent dyspnea. Which action should the nurse take?
A Assist the client with pursed-lip breathing
B Place the client in low-Fowler's position.
C Lower the rate of oxygen flow.
D Instruct the client to breathe into a paper bag.

Question Explanation
Correct Answer is A
Rationale: The nurse should assist the client with pursed-lip breathing. Pursed-lip breathing
during periods of dyspnea in clients with chronic obstructive pulmonary disease (COPD) helps to
control the rate and depth of respirations. This will also help to prevent alveolar collapse and
improve oxygenation. The other actions are not appropriate for this client.
Concepts tested

Question 4143
A client is admitted with severe injuries resulting from an auto accident. The client's vital signs
are BP 120/50 mmHg, pulse rate 110 bpm, and respiratory rate of 28 breaths per minute. Which
action should the nurse complete first?
A Administer oxygen as ordered.
B Initiate the ordered intravenous therapy.
C Initiate continuous blood pressure monitoring.
D Institute continuous cardiac monitoring.

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Question Explanation
Correct Answer is A
Rationale: Early findings of shock are associated with hypoxia and manifested by a rapid heart
rate and rapid respirations. The nurse should use the Airway-Breathing-Circulation approach to
prioritize interventions. Therefore, maintaining adequate oxygenation is critical and oxygen
should be administered first. The other interventions are secondary to oxygen therapy.
Concepts tested

Question 4144
The nurse is providing discharge teaching to a client who has had a total hip arthroplasty
performed. Which instruction should the nurse include?
A Do not cross your legs at the ankles or knees.
B Avoid climbing stairs for 3 months.
C Sleep only on your back and not on your side.
D Ambulate using crutches only.

Question Explanation
Correct Answer is A
Rationale: Clients who underwent a hip arthroplasty or replacement are at risk for dislocating
the new hip joint if certain precautions are not followed. The risk will vary, depending on the
surgical approach (anterior vs. posterior). To prevent a post-surgical hip dislocation, the nurse
should instruct the client to prevent hip flexion beyond 90 degrees or hip hyperextension.
Furthermore, it is generally recommended to keep the legs slightly abducted and avoid adduction
such as crossing the legs. The other instructions are not appropriate or required following a hip
arthroplasty.
Concepts tested

Question 4145
The nurse is conducting a teaching session for a group of new nurses about types of oxygen
delivery systems. Which system provides the most accurate delivery of oxygen?
A A partial non-rebreather mask
B A simple face mask
C A Venturi mask
D A nasal cannula

Question Explanation
Correct Answer is C
Rationale: The most accurate way to deliver oxygen to a client is through a Venturi or Venti
mask. The Venti mask is a high flow device that traps 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 with this system. The maximum amount of
oxygen that can be delivered by a Venti mask is approx. 55%.
Concepts tested

Question 4146
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The nurse is caring for a 4-year-old child with a greenstick fracture. The nurse is teaching the
parents about the child's fracture. How should the nurse describe this type of fracture?
Question 16 Answer Choices
A "A child's bone is more flexible and can be bent 45 degrees before breaking."
B "Your child's bones are weak and will break more easily."
C "Bones of children are more porous than adults', leading to incomplete breaks."
D "Fractures in children are harmless and tend to heal quickly."

Question Explanation
Correct Answer is C
Rationale: Bones in children are generally more porous than adult bones. This allows the pliable
bones of growing children to bend, buckle, and break in a "greenstick" manner. A greenstick
fracture occurs when a bone is angulated beyond the limits of bending. The compressed side
bends and the tension side develops an incomplete fracture. The other statements are not correct.
Concepts tested

Question 4147
A home health nurse is teaching the parents of a pediatric client with acute spasmodic croup.
Which interventions are most important to include?
A Antihistamines to decrease allergic responses
B Antibiotic therapy for 10 to 14 days
C Sedation as needed to prevent exhaustion
D Humidified air with an increase in oral fluids

Question Explanation
Correct Answer is D
Rationale: The most important aspects of home care for a child diagnosed with acute spasmodic
croup are humidified air and increased oral fluids. Humidified air helps reduce vocal cord
swelling. Taking the child out into the cool night air for 10 to 15 minutes can also reduce
nighttime symptoms. Adequate systemic hydration aids mucociliary clearance by keeping
secretions thin and easy to remove with minimal coughing effort.
Concepts tested

Question 4148
The nurse is admitting a male client who is newly diagnosed with a frontal lobe brain tumor.
Which statement by the client's spouse would support this diagnosis?
A "His breathing rate is usually below 12."
B "I find the mood swings hard to deal with."
C "It seems that he has to urinate more frequently."
D "He has a hard time reading small print."

Question Explanation
Correct Answer is B
Rationale: The frontal lobe of the brain controls affect, judgment and emotions. Dysfunction in
this area results in symptoms such as emotional lability, changes in personality, inattentiveness,

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flat affect and inappropriate behavior. The other statements do not pertain to symptoms or
changes in behavior typically seen with frontal lobe problems.
Concepts tested

Question 4149
Which finding should alert the nurse to the possible presence of a cataract in a client?
A Farsightedness and loss of central vision
B Blurred vision and reduced color perception
C Nearsightedness and loss of peripheral vision
D Dull aching in the eye and eyelids

Question Explanation
Correct Answer B
Rationale: As the lens becomes opaque and less able to refract light appropriately, the client will
experience blurred vision and a reduced ability to distinguish among different colors. The
development of a cataract does not typically cause loss of peripheral or central vision and visual
acuity, nor does it result in aching of the eye or eyelids.
Concepts tested

Question 4150
The nurse is evaluating self-management of a client who has type 1 diabetes. Which statement
made by the client should be of highest concern?
A "I had a penny in my shoe all day last week, and I didn't even realize it until I took my shoes
off!"
B "Here are my glucose test readings that I wrote on my calendar. I check my blood sugar twice
a day."
C "I count the number of carbohydrates I eat. I eat several servings of fresh fruit per day."
D "I give my insulin to myself in my thighs and belly. I make sure to alternate the sites."

Question Explanation
Correct Answer is A
Rationale: The client's statement about having a penny in their shoe without realizing it, indicates
this client may have peripheral neuropathy. Peripheral neuropathy can lead to lack of sensation
in the lower extremities. When clients cannot feel potential tissue injuries (something in their
shoe), they are at high risk for impaired skin integrity such as diabetic foot ulcers. The other
statements indicate that the client is managing their diabetes appropriately.
Concepts tested

Question 4151
A client who is two days post abdominal surgery has the following vital signs: blood pressure of
120/70 mm Hg, heart rate of 110 bpm, respiratory rate of 26 breaths per minute and a
temperature of 100.4°F (38°C). The client suddenly develops severe shortness of breath,
cyanosis and pallor. Which assessment is the priority?
A Auscultate the lungs for diminished breath sounds.
B Palpate the pulses for bounding and irregularity.

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C Check for orthostatic hypotension.
D Assess the pupils for unequal responses to light.

Question Explanation
Correct Answer is A

Question 4152
The nurse is conducting teaching with a family whose newborn infant was diagnosed with
hypothyroidism. Which point is important for the nurse to emphasize during the teaching?
A Hormone replacement therapy will prevent complications.
B Expect the child to be developmentally delayed.
C This rare problem is always hereditary
D Physical growth will be stunted.

Question Explanation
Correct Answer is A
Rationale: It is important to emphasize that early identification (ideally before 13 days old) and
continued treatment with levothyroxine thyroid hormone replacement will correct
hypothyroidism in newborns and prevent future problems. If undetected and untreated,
hypothyroidism can result in poor growth, weight gain, slow heart rate, low blood pressure and
babies who are unusually quiet. An untreated child will be at risk for permanent brain damage
and intellectual disabilities. Approximately one in every 4,000 babies is born with
hypothyroidism. Congenital hypothyroidism can be caused by a variety of factors, only some of
which are genetic.
Concepts tested

Question 4153
The parents of a 5-month-old infant report that the infant has "vomited 9 times in the past six
hours." Which complication should the nurse monitor the infant for?
A Hemodilution
B Metabolic alkalosis
C Respiratory acidosis
D Hypervolemia

Question Explanation
Correct Answer is B
Rationale: Vomiting results in a loss of acid from the stomach. Prolonged vomiting results in
excess loss of acid and leads to metabolic alkalosis. Manifestations of metabolic alkalosis
include irritability, increased activity, hyperactive reflexes, muscle twitching and elevated pulse.
Concepts tested

Question 4154
The nurse on a critical care unit is admitting a client who is experiencing a hypertensive urgency
or crisis. Which assessment is the priority?
A Heart rate

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B Orientation
C Pedal pulses
D Lung sounds

Question Explanation
Correct Answer is B
Rationale: The organ most susceptible to damage in hypertensive crisis is the brain, due to the
high risk for rupture of cerebral blood vessels leading to a stroke or hemorrhage. Therefore, a
neurologic assessment that should include orientation and level of consciousness is
the priority for this client.
Concepts tested

Question 4155
The nurse is caring for a child diagnosed with Kawasaki disease. The nurse should monitor the
child for which potential complication?
A Pulmonary embolism
B Occlusions at the vessel bifurcations
C Coronary artery aneurysm
D Chronic vessel plaque formation

Question Explanation
Correct Answer is C
Rationale: Kawasaki disease (mucocutaneous lymph node syndrome or infantile polyarteritis),
affects the mucous membranes, lymph nodes, walls of the blood vessels and the heart. It can
cause inflammation of the arteries, especially the coronary arteries of the heart, which can lead to
aneurysms and possible myocardial infarction in the child. The other complications are not
typically seen with Kawasaki disease.
Concepts tested

Question 4156
A client diagnosed with testicular cancer has undergone a unilateral orchiectomy. The client
expresses fears about his prognosis. What should the nurse understand about this type of cancer?
A This cancer has a five-year survival rate of 90% or greater with early diagnosis and treatment.
B This surgery causes impotence and infertility.
C With early intervention, the cure rate for testicular cancer is about 50%.
D Intensive chemotherapy is the treatment of choice following surgery.

Question Explanation
Correct Answer is A
Rationale: With aggressive treatment and early detection/diagnosis the cure rate is generally
90% or greater. The other options are incorrect information. After unilateral orchiectomy, the
remaining testicle can produce adequate sperm for fertility and impotence is unlikely.
Concepts tested

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Question 4157
As a client is being discharged following resolution of a spontaneous pneumothorax, the client
tells the nurse, "I'm going on a beach vacation next week." The nurse should instruct the client to
avoid which activity?
A Surfing
B Scuba diving
C Swimming
D Sun bathing

Question Explanation
Correct Answer is B
Rationale: The nurse would strongly emphasize the need for the client with a history of
spontaneous pneumothorax problems to avoid high altitudes, flying in an unpressurized (open)
aircraft and scuba diving. The negative pressure associated with diving could cause the lung to
collapse again.
Concepts tested

Question 4158
The nurse is assigned to a client who is newly diagnosed with active tuberculosis. Which
intervention is the priority?
A Place the client in a private, negative pressure room.
B Reinforce hand washing before and after entering the room.
C Have the client dispose of soiled tissues in a separate bag.
D Collect several sputum samples for testing.

Question Explanation
Correct Answer is A
Rationale: A client with active tuberculosis should be hospitalized in a negative pressure room,
i.e., airborne precautions, to prevent spread of the disease. Placing the client on on airborne
precautions is the priority because this bacteria can be suspended in the air for long periods of
time and may be carried for long distances on air currents, infecting others.
Concepts tested

Question 4159
The nurse receives change-of-shift report on an 80-year-old client diagnosed with middle-stage
Alzheimer's disease. Which information should be of highest concern?
A A change in the color and temperature of the client's fingers and toes.
B An increase in the client's basal heart rate by 10 bpm.
C A 10 mm Hg drop in the client's diastolic blood pressure.
D Reports of increased confusion, agitation and withdrawal.

Question Explanation
Correct Answer is D

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Rationale: Infections and pain can quickly exacerbate common symptoms of Alzheimer's
disease, including confusion, agitation or withdrawal. A urinary tract infection (UTI) is one of
the most common causes of sudden behavior changes in older clients. Because a UTI can quickly
progress to urosepsis, the neurologic changes are of highest concern.
Concepts tested

Question 4160
A client is admitted for first and second degree burns on the face, neck, anterior chest and hands.
Which action should be the nurse's priority?
A Assess for dyspnea or stridor.
B Administer pain medication.
C Cover the areas with dry sterile dressings.
D Initiate intravenous therapy.

Question Explanation
Correct Answer is A
Rationale: Due to the location of the burns, the client is at risk for the development of upper
airway edema and subsequent respiratory distress. The other options are correct, but
the priority is to assess breathing and manage the airway. The client with any signs of airway
injury may need be intubated.
Concepts tested

Question 4161
The nurse is caring for a child who was diagnosed with coarctation of the aorta. Which finding
should the nurse expect when assessing the child?
A Diminished carotid pulses
B Bounding pulses in the arms
C Normal femoral pulses
D Strong pedal pulses

Question Explanation
Correct Answer is B
Rationale: Coarctation of the aorta, which is a narrowing or constriction of the descending aorta,
causes increased blood flow to the upper extremities, resulting in a bounding pulse in the arms.
Cardinal signs include resting systolic hypertension, absent or diminished femoral and pedal
pulses and a widened pulse pressure.
Concepts tested

Question 4162
The nurse is completing a head-to-toe assessment on a client. The nurse notes a pulsating mass in
the client's periumbilical area. Which assessment is appropriate for the nurse to perform?
A Measure the length
B Percuss
C Palpate

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D Auscultate

Question Explanation
Correct Answer is D
Rationale: The nurse should auscultate the mass. If the finding of a bruit is present, this could
confirm the presence of an abdominal aortic aneurysm. The mass should not be palpated or
percussed because of the risk of rupture.
Concepts tested

Question 4163
The nurse is assessing a client who just returned to the medical surgical unit after a segmental
lung resection surgery. During the assessment, the client is coughing and clearing their throat.
What is the first action the nurse should take?
A Apply the pulse oximeter and monitor oxygen saturation.
B Administer the PRN pain medication.
C Assist the client to turn, deep breathe and cough.
D Suction excessive tracheobronchial secretions.

Question Explanation
Correct Answer is D
Rationale: This type of surgery involves removing a bronco-vascular segment of a lung lobe. It
is typically used to remove small, peripheral lung tumors. Surgical manipulation during this
procedure, along with anesthesia, and increased mucus production can lead to airway
obstruction, which is why the nurse may need to suction the client if there are excessive
secretions. The first action the nurse should take is to suction the excessive secretions. Since this
client just returned from surgery, it is not the time to ask the client to turn, cough and deep
breathe. Vital signs and oxygen saturation are important data to gather, but clearing the client's
airway by suctioning needs to be done first.
Concepts tested

Question 4164
The nurse is caring for a client who is diagnosed with Hodgkin's disease and is scheduled for
radiation therapy to the whole body. The nurse would expect the client to experience which side
effect?
A High fever
B Nausea
C Neutropenia
D Night sweats

Question Explanation
Correct Answer is B
Rationale: As a result of radiation therapy, which is at the lymph nodes throughout the body,
nausea often results (radiation sickness). Night sweats are an expected finding with Hodgkin's

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disease. These clients are not likely to have a high fever because the lymphatic or immune
system is not fully functional. Neutropenia is a side effect of chemotherapy.
Concepts tested

Question 4165
A client diagnosed with an acute anterior myocardial infarction is receiving nitroglycerin and
heparin intravenously. The client still reports chest pain. Which action should the nurse take?
A Review and compare serial ECG strips.
B Auscultate heart and lung sounds.
C Administer intravenous morphine sulfate as ordered.
D Administer antidysrhythmic drugs as indicated.

Question Explanation
Correct Answer is C
Rationale: Nitrates are useful for pain control due to their coronary vasodilator effects. The
nurse will titrate the intravenous nitroglycerin infusion for chest pain according to standing
orders, but if chest pain is unrelieved by the nitroglycerin infusion, the nurse can administer
morphine intravenously (IM injections are avoided because they can alter the CPK). Morphine
not only relieves pain and reduces anxiety, but also dilates the blood vessels. After giving the
pain reliever, the nurse can do a more in-depth assessment of the client (auscultate heart and lung
sounds, review ECGs, vital signs and labs).
Concepts tested

Question 4166
The nurse is providing care for a 9-year-old child with cerebral palsy who has recently been
admitted for repeated episodes of aspiration pneumonia and weight loss. During a discussion
with the child's caregivers, which statement by the nurse demonstrates client advocacy?
A "Let's review some deep breathing and coughing exercises."
B "I will show you how to do manual jaw control during feedings."
C "It is possible that we may need to discuss inserting a feeding tube."
D "An orthotic device may help with positioning during feedings."

Question Explanation
Correct Answer is C
Rationale: Deep breathing and coughing exercises may be helpful, but they will not prevent
aspiration. The nurse should reinforce manual jaw control and proper positioning during feeding.
However, due to repeated episodes of aspiration, it is likely that the client is having significant
difficulty controlling the muscles of the tongue/throat and jaw. The nurse needs to discuss the
possibility of inserting a feeding tube to prevent future complications associated with repeated
aspiration and weight loss.
Concepts tested

Question 4167
The nurse in a primary health care provider's office is talking to a 35-year-old female client about
her new diagnosis of uterine fibroids. Which statement by the woman indicates that additional
teaching is needed?
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A "Fibroids occur more frequently in women my age but no one knows what causes them."
B "Uterine fibroids are noncancerous tumors that grow slowly."
C "I sometimes experience pelvic pressure and pain, along with heavy menstrual bleeding."
D "Even if the fibroids do not cause problems, they must still need to be taken out."

Question Explanation
Correct Answer is D
Rationale: Fibroids that cause no findings may require only "watchful waiting". The client may
just need pelvic exams or ultrasounds periodically to monitor the fibroid growth. Treatment for
the symptoms of fibroids (e.g. painful menses and heavy periods) may include oral
contraceptives, an intrauterine device (IUD), iron supplements to prevent or treat anemia (due to
heavy periods), non-steroidal anti-inflammatory drugs (NSAIDs) for cramps or pain or even
short-term hormonal therapy to help shrink the fibroids. Surgical removal using my lobectomy or
hysterectomy is usually reserved as a final alternative after other treatment options have failed to
provide adequate relief.
Concepts tested

Question 4168
A hospitalized 8-month-old infant is receiving digoxin to treat Tetralogy of Fallot. Prior to
administering the next dose of the medication, the parent reports that the baby vomited one time,
just after breakfast. The infant's heart rate is 92 bpm. What action should the nurse take?
A Reduce the next dose by half and then resume the normal medication schedule.
B Double the next dose to make up for the medication lost from vomiting.
C Give the scheduled dose after the client is done eating lunch.
D Hold the medication and notify the primary health care provider.

Question Explanation
Correct Answer is D
Rationale: Toxic side effects of digoxin include bradycardia, dysrhythmia, nausea, vomiting,
anorexia, dizziness, headache, weakness and fatigue. It isn't typically necessary to hold the
medication for infants and children if there is only one episode of vomiting. However, it is
appropriate to hold the medication and notify the primary health care provider (HCP) of the
vomiting episode and the lower than normal heart rate. A digoxin level may need to be drawn.
The normal resting heart rate for infants 1 to 11 months old is 100 to 160 bpm.
Concepts tested

Question 4169
The nurse witnesses a client having a seizure. Which observation is important to note to
determine the type of seizure?
A The exact time from beginning to end.
B Loss of bowel or bladder control.
C Identifying the pattern of breathing.
D The sequence and types of muscle movement.

Question Explanation

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Correct Answer is D
Rationale: All behaviors observed during and after the seizure need to be reported and recorded.
However, accurate descriptions of seizure activity and a system for recording and reporting
activity is essential to seizure management. For example, during the seizure event, the nurse
needs to observe the client's facial expression, muscle tone, movements (e.g. jerking or
twitching) the parts of the body involved, and any automatic or repeated movement (e.g.
lipsmacking, chewing, swallowing).
Concepts tested

Question 4170
The nurse is preparing a client for discharge following inpatient treatment for pulmonary
tuberculosis. Which instruction should be given to the client?
A Avoid contact with children, pregnant women or immunosuppressed persons.
B Continue taking medications until symptoms are relieved.
C Take medication with aluminum hydroxide if epigastric distress occurs.
D Continue taking medications as prescribed.

Question Explanation
Correct Answer is D
Rationale: Early cessation of treatment may lead to development of drug-resistant tuberculosis
(TB). Active TB is usually treated with a combination of four different antibiotics (Isoniazid,
rifampin, ethambutol and pyrazinamide) and can now take anywhere from 6-12 months to
completely kill the bacteria. As with any antibiotics, clients should continue to take medications
even after they begin to feel better. There is no reason to avoid contact with children, pregnant
women or immunosuppressed persons once discharged from the hospital as long as the client is
adhering to medication schedules. Isoniazid should be taken on an empty stomach; ethambutol
can be taken with food to avoid stomach upset. If taken with TB medications, aluminum
hydroxide will interfere with absorption of these medications.
Concepts tested

Question 4171
The nurse is assessing a client who was admitted with suspected Guillain-Barré syndrome.
Which assessment findings should the nurse expect? Select all that apply.
A Weakness
B Seizures
C Diarrhea
D Paresthesia
E Hyporeflexia
F Hypotonia

Question Explanation
Correct Answer is A, D, E, F

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Rationale: Guillain-Barré syndrome (GBS) is an autoimmune process that occurs after a viral or
bacterial infection, causing acute inflammatory demyelinating polyneuropathy. Transmission of
nerve impulses is stopped or slowed. This leads to flaccid paralysis with muscle denervation and
atrophy. The main features of GBS include acute, ascending, rapidly progressive, symmetric
weakness of the limbs. The first symptoms are weakness, paresthesia (numbness and tingling),
and hypotonia (reduced muscle tone) of the limbs. Reflexes in the affected limbs are weak or
absent. Diarrhea and seizures are not typically associated with GBS.
Concepts tested

Question 4172
A client admitted with congestive heart failure is experiencing severe dyspnea and states, "I feel
like something is terribly wrong!" The client is restless and begins to cough up large amounts of
pink, frothy sputum. The client's skin is a dusky, gray color. His oxygen saturation levels have
decreased from 92% to 76% in the last hour. Which action should the nurse implement first?
A Check vital signs
B Call the health care provider
C Place the bed in high Fowler's position
D Administer the PRN ordered oxygen

Question Explanation
Correct Answer is D
Rationale: When dealing with a medical emergency, the rule is to assess airway first, then
breathing, and then circulation. Starting oxygen is the priority. The other actions should also be
implemented as quickly as possible, including activation of the rapid response team. The client is
experiencing an acute episode of fulminant pulmonary edema, likely as a result of a new and
severe cardiac event and possible cardiogenic shock. Emergency assessment and intervention is
indicated to prevent cardiac arrest and possible death.
Concepts tested

Question 4173
The nurse in a primary care office is examining a 15-month-old child with suspected otitis
media. Which group of findings should the nurse anticipate?
A Periorbital edema, absent light reflex and translucent tympanic membrane
B Irritability, rhinorrhea, and bulging tympanic membrane
C Vomiting, pulling at ears and pearly white tympanic membrane
D Diarrhea, retracted tympanic membrane and enlarged parotid gland

Question Explanation
Correct Answer is B
Rationale: Clinical manifestations of otitis media include irritability, rhinorrhea, bulging
tympanic membrane, and pulling at the ears.
Concepts tested

Question 4174

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The nurse and a student nurse are discussing the health issues related to a laboring HBsAg-
positive client. Which of these comments by the student is incorrect and indicates a need for
further instruction?
A "The infant will receive the hepatitis B immune globulin within 12 hours after birth."
B "The HBsAg-positive mother should not breastfeed her baby."
C "The HBsAg-positive mother should be reported to the state or local health department."
D "The infant will receive the hepatitis B vaccine within 12 hours after birth."

Question Explanation
Correct Answer is B

Question 4175
The nurse suspects that the client is in cardiogenic shock, following a massive myocardial
infarction. Which finding would support the nurse's suspicion?
A Bradycardia
B Decreased or muffled heart sounds
C Bounding pulses
D Increased cardiac output

Question Explanation
Correct Answer is B
Rationale: Cardiogenic shock involves decreased cardiac output and evidence of tissue hypoxia
in the presence of adequate intravascular volume; it is the leading cause of death in acute
myocardial infarction. Findings of cardiogenic shock include hypotension, rapid and faint
peripheral pulses, distant-sounding, decreased heart sounds, cool and mottled skin, oliguria and
altered mental status.
Concepts tested

Question 4176
The client is admitted with a pressure ulcer that's two inches in diameter with no tunneling. It is a
shallow open ulcer with loss of dermis and a red/pink wound bed. The nurse observes some
serous drainage. What intervention does the nurse anticipate will be ordered to treat this wound?
A Alternating pressure pad overlay for the bed
B Alginate dressing with silver added
C Hydrogel dressing
D Whirlpool treatment and debridement

Question Explanation
Correct Answer is C
Rationale: This ulcer is a partial thickness wound. These types of wounds heal by tissue
regeneration, which is why the nurse would expect a gel dressing to be ordered. This dressing
will keep the wound moist, provide protection from infection and promote healing; also, the cool
sensation provided by the gel offers pain relief. Pink/red wound edges are considered normal in
the inflammatory stage of healing; the wound does not require debridement. There is nothing to
indicate that there's an infection, which is why the alginate with silver is not needed; also,

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alginate dressings are better for wounds with moderate-to-heavy drainage and are good for filling
cavities or tracts. An alternating pressure pad overlay would not treat the wound.
Concepts tested

Question 4177
The labor and delivery nurse is assessing a client in labor and notes a loop of the umbilical cord
protruding from the vagina. Which action should the nurse take first?
A Place the client in a knee-chest position
B Apply oxygen by mask
C Notify the health care provider
D Check the fetal heart rate

Question Explanation
Correct Answer is A
Rationale: A prolapsed umbilical cord is a medical emergency, which can result in brain damage
or death to the fetus if not treated promptly and properly. Immediate action is needed to relieve
pressure on the cord to prevent the risk of fetal hypoxia. A Trendelenburg or knee-chest position
accomplishes this and should be done first. Then the nurse should implement the other actions.
Concepts tested

Question 4178
An older adult client, admitted after a fall at home, begins to seize and loses consciousness. What
action should the nurse do next?
A Stay with client and monitor the condition
B Collect pillows and pad the side rails of the bed
C Announce a cardiac arrest and plan to assist with intubation
D Place an oral airway in the mouth and suction

Question Explanation
Correct Answer is A
Rationale: For the client's safety, remain at the bedside and observe respirations, the movements
of the extremities and level of consciousness. Prepare to clear the airway or suction if obstructed.
If suction equipment is not at the bedside, request that someone else get it for you, rather than
leaving the client. Do not place anything in the client's mouth. For safety, do not leave the client
unattended. A cardiac arrest should only be announced if pulse or respirations are absent after the
seizure.
Concepts tested

Question 4179
An unlicensed assistive person (UAP) is giving a bath to a 5-year-old client with Wilms tumor.
The UAP asks the nurse why there is a sign above the bed that says, "Do not palpate/press on
abdomen." What is the best response by the nurse?
A "Pressing on the abdomen might cause a bowel obstruction."
B "Pressing on the abdomen could cause the tumor to spread."
C "Pressing on the abdomen would be very painful for the child."

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D "Pressing on the abdomen will cause the tumor to bleed."

Question Explanation
Correct Answer is B
Rationale: Wilms tumor (nephroblastoma) is a childhood cancer. It is the most common kidney
tumor of childhood. The most common presenting sign is swelling or mass within the abdomen.
The mass is characteristically firm, nontender, confined to one side and deep within the flank.
The mass usually is discovered during routine bathing or dressing of the child.
When caring for a child with Wilms tumor, it is important not to palpate the tumor or press on
the abdomen, because manipulation of the mass may cause dissemination of cancer cells. To
reinforce the need for caution, a sign should be posted near the bed that reads "Do not
palpate/press on abdomen."
Concepts tested

Question 4180
The nurse is evaluating an older adult client who had a generalized, tonic-clonic seizure. The
client is drowsy, but moves all extremities. Vital signs are stable and there is vomit on the client's
clothes and face. Which complication is the priority to monitor the client for?
A Pneumonia
B Increased intracranial pressure
C Dehydration
D Urinary incontinence

Question Explanation
Correct Answer is A
Rationale: The presence of vomitus indicates that the client vomited during the seizure and the
likelihood of aspiration is high. Therefore, the priority is to monitor the client for development
of pneumonia. Aspiration pneumonia results from the abnormal entry of material from the mouth
or stomach into the trachea and lungs. Conditions that increase the risk for aspiration include
decreased level of consciousness (e.g., seizure). The aspirated material (food, water, vomitus,
oropharyngeal secretions) triggers an inflammatory response. The most common form of
aspiration pneumonia is a primary bacterial infection. The other complications are not typically
associated with a seizure.
Concepts tested

Question 4181
A 2-year-old child has been diagnosed with cystic fibrosis. The child's parent asks the nurse what
is most concerning about the disease. Which is the appropriate response from the nurse?
A "Thick, sticky secretions from the lungs are a constant challenge."
B "Cystic fibrosis results in nutritional concerns that can be dealt with."
C "There is a high probability of life-long complications."
D "You will work with a team of experts and have access to a support group."

Question Explanation
Correct Answer is A

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Rationale: The primary factor, and the one responsible for many of the clinical manifestations of
cystic fibrosis, is mechanical obstruction caused by the increased viscosity of mucous gland
secretions.

Because of the increased viscosity of bronchial mucus, there is greater resistance to ciliary action
(probably secondary to infection and ciliary destruction), a slower flow rate of mucus and
incomplete expectoration, which also contributes to the mucus obstruction. This retained mucus
serves as an excellent medium for bacterial growth. Reduced oxygen–carbon dioxide exchange
causes variable degrees of hypoxia, hypercapnia and acidosis.

In severe cases, progressive lung involvement, compression of pulmonary blood vessels and
progressive lung dysfunction frequently lead to pulmonary hypertension, cor pulmonale,
respiratory failure and death. Pulmonary complications are present in almost all children with
cystic fibrosis, but the onset and extent of involvement are variable.
Concepts tested

Question 4182
The nurse is assessing a client who was admitted to the hospital with a diagnosis of right-sided
heart failure. Which assessment findings should the nurse expect? Select all that apply.
A Dependent edema
B Anorexia
C Orthopnea
D Cough
E Polyuria
F Ascites

Question Explanation
Correct Answer is A, B, F
Rationale: The classic findings of right-sided heart failure arise from blood backing up into the
portal and systemic circulation, resulting in abdominal organ engorgement, ascites, loss of
appetite (anorexia), and dependent edema. Orthopnea and cough are more commonly seen with
left-sided heart failure. Polyuria is not a manifestation of right-sided heart failure.
Concepts tested

Question 4183
The nurse is evaluating a client admitted for exacerbation of chronic obstructive pulmonary
disease (COPD). The client is receiving 2 liters of oxygen per nasal cannula and reports
persistent dyspnea. Arterial blood gas results show a PaO2 65, pH 7.38, PaCO2 50, HCO3 28.
Which action should the nurse take next?
A Administer a bronchodilator
B Increase the oxygen flow rate
C Encourage the use of incentive spirometry
D Prepare the client for intubation

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Question Explanation
Correct Answer is B
Rationale: The client's ABG results show hypoxemia and an expected respiratory acidosis. The
likelihood of decreasing the respiratory drive from higher oxygen administration in clients with
COPD is low and does not outweigh the potentially serious consequences of untreated
hypoxemia. Therefore, the nurse should next increase the oxygen flow rate until an acceptable
oxygen saturation level is reached. The other actions are premature at this time or do not address
the issue of the hypoxemia.
Concepts tested

Question 4184
The nurse is providing education to a patent diagnosed with chronic kidney disease, stage 5.
Which statement made by the client indicates that teaching has been effective?
A "I know I have a high risk of clot formation since my blood is thick from too many red cells."
B "I can expect to have periods of little urine and then sometimes a lot of urine."
C "I have to go for epoetin (Procrit) injections at the health department."
D "My bones will be stronger with this disease since I will have higher calcium than normal."

Question Explanation
Correct Answer is C
Rationale: Anemia in end-stage renal failure is caused by reduced endogenous erythropoietin
production in the kidney. Anemia in primary end-stage renal disease is treated with subcutaneous
injections of Procrit or Epogen to stimulate the bone marrow to produce red blood cells. With
kidney failure, too much phosphorus can build up in the blood and calcium is pulled from the
bones, resulting in weakened bones. The statement about producing variable amounts of urine is
incorrect, as the client will produce little to no urine at this stage of the disease.
Concepts tested

Question 4185
The emergency room nurse is assessing a client admitted with unstable angina. Which lab test is
the priority for this client?
A Serum creatinine
B Serum potassium
C Troponin
D Hemoglobin

Question Explanation
Correct Answer is C
Rationale: Cardiac-specific troponin is a heart muscle protein released into circulation after
injury or infarction. Normally, the level in the blood is very low, so a rise in level is diagnostic of
myocardial infarction (MI) or injury. Troponin is the priority biomarker of choice in the
diagnosis of acute coronary syndromes.
Concepts tested

Question 4186

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A nurse is providing information to a client who is newly diagnosed with tuberculosis (TB). The
nurse should be sure to include which statement when teaching the client about managing this
disease?
A "Follow up with your primary care provider in three months."
B "Continue to take your medications even when you are feeling fine."
C "Isolate yourself from others until you are finished taking your medication."
D "Continue to get yearly tuberculin skin tests."

Question Explanation
Correct Answer is B
Rationale: The client with TB needs is to understand the importance of medication compliance,
even when the client is no longer having any symptoms. TB treatment usually requires a
combination of medications with treatment for at least six months. Stopping treatment or
skipping doses can lead to a drug-resistant form of TB. Clients are most infectious early in the
course of therapy but the numbers of acid-fast bacilli are greatly reduced as soon as two weeks
after therapy begins. Once clients no longer have a productive cough, they are not considered
contagious.
Concepts tested

Question 4187
The nurse in a labor and delivery unit is assessing a client who is in the first stage of labor. The
client reports that they felt their "water break" a few moments ago. On visual inspection, the
nurse notes a short loop of the umbilical cord protruding from the vagina. Which action should
the nurse take first?
A Administer hi-flow oxygen to the mother.
B Place the client in a knee-chest position.
C Insert a gloved hand into the vagina and hold the presenting part off the cord.
D Notify the health care provider immediately.

Question Explanation
Correct Answer is C
Rationale: A prolapsed cord is a medical emergency. The prolapsed part of the cord is being
compressed by the presenting part of the fetus, causing occlusion of blood flow and fetal
hypoxia. If not relieved within a few minutes, it will result in central nervous damage or death of
the fetus. Pressure on the cord must be relieved first and can be accomplished by the nurse
placing a gloved hand or fingers into the vagina and holding the presenting part off the umbilical
cord.
Concepts tested

Question 4188
The nurse is assigned to care for a client who was diagnosed with an intracranial aneurysm that
has since resolved. To minimize the risk of another rupture, the nurse should plan to take which
action?
A Keep the client in a upright sitting position
B Apply a warming blanket for temperatures of 98 °F (36.6 C°) or less

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C Treat any elevation in blood pressure
D Avoid arousal of the client except for family visits

Question Explanation
Correct Answer is C
Rationale: Treating any blood pressure elevation and reducing stress by maintaining a quiet
environment, including during family visits, will assist in minimizing the risk of a cerebral bleed.
An upright sitting position with the pressure on the hip area can lead to increased intracranial
pressure; this position should be avoided. A warming blanket is inappropriate to use.
Concepts tested

Question 4189
The nurse is admitting a 10-month-old infant with suspected bacterial meningitis. Which
intervention should the nurse implement first?
A Initiate droplet precautions
B Establish a peripheral venous access device
C Administer analgesics and antipyretics as needed
D Measure head circumference

Question Explanation
Correct Answer is A
Rationale: Bacterial meningitis is an acute inflammation of the meninges and cerebrospinal fluid
(CSF). Meningitis is contagious and can be transmitted by droplets from nasopharyngeal
secretions of infected individuals. The first intervention should be to place the child on droplet
precautions to prevent the transmission to others and spread the infection.
Concepts tested

Question 4190
The nurse is assessing a 1-month-old infant. Which finding should the nurse
report immediately?
A Abdominal respirations
B Irregular breathing rate
C Inspiratory grunt
D Increased heart rate with crying

Question Explanation
Correct Answer is C
Rationale: Inspiratory grunt is an abnormal finding and indicates respiratory distress in infants.
Other signs of respiratory distress in this age group are nasal flaring, often the initial finding, as
well as sternal and intracostal retractions. Abdominal breathing is a normal expected breathing
process for infants. The other findings are also normal in infants.
Concepts tested

Question 4191

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A 3-year-old child presents with exam findings that may suggest a neuroblastoma. The nurse is
collecting information from the child's parents. Which statement by the parent is suggestive of
neuroblastoma and requires follow-up by the health care provider?
A "He seems to be getting weaker and weaker and is sometimes unsteady on his feet."
B "We keep having to buy him larger size pants because he's growing so big around the waist."
C "Our child has been quieter than normal lately and has lost weight."
D "He doesn't seem to be going to the bathroom as much and his urine is dark yellow in color."

Question Explanation
Correct Answer is B
Rationale: One of the most common signs of neuroblastoma is increased abdominal girth due to
the mass or tumor in the abdomen. The mass can cause pain and/or a feeling of fullness and the
pressure may affect the child's bladder or bowel. Although the child with a neuroblastoma may
not want to eat (which can lead to weight loss), this finding could have many causes. A more
significant finding would be if the parents reported that child keeps outgrowing clothing or that
clothing is tight around the abdomen.
Concepts tested

Question 4192
A child is injured on the school playground and appears to have a fractured leg. What is
the first action that the school nurse should take?
A Immobilize the limb and joints above and below the injury
B Call for emergency transport to the hospital
C Assess the child and the extent of the injury
D Apply cold compresses to the injured area

Question Explanation
Correct Answer is C
Rationale: Application of the nursing process dictates that assessment is the first step in the
provision of care. The 6 Ps of vascular impairment (pain, pulse, pallor, paresthesia, paralysis and
poikilothermia (coolness) can be used as a guide for assessment of the injured leg. The other
options would be done in this sequence —immobilize, call 911 and then apply ice as indicated.
Concepts tested

Question 4193
After placement of a ventriculoperitoneal (VP) shunt as a treatment for hydrocephalus, the
parents of an infant ask the nurse: "Why is there a small incision on the abdomen?" Which
response by the nurse is most appropriate for explaining the purpose of the incision?
A "That's what is used for insertion of the catheter into the stomach."
B "It's used to visualize the abdominal organs for correct catheter placement."
C "It's there so the tubing can be inserted into the urinary bladder."
D "It's used to pass the catheter into the abdominal cavity."

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Question Explanation
Correct Answer is D
Rationale: The preferred procedure in the surgical treatment of hydrocephalus is the placement
of a ventriculoperitoneal shunt. This shunt procedure provides primary drainage of the
cerebrospinal fluid from the ventricles to an extracranial compartment, which is commonly the
peritoneum. A small incision is made in the upper quadrant of the abdomen so the shunt tip can
be guided into the peritoneal cavity.
Concepts tested

Question 4194
The nurse is teaching the parents of a child with sickle cell disease about ways to prevent
complications and crises. What information would be a priority for the nurse to emphasize to the
family?
A The child can maintain normal activity with some restrictions
B The child should be cautious of being exposed to people with a cold or fever
C The child may not be able to follow routine immunization schedules
D The child should avoid becoming overheated or dehydrated during physical activity and
exercise

Question Explanation
Correct Answer is D
Rationale: The goal of sickle cell treatment is to manage and control symptoms and to prevent
sickle cell crisis. Fluid loss caused by overheating and dehydration can trigger a sickle cell crisis.
People with sickle cell anemia need to keep their immunizations up-to-date, treat infections
quickly and avoid too much sun exposure.
Concepts tested

Question 4195
The client is diagnosed with infective endocarditis (IE) and has been receiving antibiotic therapy
for four days. Which finding suggests that the antibiotic therapy has not been effective and must
be reported to the health care provider immediately?
A Muscle tenderness
B Nausea with vomiting
C Temperature of 103° F (39.5° C)
D Streaks of red under the nails

Question Explanation
Correct Answer is C
Rationale: Findings of IE include skin rash (petechiae) and small areas of bleeding (splinter
hemorrhages) under the fingernails. Muscle or joint pain or weakness are also common
symptoms of IE. Nausea and vomiting may be side effects of the treatment; these findings
probably would have appeared shortly after beginning treatment. Prolonged fever after 72 hours
of antibiotic therapy indicates the antibiotic regime is not effective against the strain of
microorganism - the nurse must call the HCP about this finding. Surgical intervention may be
indicated for persistent sepsis after 72 hours of appropriate antibiotic treatment.
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Concepts tested

Question 4196
The nurse auscultates bibasilar inspiratory crackles in a 68-year-old client with systolic heart
failure and an ejection fraction of 30%. Which other finding should the nurse expect based on
this diagnosis?
A Peripheral edema
B Nail clubbing
C Chest pain
D Fatigue

Question Explanation
Correct Answer is D
Rationale: Systolic heart failure is the result of a pumping problem, which is why the ejection
fraction is reduced (normal is 60%). Heart failure can be caused by a heart attack, but chest pain
is not normally a finding in heart failure. Nail clubbing is usually associated with disorders of the
lungs. Exertional dyspnea and fatigue are common in clients with left-sided (systolic) heart
failure due to fluid backing up into the lungs and pulmonary congestion. Peripheral edema is
more commonly seen with right-sided (diastolic) heart failure.
Concepts tested

Question 4197
The nurse is working in a long-term health care facility and assessing several clients. Which
client is at highest risk for developing a pressure ulcer?
A A 79-year-old malnourished client on bed rest
B An incontinent client who has had three diarrhea stools in the past hour
C An 80-year-old ambulatory client with a history of diabetes mellitus
D An obese client who uses a wheelchair

Question Explanation
Correct Answer is A
Rationale: Weighing significantly less than ideal body weight increases the number and surface
area of bony prominences, which are susceptible to pressure ulcers. In addition, malnutrition is a
major risk factor for pressure ulcers, from poor hydration and inadequate protein intake. Note
that this is a priority question so that all of the clients are at risk for pressure ulcers. However, the
question asks for the client with the highest risk.
Concepts tested

Question 4198
A 12-year-old child with cancer is distraught about the alopecia that occurred after the last
chemotherapy treatment. Which nursing interventions are appropriate to address this side effect
of chemotherapy? Select all that apply.
A Practice and teach thorough hand washing
B Allow the child to choose a cap, scarf, wig or other head cover to use
C Encourage visits from friends before discharge from the hospital

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D Administer prescribed antiemetic medication before nausea is too severe

Question Explanation
Correct Answer is B, C
Rationale: Alopecia is the loss of hair, which is a frequent side effect of certain types of
chemotherapy. Although it is not life-threatening, the body image change is difficult for many
individuals, particularly children and adolescents. Encouraging visits from friends before
discharge helps the young client and friends adjust. Wearing preferred forms of head cover-ups
increases comfort and decreases embarrassment. The other options are proper interventions for
chemotherapy, but do not help the client with hair loss.
Concepts tested

Question 4199
A school nurse is called to the playground for an episode of mouth trauma. The nurse finds that
the front tooth of a 9-year-old child has been avulsed ("knocked out"). After recovering the tooth,
which action should the nurse take?
A Ask the child to replace the tooth even if the bleeding continues
B Rinse the tooth in water before placing it into its socket
C Place the tooth in a clean plastic bag for transport to the dentist
D Hold the tooth by the roots until reaching the emergency room

Question Explanation
Correct Answer is B
Rationale: Following avulsion of a permanent tooth, it is important to rinse the dirty tooth in
water, saline solution or milk before re-implantation. If possible, replace the tooth into its socket
within 30 minutes while avoiding contact with the root. The child should be taken to the dentist
as soon as possible
Concepts tested

Question 4200
A child is admitted to the hospital with findings consistent with rheumatic fever. During the
admission process, which statement made by a parent would the nurse associate with this
disease?
A "Our child had a sore throat a month ago, which I treated with an herbal remedy."
B "Our child is being tested for allergies and has reacted to some allergens."
C "Both ears were infected when our child was 3-months-old."
D "Last week both feet had a fungal skin infection."

Question Explanation
Correct Answer is A
Rationale: Evidence supports a strong relationship between group A streptococcal infections and
subsequent rheumatic fever (usually within two to six weeks). Therefore, the history of sore
throat may have been an undiagnosed strep A infection. Appropriate antibiotic treatment of strep
throat is the most effective way to reduce the risk of developing rheumatic fever.
Concepts tested

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Question 4201
A nurse is caring for a client who has developed cardiac tamponade. Which finding would the
nurse anticipate?
A Bradycardia
B Pleural friction rub
C Widening pulse pressure
D Distended neck veins

Question Explanation
Correct Answer is D
Rationale: In cardiac tamponade, intrapericardial pressures prevent adequate filling of the heart
from the vena cava, and reduce cardiac output. As a result, venous pressures rise and the neck
veins become distended.
Concepts tested

Question 4202
The client is admitted with the diagnosis of chronic obstructive pulmonary disease (COPD).
Which findings would require the nurse's immediate attention?
A Nausea and vomiting
B Frequent productive cough with brownish sputum
C Restlessness and confusion
D Low-grade fever and cough

Question Explanation
Correct Answer is C
Rationale: Hypoxia and respiratory failure in COPD may be signaled by excessive somnolence,
restless, aggressiveness, confusion, central cyanosis and shortness of breath. When these findings
occur, the oxygen saturation and arterial blood gases (ABGs) should be assessed and oxygen
should be rapidly titrated upward to correct the hypoxia. Signs of respiratory distress or failure
may necessitate the use of ventilatory assistance BIPAP or emergent intubation and mechanical
ventilation. Cough, discolored sputum, and fever may indicate a respiratory infection such as
pneumonia, but this is a less urgent situation.
Concepts tested

Question 4203
A client, admitted with palpitations and dyspnea, is diagnosed with atrial fibrillation (AF).
Normal sinus rhythm is later restored using pharmacologic interventions. In addition to
controlling cardiac rate and rhythm, the nurse understands that treatment for AF should include
which additional intervention?
A Cardioversion
B Coronary artery bypass graft surgery
C Catheter ablation
D Anticoagulation

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Question Explanation
Correct Answer is D
Rationale: In addition to rate and rhythm control, acute management of AF includes
anticoagulation. Effective anticoagulation in clients with AF significantly reduces the risk of
stroke and other thromboembolic events. When a client does not respond to pharmacologic
interventions to restore sinus rhythm, cardioversion is used. Catheter ablation is used to destroy
the triggers in the atrium for AF, but is not the first line of treatment. Bypass surgery is not used
to treat AF.
Concepts tested

Question 4204
The nurse is assessing a client who has an oral endotracheal tube with mechanical ventilation.
Which finding requires immediate action by the nurse?
A Visible mist in the ventilator circuit
B Pulse oximetry reading of 86%
C Client is unable to speak
D Diminished breath sounds bilaterally

Question Explanation
Correct Answer is B
Rationale: Pulse oximetry should not be lower than 90% saturation; therefore a pulse oximetry
reading of 86% requires immediate action. Breath sounds are diminished but heard bilaterally so
the placement of an endotracheal tube ET is most likely in the proper position. A client with an
ET tube in place will not be able to speak when the ET tube balloon Is inflated. Due to the need
for humidification with mechanical ventilation, it would be expected to have a fine mist visible.
Concepts tested

Question 4205
The home health nurse is developing a plan of care for a 3-year-old client diagnosed with
cerebral palsy (CP). Which goals are the priority for this client? Select all that apply.
A Prevent seizures
B Treat muscle spasms
C Arrange for genetic counseling
D Select appropriate school environment

Question Explanation
Correct Answer is A, B
Rationale: Cerebral palsy (CP) is defined as a disorder of posture and movement from static
brain injury perinatally or postnatally, which limits activity. In addition to motor disorders, the
condition often involves disturbances of sensation, perception, communication, cognition, and
behavior. Some of the disabilities associated with CP are visual impairment, hearing impairment,
behavioral problems, communication and speech difficulties, seizures, and intellectual
impairment. The priority goals at this age should include the prevention of seizure activity and
correction of any associated physical defects and physical/occupational therapy to promote
mobility and movement or the ability to move from one place to another (locomotion). Children

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with CP often suffer from muscle spasms and seizures and typically require pharmacotherapy for
both. The other interventions are not appropriate at this age. CP is not a genetic disease.
Concepts tested

Question 4206
The nurse is performing a respiratory assessment on a newborn. Which assessment finding
would require intervention by the nurse?
A Rapid, shallow respirations
B Short periods of apnea (<10 seconds)
C Nasal flaring
D Symmetric chest movement

Question Explanation
Correct Answer is C
Rationale: Newborn respirations are often rapid, shallow and irregular with short periods of
apnea (<15 seconds). The respiratory rate of a newborn is dependent on their activity level but
ranges from 30 to 60 breaths per minute and chest movement should be symmetrical. While
rapid, the respirations should not be labored. Nasal flaring, cyanosis, sternal retractions and
expiratory grunting are signs of respiratory distress and should be further evaluated.
Concepts tested

Question 4207
The nurse is caring for a child diagnosed with seizures. While teaching the family and the child
about the medication phenytoin, which concept should the nurse emphasize?
A Maintain good oral hygiene and dental care
B A rash is normal with this medication
C Omit the medication if the child is seizure-free
D Serve a diet that is high in iron

Question Explanation
Correct Answer is A
Rationale: Gingival hyperplasia may occur with this medication. It is important that good oral
hygiene is maintained. The medication should never be stopped, even if the child is seizure-free.
A sudden discontinuation could result in status epilepticus. A diet high in iron interferes with
phenytoin absorption and will reduce the effectiveness. A blister-like rash is not normal with this
medication and could indicate medication-related Stevens-Johnson syndrome, which is a serious
disorder of the skin and mucous membranes.
Concepts tested

Question 4208
A nurse is caring for a child who underwent a tonsillectomy an hour ago. The child's parents
report to the nurse that the child feels very warm. Which intervention should the nurse do first?
A Offer the child cold oral fluids.
B Administer the prescribed acetaminophen.
C Reassure the parent that this is normal after surgery.

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D Measure the child's temperature.

Question Explanation
Correct Answer is D
Rationale: While a low-grade fever (>101°F or 38.3°C) is common after surgery, the nurse
should assess the child's temperature prior to any action. The health care provider (HCP) should
be contacted if the temperature is higher than 101.5° (38.6°C). After evaluating the child's
temperature, the other options may be implemented. However, the child should not drink fluids
until they are alert and should not be given straws, acidic juices, or red/brown fluids. Straws and
acidic juices may cause surgical site damage and red/brown fluids may be confused with blood
in emesis.
Concepts tested

Question 4209
Several hours after a total gastrectomy, the client's nasogastric tube (NGT) stops draining. After
referring to the postoperative orders, which order will the nurse implement first?
A Notify the surgeon
B Irrigate the nasogastric tube
C Reposition the tube until it begins to drain
D Increase the amount of suction by 5 mmHg

Question Explanation
Correct Answer is B
Rationale: After surgery, the nurse should closely monitor the nasogastric tube (NGT) to ensure
it is suctioning appropriately. Irrigating the NGT is appropriate because these tubes may become
clogged. A clogged NGT could lead to acute gastric dilation after surgery. This intervention
should be performed first.
Concepts tested

Question 4210
During a routine clinic visit, the nurse is providing education to a client with a history of Type 1
diabetes mellitus. The client's glycosylated hemoglobin (HbA1C) was 11%. Based on this result,
which teaching concept should the nurse emphasize?
A Proper storage of oral medication used to decrease glucose level
B Rotate injection sites with every injection
C Assess blood sugar and treat with insulin before meals and at bedtime
D Continue with the current effective regimen

Question Explanation
Correct Answer is C
Rationale: Type 1 diabetes mellitus is caused by an autoimmune destruction of the beta cells
within the pancreas. These cells are responsible for making insulin. Because of this the client
will be dependent on insulin and no oral antihyperglycemic agents will be effective. A
glycosylated hemoglobin of 11% is elevated and indicates inadequate glucose control over a

Page | 1369
period of 2 to 3 months. Rotation of sites should be done regularly to prevent skin breakdown
and to ensure proper delivery of the drug, but it is not a priority at this time.
Concepts tested

Question 4211
The nurse is admitting a client diagnosed with uncontrolled hypertension. Which of the
following questions is a priority for the nurse to ask?
A "Describe your family's cardiovascular history."
B "Tell me about your usual diet for one day."
C "Describe your usual exercise and activity patterns."
D "What over-the-counter medications do you take?"

Question Explanation
Correct Answer is D
Rationale: Over-the-counter (OTC) medications, especially those that treat cold symptoms, can
increase blood pressure. Clients diagnosed with hypertension should be educated to avoid OTC
medications that contain phenylephrine and look for OTC cold medication specifically design for
people with hypertension. The other options are essential parts of this client's medical history.
However, they do not pose the greatest risk to the client.
Concepts tested

Question 4212
A client is transported to the emergency department following a boating accident and submersion
in cold water. The client is conscious, shivering and confused. What interventions should the
nurse implement? Select all that apply.
A Provide warmed blankets
B Massage extremities
C Remove wet clothing
D Administer warmed IV fluids as ordered

Question Explanation
Correct Answer is A, C, D
Rationale: The client is at risk for hypothermia. The nurse should remove wet clothing carefully.
External rewarming, such as warmed blankets or heat packs, which are placed under the arms
and on the neck, chest and groin. The client may also be ordered to receive warmed IV fluids and
humidified oxygen to help stabilize the core temperature. Monitoring should include vital signs,
level of consciousness, cardiac rhythm and core body temperature. The client should not receive
any oral fluids until their condition is stabilized and extremities should not be massaged.
Concepts tested

Question 4213
The nurse is caring for a newly admitted 6 month-old infant diagnosed with nonorganic failure-
to-thrive (NOFTT). What findings would the nurse expect to observe during the initial
assessment?
A Irritable and "colicky," making no attempts to turn or sit up

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B Alert, laughing, playing with a rattle and sitting with support
C Pale skin, thin arms and legs and uninterested in surroundings
D Dusky in color with poor skin turgor over abdomen

Question Explanation
Correct Answer is C
Rationale: Diagnosis of NOFTT is weight consistently below the 3rd to 5th percentile for age and
gender, progressive decrease in weight to below the 3rd to 5th percentile, or a decrease in the
percentile rank of two major growth parameters in a short period of time. The nurse would
expect to see a child who avoids eye contact, has pale skin, thin arms and legs, and is easily
fatigued. NOFTT is due to psychosocial problems such as neglect, lack of knowledge about
proper feeding or of the infant's needs. Many times the child engages in self-stimulatory
behaviors (head banging or rocking) and is wary of close contact with people.
Concepts tested

Question 4214
The school nurse is educating teachers that the number of children diagnosed with fifth disease
has increased. Which clinical manifestation of fifth disease should the nurse emphasize to the
teachers?
A Koplik spots appear first followed by a rash that appears first on the face and spreads
downward
B Macule that rapidly progresses to papule and then vesicles
C Bright red cheeks, with a "slapped face" appearance
D Discrete rose pink macules will appear first on the trunk and fade when pressure is applied

Question Explanation
Correct Answer is C
Rationale: Fifth disease is also referred to as parvovirus infection or erythema infectiosum.
Some people may call it slapped-cheek disease because of the face rash that develops resembling
slap marks. It is also commonly called fifth disease because it was fifth of a group of once-
common childhood diseases that all have similar rashes. The other four diseases are measles,
rubella, scarlet fever and Dukes' disease. People will not know that a child has parvovirus
infection until the rash appears, and by that time the child is no longer contagious.
Concepts tested

Question 4215
The nurse is caring for a client receiving mechanical ventilation when the device signals a high-
pressure alarm. The nurse should include what assessments in addressing this alarm? Select all
that apply.
A Assess client for partial or total extubation
B Assess for obstructing secretions
C Assess tubing to ensure it is not kinked
D Assess client for signs of bronchospasm

Question Explanation

Page | 1371
Correct Answer is B, C, D
Rationale: High pressure alarms are usually caused by something preventing or blocking air
from being delivered by the ventilator to the lungs. Common causes for this include kinked
tubing, secretions and/or bronchospasms, or the client fighting the tube. Low pressure alarms are
usually caused by air escaping the closed unit. A total or partial extubation would cause a low-
pressure alarm.
Concepts tested

Question 4216
A nurse is caring for a client who is being evaluated for a possible myocardial infarction. The
nurse notes what appears to be ventricular tachycardia on the cardiac monitor. Which action is
a priority for the nurse?
A Assess airway, breathing and circulation
B Begin cardiopulmonary resuscitation
C Prepare for immediate defibrillation
D Notify the rapid response team and the health care provider

Question Explanation
Correct Answer is A
Rationale: The nurse must treat the client, not the cardiac monitor. Always assess the client to
determine the next step. This focused assessment includes checking the client's airway,
breathing, and circulation (ABCs) and for signs of low cardiac output. Signs of low cardiac
output include chest pain, dyspnea, hypotension and an altered level of consciousness. These
clinical manifestations would indicate a need for cardioversion and other emergency
interventions. The other options would be appropriate after the nurse has assessed the client.
Concepts tested

Question 4217
A client with possible Hepatitis C discusses his health history with the nurse. The nurse should
recognize which statement by the client as the most important in supporting this diagnosis?
A "I ate the best raw oysters last week."
B "I have had unprotected sexual contact with at least one person."
C "I had a blood transfusion in 1990."
D "I got back from Africa a few weeks ago."

Question Explanation
Correct Answer is C
Rationale: The client who received a blood transfusion prior to screening for Hepatitis C (prior
to July 1992) may show findings many years later due to Hepatitis C being asymptomatic in the
early stages. Other risk factors for Hepatitis C include those who have been on long-term
hemodialysis and have regular contact with blood at work. Contracting Hepatitis C from having
unprotected sex with a person who has Hepatitis C is rare. However, unprotected sex with
multiple partners does increase the risk. Eating raw oysters or drinking contaminated water
would increase the risk of Hepatitis A. Travel to Africa would increase the risk of exposure to
malaria from mosquitos carrying the disease as well as HIV if the person were exposed to blood
carrying the infection or had unprotected sex with someone who was HIV positive.
Page | 1372
Concepts tested

Question 4218
The nurse is caring for a client who was diagnosed with a deep vein thrombosis (DVT). The
client reports sudden shortness of breath and the oxygen saturation decreases to 87% on room
air. Which intervention is a priority action by the nurse?
A Administer oxygen to maintain a saturation of 92%
B Call the health care provider (HCP)
C Administer the PRN albuterol nebulizer
D Begin continuous cardiac monitoring

Question Explanation
Correct Answer is A
Rationale: An acute onset of dyspnea and hypoxia is a classic finding of pulmonary embolism
(PE). A client with a DVT has a risk for part of the clot breaking off and traveling to the lungs.
The administration of oxygen to correct hypoxia is the highest priority. After administering
oxygen, the HCP would need to be notified and the nurse should anticipate orders for diagnostic
tests (Pulmonary Angiogram, d-dimer, CT scan). Albuterol nebulization is a standard treatment
for respiratory distress related to asthma, COPD and anaphylaxis. However, it is not used for
dyspnea due to a PE.
Concepts tested

Question 4219
The nurse is monitoring the level of consciousness for a client who experienced a head injury.
During the last assessment, the client scored a 15 on the Glasgow Coma Scale (GCS). Now, the
client opens eyes to verbal command (GCS 3), has purposeful movement to painful stimulus
(GCS 5) and is using inappropriate words (GCS 3). Which intervention by the nurse should be
implemented first?
A Raise the head of the bed
B Call the rapid response team and health care provider
C Continue to monitor level of consciousness
D Increase the flow of oxygen

Question Explanation
Correct Answer is B
Rationale: The GCS measures the client's highest motor response, verbal response, and eye
response with scores ranging from 3 to 15. The GCS can be used to monitor progress and predict
a client's outcome or prognosis. In the last assessment, this client was scored a 15 on the GCS,
which indicates the baseline. Upon reassessment, the client's responses have decreased indicating
a worsened neurological state. This requires urgent intervention and the rapid response team and
health care provider should be notified. If the nurse continues to monitor the level of
consciousness without notifying the HCP and the rapid response team, the client's condition
could worsen. It is possible the change is related to increased intracranial pressure (ICP), but this
needs to be determined before the other actions are taken.
Concepts tested

Page | 1373
Question 4220
A nurse is caring for a client diagnosed with an obstructing renal calculus. Which focus of the
health care provider's orders would the nurse prioritize?
A Push oral fluids
B Start intravenous antibiotics
C Apply warm compress over flank area
D Morphine sulfate for pain control

Question Explanation
Correct Answer is D
Rationale: The priority action for an obstructing renal calculus (kidney stone) is to provide
prompt relief for the severe pain. Oral hydration or intravenous fluids will help move the stone
though the urinary system, but would be prioritized after pain management. Applying a warm
compress over the flank may help pain, but would be prioritized after narcotic analgesics for this
diagnosis. A kidney stone is not an infection and does not indicate the need for intravenous
antibiotics.
Concepts tested

Question 4221
The nurse is caring for a client who is frequently admitted for acute exacerbations of asthma. The
client admits that she does not use her medications as prescribed because she often does not feel
short of breath. Which explanation by the nurse best describes the long-term consequences of
uncontrolled airway inflammation?
A Lung remodeling and permanent changes in lung function will result
B The alveoli will degenerate and balloon out
C Chronic bronchoconstriction of the large airways will occur
D The client will experience frequent bouts of pneumonia

Question Explanation
Correct Answer is A
Rationale: Asthma is categorized as a chronic, hyper-responsive disorder affecting the terminal
bronchioles. Exacerbation of asthma or an "asthma attack" is an acute event. However, the
effects of increased number of exacerbations and not using the medication is lung remodeling.
This lung remodeling results in more narrow airways and increased mucous. By explaining the
consequences of not using the medication, the nurse is reinforcing the need for daily
management. Degeneration of alveoli causing increased expansion is a result of emphysema.
Asthma does increase the risk of pneumonia, but this option does not address the permanent
long-term issues associated with not taking the medication as prescribed. Chronic
bronchoconstriction of the large airways is not associated with asthma.
Concepts tested

Question 4222
The nurse is preparing a presentation focusing on the prevention of Lyme disease. Which
statement by a participant would require further clarification by the nurse?
A "Lyme disease can spread to my brain if I don't seek treatment."

Page | 1374
B "I will call the doctor if I see a rash that looks like a bull's eye."
C "Lyme disease is caused by a virus similar to the flu."
D "I should wear light-colored clothing and long pants when gardening."

Question Explanation
Correct Answer is C
Rationale: While the symptoms of Lyme disease are similar to influenza, Lyme disease is not
caused by a virus. Lyme disease is caused by the spirochete, Borrelia burgdorferi, which is
transmitted to humans by deer ticks. Because the ticks are so small, it is easier to see them on
light-colored clothing. Long pants and long-sleeved shirts help protect individuals from insect
bites. After being outdoors, individuals should assess their body for any ticks or rashes. Parents
should be instructed to check children for ticks and rashes. There may be a "bull's eye" rash at
the site of the tick bite. Without antibiotics, the disease can spread to the brain, heart and joints
of the body.
Concepts tested

Question 4223
A 14-month infant is brought to the emergency department with irritability, lethargy for two
days, dry skin and increased pulse rate. What additional questions should the nurse ask to assist
the health care provider with determining the proper diagnosis?
A Use of daycare
B Change in eating habits
C Reverse of sleep-wake cycles
D The number of wet diapers in the past two days

Question Explanation
Correct Answer is D
Rationale: Based on these clinical findings, the nurse might suspect that the infant is dehydrated.
Asking about the number of wet diapers would assess for decreased urine output, a key finding
in dehydration. Asking about increased concentration of the urine would also be appropriate. The
other questions, while appropriate, would not provide the most helpful diagnostic information.
Concepts tested

Question 4224
The nurse is caring for a client who has suffered third-degree burns in a motor vehicle accident.
The spouse of the client asks the nurse to clarify what is meant by third-degree burn. Which is
the best response by the nurse?
A "The top layer of the skin is destroyed, exposing the dermis."
B "All layers of the skin were destroyed in the burn."
C "Muscle, tissue, and bone have been injured."
D "The skin layers are inflamed. Blisters will appear and may weep."

Question Explanation
Correct Answer is B

Page | 1375
Rationale: Burns are categorized based on the level of tissue damage. A first-degree burn is a
superficial burn that may be pink or red, warm to the touch and painful. An example of a first-
degree burn is a sunburn. A second-degree or partial thickness burn is characterized by a
blistered appearance, red or pink and painful. An example of a second-degree burn could be a
severe sunburn that has blisters. A third-degree burn or full thickness burn includes damage to all
layers of the skin and underlying tissues. The area will appear leathery and the color could range
from red to black. The area may lack sensation. A fourth-degree burn is also termed a full-
thickness burn, but involves muscle, tissue and bone.
Concepts tested

Question 4225
The nurse receives a client who was transported to the emergency department for severe
hypertension. Which finding requires immediate action by the nurse?
A Jugular vein distension
B Cough with frothy, pink sputum
C Crackles in the lung bases
D Weakness in the left arm

Question Explanation
Correct Answer is D
Rationale: In a client who has uncontrolled hypertension, weakness in the extremities is a sign
of cerebral involvement. Cerebral infarctions account for approximately 80% of the strokes in
clients with hypertension. The remaining choices indicate fluid overload, which may be
associated with heart failure related to the uncontrolled hypertension. While concerning, these
are not medical emergencies. Jugular vein distension (JVD) is due to the elevated central venous
pressure (CVP). Crackles in the bases of the lungs and a cough with frothy, pink sputum indicate
pulmonary congestion. Crackles in all lung fields accompanied by dyspnea and orthopnea would
indicate acute pulmonary edema, which would also be considered a medical emergency.
Concepts tested

Question 4226
The nurse is evaluating comprehension of a client newly diagnosed with testicular cancer. Which
statement by the client indicate an understanding of this type of cancer?
A "I will probably never be able to have children after receiving chemotherapy."
B "After surgery, I can have a prosthesis placed inside my scrotum."
C "If they find lymph node involvement, I am pretty much dead, aren't I?"
D "I should have been better about using a condom during sexual intercourse."

Question Explanation
Correct Answer is B
Rationale: Testicular cancer is a rare cancer that most often affects men between 20 and 35
years of age. With early detection and treatment, testicular cancer has a 95% cure rate. It can
occur in one testicle or both. Surgery is the main treatment for testicular cancer. For stage 0 or 1
(localized disease), a unilateral orchiectomy is usually performed. A gel-filled silicone prosthesis
may be surgically implanted into the scrotum at the time of the orchiectomy or later if the client

Page | 1376
desires. If there are concerns about sterility, the client has the option of sperm storage. Sexual
intercourse, with or without a condom, does not cause testicular cancer.
Concepts tested

Question 4227
The nurse is performing a surgical dressing change on a client who had a laparotomy five days
ago. The nurse notices the incision edges are separated and there is a visible bulge of organ tissue
protruding from the wound opening. Which is the best way for the nurse to dress the incision
before leaving the room to call the surgeon?
A Place iodine-soaked gauze over the wound and then cover it with an abdominal pad.
B Approximate the wound edges as much as possible with wound-closure strips.
C Apply antibiotic ointment to the wound and cover it with a non-adherent dressing.
D Cover the wound with sterile gauze moistened with sterile 0.9% saline.

Question Explanation
Correct Answer is D
Rationale: This client likely has a wound evisceration, a complication of surgery. An
evisceration is when a surgical wound opens and has protrusion of internal organs. This is
considered a surgical emergency. The nurse should notify the surgeon of this finding
immediately. When evisceration occurs, the best way to dress the wound is to cover it with
sterile gauze dampened with sterile 0.9% saline using sterile technique.
Concepts tested

Question 4228
The nurse is taking a health history from the parents of a child who is admitted for Reye's
syndrome. Which recent illness would the nurse identify as a significant risk of developing
Reye's syndrome?
A Hepatitis
B Influenza
C Meningitis
D Rubeola

Question Explanation
Correct Answer is B
Rationale: Varicella (chickenpox) and influenza are viral illnesses that have been identified as
risks for the development of Reye's syndrome. It is important for nurses to educate parents to not
use aspirin in children (birth to 19 years of age). The use of aspirin in the presence of viral
infections can increase the risk of Reye's syndrome for children.
Concepts tested

Question 4229
The nurse is caring for a client who has end-stage renal disease and is scheduled for
hemodialysis later today. The client has an arteriovenous fistula. Which interventions should the
nurse implement to help prepare the client for dialysis? Select all that apply.

Page | 1377
A Weigh the client
B Assess the patency of the fistula
C Hold all oral medications
D Ensure the client eats a high fiber, high protein breakfast

Question Explanation
Correct Answer is A, B
Rationale: The nurse should administer medications as prescribed, such as vitamin D and
sevelamer (a phosphate binder). These medications may be prescribed to help control both serum
calcium and phosphate levels. Some medications that are dialyzable or could lower blood
pressure are held until after the procedure. The client should eat a meal that is easily digestible at
least 2 hours before the procedure begins. A meal high in fiber and protein is not easily digested.
The nurse should assess the client's weight as a baseline prior to the procedure and measure vital
signs. The access site should be assessed including palpating a thrill, auscultating a bruit and
palpating pulses and circulation distal to the site.
Concepts tested

Question 4230
The nurse in the emergency department is assessing a client diagnosed with an acute asthma
attack. Which assessment finding would support this diagnosis?
A Fever and chills
B Sharp pain during inspiration
C Loose, productive cough
D Diffuse expiratory wheezes

Question Explanation
Correct Answer is D
Rationale: Asthma is characterized as a hyper-responsive inflammatory disorder of the terminal
bronchioles. The inflammation causes constriction of the smooth muscle around the bronchioles
(bronchoconstriction). These changes make it difficult for air to enter the lungs, resulting in
wheezes. The other findings are not typically seen with an acute asthma attack.
Concepts tested

Question 4231
The nurse is obtaining the health history of a 71-year-old client who is being admitted for mitral
valve replacement surgery related to mitral valve stenosis. During the health history, the nurse
should ask if the client experienced which health issue as a child?
A Hay fever
B Encephalitis
C Rheumatic fever
D Measles

Question Explanation
Correct Answer is C

Page | 1378
Rationale: Clients that present with mitral valve stenosis often have a history of rheumatic fever
or bacterial endocarditis as a child. These illnesses cause valvular damage due to the infection,
which leads to thickening and calcification of the valve. These changes will affect the cardiac
system by causing the left atrium to dilate, the left atrial pressure to increase, the pulmonary
pressure to increase, and the right ventricle will hypertrophy. The client will experience
shortness of breath on exertion, paroxysmal nocturnal dyspnea, palpitations, and dry cough.
Eventually, the client will experience right-sided heart failure.
Concepts tested

Question 4232
The nurse is caring for a newborn with tracheoesophageal fistula (TEF). Which assessment is
the highest priority?
A Observe the newborn for cyanosis
B Observe the newborn for tachycardia with activity
C Monitor for fever over 101°F (38.3°C)
D Monitor intake and output

Question Explanation
Correct Answer is A
Rationale: With TEF, there is an abnormal opening between the trachea and esophagus. Fluids
can easily be aspirated into the trachea and lungs. The 3 Cs of TEF are choking, coughing, and
cyanosis. The priority is to prevent aspiration and maintain an open airway. The other options are
appropriate when monitoring any newborn. However, they are not specific to TEF.
Concepts tested

Question 4233
The nurse is assessing a client admitted for acute exacerbation of chronic obstructive pulmonary
disease. Which assessment finding would support this diagnosis?
A Inspiratory laryngeal stridor
B Crackles in the lung bases
C An S3 heart sound
D Audible expiratory wheezing

Question Explanation
Correct Answer is D
Rationale: The nurse must be able to identify and differentiate assessment findings, such as
adventitious lung sounds. Wheezing is associated with a narrowed, smaller airway. In an acute
episode of obstructive airway disease, breathing is likely to be characterized by wheezing on
expiration. This sound can often be heard without the use of a stethoscope. The other assessment
findings are not typically seen with this diagnosis.
Concepts tested

Question 4234
A nurse is interviewing the parents of a child who was recently diagnosed with asthma. During
data collection, which question is a priority for the nurse to ask?
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A "Have you recently purchased new furniture?"
B "Do you have plants in the home?"
C "Do any pets live in the home?"
D "Did you paint your home recently?"

Question Explanation
Correct Answer is C
Rationale: Many cases of childhood asthma are associated with environmental triggers, such as
animal dander. These triggers stimulate the inflammatory response and constriction of the
terminal bronchioles. Animal dander is a very common allergen affecting children and adults.
Other triggers include pollens, carpeting, cigarette smoke, and household dust.
Concepts tested

Question 4235
The nurse is discussing health promotion activities with a group of new parents. One parent
expresses concern about Reye's syndrome and asks about prevention methods. How should the
nurse respond?
A "Avoid the use of aspirin for viral infections in children."
B "Seek medical attention for serious injuries."
C "Report exposure to this illness as soon as possible."
D "Immunize your child against this disease."

Question Explanation
Correct Answer is A
Rationale: The nurse should educate the parents about reading drug labels for over-the-counter
(OTC) medication and following the directions closely. To answer the parent's question, the
nurse should explain that salicylates, such as aspirin, are contraindicated for children with viral
infections such as chickenpox or influenza due to an increased risk of Reye's syndrome. Since
viral infections can be common in children, salicylates should be generally avoided in children
under the age of 19.
Concepts tested

Question 4236
The nurse is caring for a client with Type I diabetes. Which finding requires immediate
intervention by the nurse?
A Reduced sensation in the periphery
B Mild discomfort at the injection site
C Intense thirst and increased urination
D Diaphoresis and shakiness

Question Explanation
Correct Answer is D
Rationale: When caring for a client with diabetes mellitus, the nurse must be knowledgeable
about the clinical manifestations of hyperglycemia and hypoglycemia. Hyperglycemia is
characterized by polyphagia, polydipsia, and polyuria (the 3 Ps). The client will also experience

Page | 1380
weight loss as the cells are not receiving adequate amounts of glucose for energy. Signs of
hypoglycemia include diaphoresis (sweating) with cool skin. The client may shake and become
confused. It is critical that the nurse recognize these signs and assess the client's blood sugar.
Hypoglycemia will require immediate attempts to raise blood sugar and prevent diabetic coma.
Hyperglycemia, while concerning, is not as critical as hypoglycemia. Decreased sensation in the
periphery is a finding consistent with diabetic neuropathy, which develops over time. The client
may describe sensations of tingling, pain, or numbness. The client may feel mild discomfort at
the site of insulin injections, and this should be monitored.
Concepts tested

Question 4237
The nurse is caring for a client on peritoneal dialysis. While performing a dialysate exchange,
which finding(s) would alert the nurse that the client has developed an acute complication?
A Respiration rate of 30 with crackles throughout the lung fields
B Catheter dressing saturated with clear fluid
C Client sleeps throughout fluid exchange
D Pulse 86 and blood pressure 112/74

Question Explanation
Correct Answer is A
Rationale: The development of an increased respiratory rate with crackles bilaterally indicates
fluid overload, which is an acute complication of peritoneal dialysis. The vital signs are normal.
Sleeping throughout the fluid exchange is normal and indicates the client is comfortable. Clear
fluid on the dressing around the catheter indicates leakage of the dialysate fluid and can be
controlled by instilling less fluid with each exchange.
Concepts tested

Question 4238
The recovery room nurse is caring for an infant following the surgical correction of a ventricular
septal defect. Which nursing assessment is the priority?
A Blanch nail beds for color and refill
B Auscultate for pulmonary congestion
C Monitor for the equality of peripheral pulses
D Observe for postoperative dysrhythmias

Question Explanation
Correct Answer is D
Rationale: A ventricular septal defect (VSD) is an abnormal opening between the right and left
ventricles of the heart. Surgical repair of this defect focuses on closing the abnormal opening
between the ventricles. Because this area is shared by the atrioventricular bundle (bundle of His),
which is part of the cardiac electrical conduction system, the priority is to monitor for
postoperative dysrhythmias. The other assessments are also important but do not take priority
over monitoring for dysrhythmias.
Concepts tested

Question 4239
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A nurse arrives at a child daycare center that was the site of an explosion. Which child should be
tagged "green," or needing minimal treatment?
A An infant with bulging of the anterior fontanel while crying
B A preschooler with a lower leg fracture on one side and an upper leg fracture on the other
C A toddler with severe and deep abrasions over 98% of the body
D A school-age child with singed eyebrows and hair

Question Explanation
Correct Answer is A
Rationale: In a disaster or mass casualty situation, the color-coded triage system is used to
identify victims based on the severity of injuries. The "black" category is for victims who are
already deceased or have such extensive injuries that they would not be expected to survive. The
"red" category is for clients needing immediate treatment for survival, such as those with chest
injuries or open fractures. The "yellow" category means the client does have a chance of survival
with medical intervention. The "green" category means that the victim needs minimal treatment
and will be expected to survive the injuries. A bulging fontanel with crying is to be expected in
an infant; therefore, this client should receive a green tag.
Concepts tested

Question 4240
The nurse is developing a plan of care for a client who underwent total hip arthroplasty 24 hours
ago. Which interventions should the nurse include? Select all that apply.
A Assist the client with a clear liquid diet
B Encourage the use of an abduction pillow or splint between the legs
C Encourage the client to use the incentive spirometer every 2 hours
D Encourage the client to perform leg exercises while in bed
E Remind the client to not bend the knee of the affected leg while seated
F Provide a seat riser for the toilet or commode

Question Explanation
Correct Answer is B, C, D, F
Rationale: To prevent postoperative complications and complications related to immobility, the
client should be up in a chair as soon as possible after surgery. While seated, the client should
bend the affected leg at the knee. The nurse should reinforce the teaching of simple leg exercises
while in bed and the use of an abduction pillow or foam wedge to prevent adduction. To prevent
atelectasis and pneumonia the client should be encouraged to use an incentive spirometer every 2
hours. Once the client is alert after surgery and not experiencing nausea or vomiting, they can
resume a regular diet.
Concepts tested

Question 4241

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The nurse is caring for a 14-year old child who has been tentatively diagnosed with
hyperthyroidism. Which of these findings noted on the initial nursing assessment require
intervention by the nurse?
A A 10% weight loss in the last month despite an excellent appetite
B An apical heart rate of 190 bpm
C A comment by the client, "I just can't sit still."
D A report of irritability worsening in the past two weeks

Question Explanation
Correct Answer is B
Rationale: Hyperthyroidism is the result of an overactive thyroid gland and is characterized by
increased metabolism. The clinical manifestations of hyperthyroidism may include goiter
(enlarged thyroid), hyperactivity, heat intolerance, tachycardia, warm skin, exophthalmos, and
weight loss. The parents may notice the child has difficulty sleeping and poor school
performance related to distractibility. A sudden increase in the client's heart rate, blood pressure,
or level of irritability may be associated with thyroid storm. Thyroid storm is caused by a sudden
release of thyroid hormones and is a medical emergency that could progress to heart failure and
shock. The other options are expected related to the tentative diagnosis of hyperthyroidism.
Concepts tested

Question 4242
A client with late-stage lung cancer was started on chemotherapy two days ago and might be
experiencing tumor lysis syndrome. Which findings support this diagnosis? Select all that
apply.
A A serum creatinine level of 2.4 mg/dL
B A serum calcium level of 13.8 mg/dL
C A serum phosphorus level of 1.8 mg/dL
D A serum uric acid level of 22 mg/dL
E Weakness and muscle cramps
F A serum potassium level of 3.0 mg/dL

Question Explanation
Correct Answer is A, D, E
Rationale: Tumor lysis syndrome (TLS) is a metabolic complication in response to
chemotherapy and is a medical emergency. Massive cell destruction releases intracellular
components, such as potassium and phosphate, that are metabolized into uric acid. High levels of
uric acid crystalize in the distal tubules of the kidneys and lead to acute kidney injury (AKI), as
evidenced by the elevated creatinine level. TLS usually occurs within 24-48 hours after the
initiation of chemotherapy and may persist for about 5-7 days. Hallmark signs of TLS include
hyperuricemia, hyperphosphatemia, hyperkalemia, and hypocalcemia. In addition, the client
might experience weakness, muscle cramps, nausea and vomiting (N/V), and diarrhea.
Concepts tested

Question 4243

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Upon entering a client's room, the client is found to be unresponsive and is not breathing. After
immediately calling for help, what is the next action the nurse should take?
A Maintain an open airway
B Check for a carotid pulse
C Deliver 30 chest compressions
D Give two rescue breaths

Question Explanation
Correct Answer is B
Rationale: According to the American Heart Association's basic life support, the first step after
determining a victim is unresponsive is to call for help. The next step is to check for a pulse (for
no more than 10 seconds). If there is no pulse, the rescuer should begin CPR (30 chest
compressions followed by 2 ventilations).
Concepts tested

Question 4244
A client is admitted with a diagnosis of myocardial infarction (MI) and reports having chest pain.
The nurse provides care based on the knowledge that pain associated with an MI is related to
which of the following findings?
A Insufficient oxygenation of the cardiac muscle
B Cardiac arrhythmia
C An electrolyte imbalance
D Fluid volume excess in the lungs

Question Explanation
Correct Answer is A
Rationale: Due to ischemia of the heart muscle, the client will experience pain. This happens
because destroyed myocardial tissue can block or interfere with normal cardiac circulation.
Concepts tested

Question 4245
The nurse is caring for a client in the postanesthesia care unit (PACU) following corrective
surgery for scoliosis. Which action should receive priority in the plan of care?
A Assess the sensation and movement of the lower extremities
B Assist to stand at the bedside within the first few hours post-surgery
C Teach client isometric exercises for the legs
D Initiate the prescribed antibiotic therapy

Question Explanation
Correct Answer is A
Rationale: Following corrective surgery for scoliosis, the neurological status of the extremities
requires priority attention in the PACU as well as the postoperative surgical units. Initiation of
antibiotic therapy should begin as soon as possible after neurological status is obtained. Getting
the patient out of bed and teaching isometric exercises will be done after the client is
neurologically cleared.

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Concepts tested

Question 4246
In which situation would a child be treated by the use of enemas followed by an antitoxin?
A A child who is diagnosed with botulism
B A child who has swallowed a handful of iron-fortified vitamins
C A child who bit into a laundry detergent packet
D A child who has eaten an undetermined number of ibuprofen tablets

Question Explanation
Correct Answer is A
Rationale: Foodborne botulism is treated by removing the contaminated food from the
gastrointestinal tract by use of enemas (or inducing vomiting) and by administration of a
botulinum antitoxin. Iron poisoning is treated with a strong laxative fluid; severe poisoning may
require intravenous chelation therapy. Non-steroidal anti-inflammatory drugs, such as ibuprofen,
are treated with activated charcoal; very large overdoses may require orogastric lavage. Since
laundry detergents are alkaline agents, intravenous therapy to promote dilution is used; tracheal
intubation with ventilation may also be required.
Concepts tested

Question 4247
The nurse in an emergency department is assessing a client who fell at home 24 hours ago.
Which finding requires the nurse's immediate attention?
A Heart rate of 98 bpm
B Baseline blood pressure of 150/90 mmHg
C Large bruise behind one ear
D Atrial fibrillation on the ECG monitor

Question Explanation
Correct Answer is C
Rationale: Although all of the findings are important, the bruising behind one ear (over the
mastoid process) requires immediate attention. Known as "Battle's sign," this sign appears 1 to 2
days post skull fracture. Other signs of a skull fracture can include bruising around the eyes,
blood leaking from the ear, headache, changes in orientation and level of consciousness, and
nausea and vomiting.
Concepts tested

Question 4248
The nurse enters a client's room as the client begins to have a tonic-clonic seizure. What action
should the nurse take?
A Place the client on one side
B Hold the client's arms at the side
C Elevate the head of the bed
D Insert a padded tongue blade in client's mouth

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Question Explanation
Correct Answer is A
Rationale: Clients should be positioned on their side. This position keeps the airway patent and
allows saliva to drain from the mouth, which prevents aspiration. The nurse should also protect
the client from injury by clearing furniture (if the client is on the floor). The client should not be
restrained nor should anything be forced in the client's mouth.
Concepts tested

Question 4249
The nurse is evaluating the understanding of disease management of a client with chronic
obstructive pulmonary disease. Which statement by the client indicates an understanding of
pursed-lip breathing?
A "Pursed-lip breathing helps me control how fast I breathe in and out."
B "I can reduce my risk of getting pneumonia with pursed-lip breathing."
C "Pursed-lip breathing prevents my mouth from getting too dry."
D "Pursed-lip breathing reduces carbon dioxide trapped in my lungs."

Question Explanation
Correct Answer is D
Rationale: Clients with chronic obstructive pulmonary disease (COPD) have difficulty exhaling
fully as a result of air trapping in the alveoli due to the disease process. Alveolar collapse can be
avoided with the use of pursed-lip breathing allowing the client to exhale more effectively. This
technique facilitates appropriate gas exchange as carbon dioxide-rich air that has been trapped in
the lungs is blown off allowing oxygen-rich air to be inhaled. This is the primary reason to use
pursed-lip breathing.
Concepts tested

Question 4250
The nurse is assessing a client diagnosed with chronic obstructive pulmonary disease (COPD).
The client is on oxygen for low PaO2 levels. Which assessment is a nursing priority to evaluate
the outcome of this therapy?
A Frequently assess coughing and sputum characteristics
B Frequently observe for skin color changes
C Frequently assess lung sounds
D Frequently evaluate oxygen saturation (SaO2) levels

Question Explanation
Correct Answer is D
Rationale: The best method to evaluate a client's oxygenation is to evaluate the SaO2. The
oxygen saturation should be around 88% to 91% for someone with COPD. This method is
equally as effective as an arterial blood gas reading to evaluate oxygenation status and is less
traumatic and expensive. Assessment of lung sounds, coughing and sputum, and color should
also be components of the respiratory assessment for a client with COPD but are less precise
indicators of the response to oxygen therapy than the oxygen saturation level.
Concepts tested

Page | 1386
Question 4251
A nurse is caring for a client after a spinal fusion to treat scoliosis. Which nursing intervention is
appropriate in the immediate postoperative period? Select all that apply.
A Encourage passive leg and ankle exercises
B Perform neurovascular checks every 8 hours
C Encourage use of patient-controlled analgesia
D Maintain bedrest with the head of the bed elevated at least 30 degrees
E Assist the client to stand and walk to the bathroom as needed
F Position the client flat in bed and logroll every 2 to 4 hours

Question Explanation
Correct Answer is A, C, F
Rationale: The client should remain flat in bed for at least 6 hours and turn from side to side
every 2 to 4 hours. The day after surgery, the client can sit up in bed a few times; the client will
get out of bed to sit in a chair on the second or third day after surgery. Clients should be
encouraged to perform isometric exercises right after surgery. Neuro checks will be performed
every 2 hours for the first 24 hours.
Concepts tested

Question 4252
The nurse is caring for a client who had a closed reduction of a fractured wrist followed by the
application of a fiberglass cast 12 hours ago. Which finding requires the
nurse's immediate attention?
A Client reports burning and tingling in the affected hand and arm
B Capillary refill of fingers on affected hand is about three seconds
C Skin warm to touch and normally colored
D Slight swelling of fingers of affected hand

Question Explanation
Correct Answer is A
Rationale: Burning and tingling, as well as intense pain out of proportion to the injury, may be an
indication of compartment syndrome requiring immediate action by the nurse to prevent
permanent muscle damage. The other findings are normal for a client in this situation.
Concepts tested

Question 4253
The nurse is assessing an 8 month-old infant diagnosed with atonic cerebral palsy. Which
statement from the parent supports this diagnosis?
A "When I put my baby on the back to sleep, there is no change in position a few hours later."
B "When I put my finger in one of the hands, there is no grasp response.”
C "My baby doesn't seem to follow when I shake toys in front of the face."
D "When it thundered loudly last night, the baby didn't even jump."

Question Explanation
Correct Answer is A

Page | 1387
Rationale: Cerebral palsy is a condition whereby motor dysfunction occurs secondary to damage
in the motor centers of the brain. It is most commonly associated with cerebral hypoxia during
the birth process. Inability to roll over by eight months of age would illustrate motor dysfunction
and a delay in the attainment of developmental milestones. Not following items could be a sign
of a visual disturbance, not responding to loud noise could be a sign of hearing disturbance, and
not grasping at eight months of age is normal as the grasp reflex begins to diminish after six
months of age.
Concepts tested

Question 4254
24 hours after a dilation and curettage (D&C), an adult female client has a hemoglobin level of
14 g/dL and a hematocrit of 42%. Which finding should the nurse expect when assessing the
client?
A Respiration rate of 36 breaths per minute
B Pale mucous membranes
C Complaints of fatigue with ambulation
D Capillary refill of less than three seconds

Question Explanation
Correct Answer is D
Rationale: The hemoglobin and hematocrit results are within normal limits for an adult female
(hematocrit 37-48%; hemoglobin 12.0-15.5 g/dL). This capillary refill time is normal. The other
assessment findings would be seen if the hemoglobin and hematocrit levels were low (anemia).
Concepts tested

Question 4255
A client has had a mitral valve replacement. Postoperative orders include monitoring pulmonary
artery pressure and pulmonary capillary wedge pressure with a pulmonary artery catheter. What
is the purpose of these actions by a nurse?
A Establish coronary artery stability
B Determine change in acid-base balance
C Assess the left ventricular end-diastolic pressure
D Compare the right ventricular pressures

Question Explanation
Correct Answer is C
Rationale: The pulmonary capillary wedge pressure is reflective of left ventricular end-diastolic
pressure. Pulmonary artery pressures are an assessment tool used to determine the ability of the
heart to receive and pump blood effectively.
Concepts tested

Question 4256
The nurse is caring for a child diagnosed with nephrotic syndrome. Which clinical manifestation
should the nurse expect to find?
A Periorbital edema Correct Answer

Page | 1388
B Bradycardia
C Weight loss
D Hyperactivity

Question Explanation
Correct Answer is A
Rationale: Nephrotic syndrome in children causes excess excretion of protein and retention of
fluid causing edema (around the eyes, feet, and ankles) and weight gain. In this type of kidney
disease, large amounts of protein are lost in the urine (proteinuria). Children may be more tired
and irritable than usual. The other manifestations are not typically seen with nephrotic syndrome.
Concepts tested

Question 4257
During an initial home visit, a nurse is discussing with family members the care of their parent
who is newly diagnosed with Alzheimer's disease. Which of these interventions would
be most helpful at this time?
A List actions to improve the client's socialization with friends
B Leave a pamphlet about relaxation techniques
C Discuss communication strategies to use with the client
D Write out an exercise routine for them to assist the client with

Question Explanation
Correct Answer is C
Rationale: Alzheimer’s disease is a progressive chronic illness that affects memory and
cognition. Communication is often the most challenging issue between caregivers and clients. At
this initial visit, the nurse should discuss effective communication strategies that support the
client and family. The other choices are important but do not address the most significant and
current need.
Concepts tested

Question 4258
The nurse is assessing a client who sustained multiple fractures, contusions, and lacerations in a
motor vehicle accident three days ago. The client suddenly becomes confused. Which findings
would support the nurse's concern that the client has developed a fat embolism? Select all that
apply.
A Elevated temperature
B Low oxygen saturation
C Petechiae on the upper anterior chest
D Dyspnea
E Hypertension

Question Explanation
Correct Answer is A, B, C, D
Rationale: Manifestations of acute confusion, hypoxia, fever, and hypotension may indicate fat
embolism in a client who has sustained multiple fractures, particularly fractures of the long

Page | 1389
bones. The occlusion of dermal capillaries by fat with increased friability of the capillaries can
result in skin petechiae. This is most common on the chest, neck, upper arm, axilla, shoulder,
oral mucous membranes, and conjunctiva.
Concepts tested

Question 4259
A client reports the experience of a sudden deep and throbbing pain in one leg. What is the
appropriate action to be taken by the nurse?
A Ambulate for several minutes
B Maintain the client on bed rest
C Suggest isometric exercises
D Apply ice to the extremity

Question Explanation
Correct Answer is B
Rationale: The finding suggests deep vein thrombosis (DVT). The client must be maintained on
bed rest, and the health care provider should be notified urgently. Deep vein thrombosis can lead
to pulmonary embolism, which is a medical emergency that can cause severe problems with gas
exchange and cardiac output and can even cause cardiac arrest. Anticoagulants are used to treat
DVT, initially being administered by IV (heparin drip) or subcutaneous injection (low-
molecular-weight heparin). This is then followed by long-term oral anticoagulation with
warfarin.
Concepts tested

Question 4260
The nurse is talking with the parents of a toddler who is newly diagnosed with retinoblastoma.
Which point is a priority when discussing this diagnosis with the parents?
A Suggest that total blindness may follow surgery
B Prepare them for their child's permanent disfigurement
C Inform them that even aggressive treatment is usually ineffective
D There is a need for genetic counseling

Question Explanation
Correct Answer is D
Rationale: Aggressive treatment of retinoblastoma can be effective. If the tumor does not
respond to chemotherapy and/or radiation therapy, the eye may need to be removed; however,
that does not necessarily mean the child will be permanently disfigured. Regardless, the
oncologist is the person who will discuss treatment options and anticipated outcomes with the
parents. The parents should be prepared for the effects of cancer on their child, but they should
also understand that retinoblastoma is a rare cancer that runs in families, and there is a high risk
for future offspring to be affected.
Concepts tested

Question 4261
A client with a history of asthma and kidney stones is admitted with a diagnosis of recurrent
renal calculi. The client experiences shortness of breath following a lithotripsy. The nurse
Page | 1390
auscultates the client's lungs and finds decreased air movement with no wheezing. The arterial
blood gas (ABG) results are pH 7.31, PaO2 53 mm Hg, PaCO2 50 mm Hg, and O2 sat 82%.
Which of the following actions are appropriate for the nurse to take? Select all that apply.
A Call respiratory therapy
B Start oxygen via nasal cannula
C Prepare for possible intubation
D Administer a short-acting bronchodilator via nebulizer
E Contact the health care provider
F Increase IV fluids
G Start high flow oxygen via face mask

Question Explanation
Correct Answer is A, C, D, E, G
Rationale: This client needs emergency treatment to open the airways and improve gas exchange.
The absence of lung sounds without wheezing indicates a severe narrowing of the airways in
asthma with minimal air movement. Emergent intervention to open the closed airway including
possible intubation is indicated. The high PaCO2 and low pH indicate respiratory acidosis due to
inadequate gas exchange. The low oxygen saturation and PaCO2 indicate severe hypoxemia
requiring high flow oxygen via a mask.
Concepts tested

Question 4262
The nurse is caring for a client who has a wound on the leg from a motorcycle accident. During a
home visit, the nurse should use which assessment parameter as an indication that this client is
experiencing normal wound healing?
A Green drainage from the center of the wound
B Pebbled red tissue in the wound base
C White patches on the outside edges of the wound
D Eschar over the surface of the wound

Question Explanation
Correct Answer is B
Rationale: As the wound granulates, pebbled red tissue in the wound base indicates healing. The
other findings indicate the wound is not healing properly or could be indicative of infection.
Concepts tested

Question 4263
A nurse is caring for a client in the coronary care unit. The display on the cardiac monitor
indicates ventricular fibrillation. What should the nurse do first?
A Perform defibrillation
B Assess the level of consciousness
C Assess the pulse
D Initiate CPR

Question Explanation

Page | 1391
Correct Answer is B
Rationale: Artifact (interference) can mimic ventricular fibrillation on a cardiac monitor. Always
treat the patient, not the monitor. If the client is truly in ventricular fibrillation, the client will be
unresponsive, and no pulse will be present. The standard of care is to verify the monitor display
with an assessment of the client's level of consciousness, shaking, and shouting to arouse
followed by a carotid pulse check. If the client is unresponsive without a pulse in ventricular
fibrillation, the most effective treatment will be electricity or defibrillation. This should be the
priority: supplementing circulation using chest compressions until the defibrillator is set up and
ready to deliver the shock.
Concepts tested

Question 4264
The client is a 16-year-old with full-thickness burns involving 20% total body surface area. After
the initial 24 hours of treatment to replace fluids, which factor is used to determine if the client's
fluid needs are being met?
A Hourly urine output
B Daily hematocrit results
C Daily weight measurements
D Parkland formula for fluids

Question Explanation
Correct Answer is A
Rationale: Burn victims are at risk for deficient fluid volume. The Parkland formula for fluid
replacement is used during the initial fluid resuscitation for burn victims. Thereafter, hourly
urine output is used to guide fluid management. The desired urine output is 30-50 mL/hour for
most adults and older children. Fluid replacement formulas (like Parkland) depend on the client's
weight on admission, and daily weights are more commonly used to determine if caloric intake is
enough to meet increased metabolic needs. Hematocrit (and hemoglobin) can be used to help
identify blood loss and RBC destruction, but they are is not used to determine fluid replacement
needs.
Concepts tested

Question 4265
Due to a recent rheumatic fever outbreak in the community, the school nurse is speaking to a
group of parents and elementary school teachers. Which information is important for the nurse to
emphasize?
A Clumsiness and behavior changes should be reported.
B Most play activities will be restricted indefinitely.
C Children may remain strep carriers for years.
D Home schooling is preferred to classroom instruction.

Question Explanation
Correct Answer is A
Rationale: Sydenham chorea is a major sign of acute rheumatic fever; it may be the only sign of
rheumatic fever in some clients. Symptoms include jerky, uncontrollable, and purposeless
movements that look like twitches (these disappear during sleep), loss of fine motor control
Page | 1392
(causing changes in handwriting), and loss of emotional control (as evidenced by inappropriate
crying or laughing). Sydenham chorea usually clears up in a few months, and no complications
are expected.
Concepts tested

Question 4266
A nurse is assessing a child at a clinic visit for a mild respiratory infection. Koplik spots are
noted on the oral mucous membranes. What should the nurse assess next?
A Urine
B Lungs
C Skin
D Sputum

Question Explanation
Correct Answer is C
Rationale: A characteristic sign of rubeola is Koplik spots (tiny white spots). These are found on
the buccal mucosa in the mouth about a few days before the onset of the measles rash (which
appears as small red, irregularly shaped spots with a bluish-white center). Although the nurse
should assess the child's lungs with any reports of a respiratory infection, these spots would
indicate that the skin should be checked for the presence of a rash. Sometimes a complication of
measles is pneumonia, but it may be a bit premature to do a sputum culture.
Concepts tested

Question 4267
The nurse is providing discharge instructions for a client diagnosed with bacterial pneumonia.
What is the most important information to convey to the client?
A "Take your temperature every day."
B "You will need another chest x-ray in six weeks."
C “Complete all of the antibiotics as prescribed."
D "Take at least two weeks off from work."

Question Explanation
Correct Answer is C
Rationale: To avoid a recurrence of infection, the client must complete all the prescribed
medications at the prescribed dosing intervals. It should be explained to the client that it may
take two weeks or more for the energy level to return to normal, but one does not necessarily
need to be off work for two weeks. The health care provider may order a follow-up chest x-ray,
but this is not always done or a priority at this time. It is also not important to take the
temperature daily unless symptoms (such as chills, shortness of breath, chest pain, night sweats)
worsen or return.
Concepts tested

Question 4268
A nurse admits a premature infant who has been diagnosed with respiratory distress syndrome
(RDS). In planning care for the infant, the nurse understands that the pathophysiology of this
disorder affects the infant's ability to do what?
Page | 1393
A Stabilize thermoregulation
B Regulate intrapulmonary airway pressures
C Adequately clear thick, sticky mucus from the lungs
D Maintain alveolar surface tension

Question Explanation
Correct Answer is D
Rationale: RDS is primarily a disease related to a developmental delay in lung maturation.
Although many factors may lead to the development of the disorder, the central factor is the lack
of a normally functioning surfactant system in the alveolar sac from immaturity in lung
development because the infant is premature. A lack of surfactant production results in the
collapse of the alveolar sacs.
Concepts tested

Question 4269
An emergency department nurse is preparing discharge instructions for a child who experienced
a seizure at school. The parent reports that this is the first seizure occurrence and denies a family
history of seizures. What information should the nurse include?
A "Do not worry. Seizure disorders can be treated with medications."
B "Long-term treatment will prevent future seizures."
C "This seizure may or may not mean your child has a seizure disorder. Further evaluation is
needed."
D "Since this was the first seizure, it may not happen again."

Question Explanation
Correct Answer is C
Rationale: There are many possible causes for a childhood seizure. Some causes are transient,
and others require long-term treatment to prevent further seizures. Causes of seizure in childhood
include fever, central nervous system conditions, trauma, metabolic alterations, and idiopathic
(unknown) etiologies. EEG, an electroencephalogram, is a test commonly used to evaluate
seizure disorders.
Concepts tested

Question 4270
A nurse is suctioning a tracheostomy tube of a client. In order to prevent unnecessary hypoxia
during the procedure, what action should the nurse take?
A Apply suction for no more than 10 seconds
B Lubricate three to four inches of the catheter tip
C Withdraw catheter in a circular motion with intermittent suction
D Maintain sterile technique throughout the procedure

Question Explanation
Correct Answer is A
Rationale: Although all of the responses are correct actions during the suctioning process,
hypoxia can result from applying suction for more than 10 seconds. The nurse should apply

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oxygen immediately before and after suctioning to allow the client to rest if more suctioning is
indicated.
Concepts tested

Question 4271
A nurse is providing education on disease management to a client with chronic obstructive
pulmonary disease (COPD). The client has a history of hypertension, smoking, and asthma. The
nurse will teach the client which activity to best prevent complications of COPD?
A Smoking cessation
B Blood pressure control
C Prevention of allergen exposure
D Prescribed oxygen use

Question Explanation
Correct Answer is A
Rationale: Smoking cessation is a primary teaching concept for a client with chronic obstructive
pulmonary disease (COPD). Smoking is the primary factor that causes the development and
progression of COPD. Maintaining stable blood pressure is important for cardiovascular health.
However, it does not specifically prevent complications of COPD. Environmental allergens can
exacerbate asthma. However, environmental factors are not the primary factor for the
development and progression of COPD. Prescribed oxygen and medications help to control
COPD but do not reverse its effects or prevent complications.
Concepts tested

Question 4272
A nurse is assisting a healthcare provider with a bronchoscopy on an older adult client. Which
pre-procedure observation prompts the nurse to intervene?
A The client’s dentures have been removed.
B The client is in the prone position.
C The client is connected to continuous pulse oximetry.
D The client has a decreased cough reflex.

Question Explanation
Correct Answer is B
Rationale: The nurse should intervene if the client is in the prone position. The client should be
placed in a sitting or supine position prior to beginning the procedure. The client’s dentures
should be removed prior to the procedure to ensure they are not damaged during insertion of the
scope. Older adults have a higher risk of respiratory distress during the procedure. Continuous
pulse oximetry is indicated. A decreased cough reflex is not a contraindication for a
bronchoscopy. The nurse will monitor the client closely after the procedure to ensure adequate
airway clearance.
Concepts tested

Question 4273
A nurse is assessing a 48-hour post-surgical client with an abdominal wound. Which clinical
manifestation indicates that the client may be developing a wound infection?
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A The wound edges are separated.
B The client’s oral temperature is 99.4°F (37.4°C).
C The wound drainage is brown and thick.
D The client’s heart rate is 105 beats/min.

Question Explanation
Correct Answer is C
Rationale: Thick, brown drainage is considered purulent and is indicative of infection. Normal
wound drainage should be thin and clear or serosanguinous. Separation of wound edges is
indicative of dehiscence, a serious wound complication. An oral temperature of 99.4°F (37.4°C)
is within normal range. An elevated heart rate is not a specific sign of wound infection.
Tachycardia can be due to pain or other physiological responses.
Concepts tested

Question 4274
A nurse is providing care to a client with negative pressure wound therapy to the left lower
extremity. The nurse notes an alarm on the device indicating a leak has been detected. Which
action will the nurse perform next?
A Change the wound dressing on the incision
B Reposition the client’s lower extremity
C Replace the negative pressure wound therapy device
D Ensure the dressing is completely sealed

Question Explanation
Correct Answer is D
Rationale: Negative pressure wound therapy requires an airtight seal around the wound dressing.
Leaks around the drape will break the seal and allow air to enter. The nurse should ensure there
are no leaks around the wound dressing or tubing. The wound dressing should be replaced only if
troubleshooting any leaks is unsuccessful. Repositioning the client’s extremity will not correct a
leak around the wound dressing or tubing. The dressing must maintain an airtight seal. The
device should be replaced only after troubleshooting for leaks or changing the wound dressing
are unsuccessful.
Concepts tested

Question 4275
A nurse is observing a new nurse perform nasopharyngeal suctioning on an adult client. The
precepting nurse will intervene if the new nurse performs which action?
A Sets the suction pressure to 190 mmHg
B Applies sterile gloves to both hands
C Suctions the client for 15 seconds
D Withdraws the catheter while rotating it

Question Explanation
Correct Answer is A

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Rationale: The precepting nurse will intervene if the suction pressure is set to 190 mmHg.
Suction should be set between 100 and 150 mmHg for adults. Pressures exceeding 180 mmHg
can cause hypoxia and damage to tissues. Sterile gloves may be applied to both hands.
Alternatively, a sterile glove may be applied to the dominant hand and a nonsterile glove to the
non-dominant hand. Intermittent suction should be applied for no more than 10-15 seconds at a
time. Rotating the catheter while withdrawing is proper technique when suctioning the airway.
Concepts tested

Question 4276
A nurse is teaching a client and their caregiver how to perform tracheostomy care at home.
Which statement by the caregiver indicates further education is needed?
A “I will clean the inner cannula with isopropyl alcohol.”
B “Reusable supplies should be cleaned with warm, soapy water.”
C “I will disinfect reusable supplies in a water and vinegar mixture.”
D "The stoma should be cleaned using circular motions moving outward.”

Question Explanation
Correct Answer is A
Rationale: The inner cannula of a tracheostomy should be cleaned with hydrogen peroxide or
saline solution at home. Isopropyl alcohol can cause potential damage to tissues. Warm, soapy
water is recommended to clean reusable supplies to prevent the growth of microorganisms. A
water and vinegar mixture is recommended to disinfect reusable supplies. The supplies should be
soaked in the mixture for 30 minutes. Circular motions moving away from the stoma prevents
recontamination of the area.
Concepts tested

Question 4277
A nurse is assessing a client with a traumatic brain injury who is unconscious. The nurse notes
pinpoint, nonreactive pupils and flaccid extremities. Which action does the nurse perform next?
A Administers a prescribed hypotonic solution
B Elevates the head of the bed
C Prepares the client for surgery
D Places the client on seizure precautions

Question Explanation
Correct Answer is B
Rationale: The client is exhibiting signs of increased intracranial pressure (ICP). Elevating the
head of the bed helps decrease ICP. Clients with ICP will be administered hypertonic, not
hypotonic, solutions to decrease fluid and pressure. The client may require surgery to alleviate
cranial pressure. However, the first intervention is to prevent further increase in pressure by
elevating the head of the bed. All clients with traumatic head injuries should be on seizure
precautions for safety. Placing the client on seizure precautions will not decrease ICP.
Concepts tested

Question 4278

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A nurse is providing early postoperative care to a client. Which intervention will the nurse
perform to prevent cardiovascular complications?
A Encourage the client to ambulate
B Teach cough and deep breathing exercises
C Apply prescribed sequential compression devices
D Explain the use of an incentive spirometer

Question Explanation
Correct Answer is C
Rationale: Sequential compression devices are applied to the lower extremities to promote
adequate blood flow and prevent cardiovascular complications, such as a blood clot. Ambulation
should occur once the client has fully recovered from anesthesia. During the early postoperative
period, the client requires continuous monitoring. Cough and deep breathing exercises and the
use of an incentive spirometer primarily prevent respiratory complications.
Concepts tested

Question 4279
A nurse is assessing a client admitted for diarrhea. The client verbalizes numbness to the lips and
muscle twitching to the extremities. Which action does the nurse perform next?
A Contact the healthcare provider
B Dim the lightning in the client’s room
C Place the client on seizure precautions
D Review the client’s latest serum calcium level

Question Explanation
Correct Answer is D
Rationale: Paresthesia of the lips and tetany (muscle twitching and cramping) are common signs
and symptoms of hypocalcemia. The nurse should review the client’s latest calcium level to
confirm hypocalcemia. The healthcare provider should be contacted after the nurse obtains all
objective and subjective data. Soft lighting is recommended to avoid overstimulation. However,
the nurse should first confirm the client’s symptoms are due to hypocalcemia. Placing the client
on seizure precautions is an appropriate intervention after the nurse reviews the calcium level to
confirm hypocalcemia.
Concepts tested

Question 4280
A nurse suspects a client with a pulmonary embolism has developed complications. Which
assessment finding is most indicative of a significant decrease in cardiac output?
A A blood pressure of 98/55 mmHg
B Client verbalization of lightheadedness
C Cyanosis to the oral mucous membranes
D Urinary output of 35 mL/hr

Question Explanation
Correct Answer is C

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Rationale: Cyanosis is the most indicative sign of decreased blood flow. Bluish discoloration of
the oral mucous membranes indicates a significant decrease in cardiac output and oxygenation. A
blood pressure of 98/55 mmHg is on the lower end of normal. Hypotension, which may indicate
decreased cardiac output, is defined as a blood pressure lower than 90/60 mmHg.
Lightheadedness is not the most indicative symptom of decreased cardiac output. Significant
decrease in cardiac output results in syncope. A urine output of 35 mL/hr is on the lower end of
normal. Urinary output should be at least 30 mL/hr.
Concepts tested

Question 4281
A nurse is providing care to a client admitted with an infected abdominal wound. Which clinical
finding will the nurse immediately report to the healthcare provider?
A Lactate level of 4 mmol/L
B White blood cell count of 11,000/mm³
C Temperature of 101°F (38.3°C)
D Heart rate of 110 beats/min

Question Explanation
Correct Answer is A
Rationale: The nurse should immediately report a lactate level of 4 mmol/L. An elevated lactate
level indicates tissue hypoxia and is indicative of septic shock. An elevated white blood cell
count is expected for a client with an infected abdominal wound. A temperature of 101°F
(38.3°C) is indicative of infection. However, this value is not critical. Although an elevated heart
rate may indicate an infectious process, 110 beats/min is not a critical value.
Concepts tested

Question 4282
A nurse is providing education on lifestyle modifications to a client with multiple sclerosis. What
will the nurse include in the teaching?
A “Restrict the amount of fluid intake to prevent volume overload.”
B “Perform high-intensity exercises to maintain muscle strength.”
C “Group activities throughout the day to allow for rest periods.”
D “Ask family members to help you communicate your needs.”

Question Explanation
Correct Answer is C
Rationale: One of the primary symptoms of multiple sclerosis is fatigue. The nurse should
encourage the client to group activities and allow for rest periods throughout the day to conserve
energy. Fluid volume overload is not a characteristic sign of multiple sclerosis. Clients should be
encouraged to increase fluid intake to prevent urinary tract infections associated with bladder
dysfunction. High-intensity exercises lead to overexertion and fatigue. Clients with multiple
sclerosis benefit from exercises such as range of motion and stretching. Asking family members
to communicate needs does not promote independence. The nurse should suggest the use of
communication boards or speech therapy to help with dysarthria.
Concepts tested

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Question 4283
A nurse is providing education on illness management to a client diagnosed with asthma. Which
client statement indicates further teaching is required?
A “It is essential to develop stress management techniques.”
B “I should avoid exercises that elevate my heart rate.”
C “It is important to prevent environmental temperature changes.”
D “I will make sure to receive the influenza vaccine.”

Question Explanation
Correct Answer is B
Rationale: Regular exercise is encouraged for clients with asthma to help promote ventilation,
perfusion, and cardiac health. The nurse should instruct the client to premedicate if needed.
Stress and emotional distress are triggering factors for asthma. The nurse should encourage the
client to practice stress management techniques. Environmental factors, such as changes in
temperature, can exacerbate asthma. Clients with asthma should be encouraged to receive
influenza and pneumonia vaccines to prevent respiratory illnesses that may worsen the symptoms
of asthma.
Concepts tested

Question 4284
A nurse prepares to insert an 18-gauge intravenous catheter into a client with hypovolemic
shock. The client asks the nurse why this is necessary. What is the nurse’s best response?
A “We need to administer vasopressors immediately.”
B “You require antibiotics to treat your condition.”
C “Emergency medications cannot be administered through a smaller catheter.”
D “Your fluid volume needs to be replaced.”

Question Explanation
Correct Answer is D
Rationale: The client requires an intravenous catheter for fluid replacement. Hypovolemic shock
is caused by a 15 to 30% decrease in intravascular volume. The first line of treatment is to
replace fluid volume. Vasopressors should be administered after fluid volume is replaced and
only if the blood pressure is not maintained. Antibiotics are administered for septic, not
hypovolemic, shock. Although a large gauge is preferred, emergency medications can be
administered through a smaller gauge if needed.
Concepts tested

Question 4285
A nurse is providing care to a client with hemorrhagic shock. The client is hypotensive and
tachycardic. Which priority action does the nurse perform to maintain organ perfusion?
A Applies pressure to the bleeding site
B Elevates the client’s lower extremities
C Initiates a peripheral intravenous line
D Monitors the client’s blood pressure

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Question Explanation
Correct Answer is B
Rationale: Organ perfusion is a priority for a client experiencing shock. Elevating the extremities
helps to shunt blood flow to vital organs and maintain perfusion. Applying pressure to the
bleeding site will prevent further hypovolemia and blood loss. However, this does not directly
maintain organ perfusion. Initiating a peripheral intravenous line is required for the
administration of fluids and medications. However, this action alone does not directly maintain
organ perfusion. Monitoring the client’s blood pressure provides an assessment of adequate
cardiac output. However, this intervention does not directly maintain organ perfusion.
Concepts tested

Question 4286
A nurse is providing care to a client with superficial partial-thickness burns to the upper
extremities. The client is in excruciating pain and is requesting analgesics frequently. The nurse
understands that the client’s response is due to which factor?
A Absence of blood flow in the subcutaneous layer
B Destruction of epithelial cells in the epidermis
C Injury to bone below the muscle tissue
D Presence of nerve endings in the dermis

Question Explanation
Correct Answer is D
Rationale: Superficial partial-thickness burns extend to the dermal layer of the skin. The dermis
contains nerve tissue that is responsible for eliciting pain. A superficial partial-thickness burn
does not extend into the subcutaneous layer. Blood flow is still present. The client’s pain is due
to nerve-ending involvement. The epidermis primarily contains epithelial cells. Bone and muscle
tissue extend beyond the subcutaneous layer. These structures are not affected in superficial
partial-thickness burns.
Concepts tested

Question 4287
A nurse is assessing a client who requires frequent repositioning in bed and is unable to assist
with mobility. The nurse notes skin tears to the client’s elbows and heels. The wounds are likely
due to which factor?
A Shear
B Friction
C Pressure
D Ischemia

Question Explanation
Correct Answer is A
Rationale: Shearing occurs when tissue layers slide against each other and injure the underlying
blood vessels and capillaries. Skin tears are likely to result when clients are pulled during
repositioning, particularly if they are unable to assist. Friction is due to pressure when two
surfaces rub against each other. A client who assists in repositioning while applying pressure to
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the joints is likely to cause a friction injury. Pressure compresses blood vessels and is evident
primarily by erythema (stage 1 pressure injury) before progressing to open skin. Ischemia is a
deficiency in blood flow that causes hypoxia and necrosis to the affected areas.
Concepts tested

Question 4288
A nurse is inserting a nasogastric tube on a client with a small bowel obstruction. Which event
indicates an adverse response to the procedure?
A The client gags and vomits green-colored emesis.
B The client begins to cough and have oxygen desaturations.
C Resistance is felt upon entering the nostril, and the client verbalizes pain.
D Gastric contents are not aspirated after insertion and flushing of the tube.

Question Explanation
Correct Answer is B
Rationale: Coughing with oxygen desaturations indicates that the tube has likely entered the
trachea. The nurse should stop the procedure, remove the tube, and assess the client’s respiratory
status. Gagging and vomiting is a common response to the insertion of a nasogastric tube. The
nurse should allow the client to rest before restarting the procedure. Resistance in one or both
nostrils is common. The nurse should inspect the nostril to ensure there are no blockages before
continuing the procedure. The absence of gastric contents may indicate the nasogastric tube is
above the stomach. The nurse should request an X-ray from the healthcare provider to confirm
placement.
Concepts tested

Question 4289
A nurse is assessing a client after an arterial puncture to obtain a blood gas sample. Which
observation prompts the nurse to immediately contact the healthcare provider?
A Absent radial pulse
B Pain to the wrist
C Bleeding to the site
D Bruising to the antecubital area

Question Explanation
Correct Answer is A
Rationale: An arterial puncture for a blood gas sample is typically performed on the radial artery.
An absent radial pulse indicates injury to the blood vessel and must be reported immediately.
Pain to the wrist is common after an arterial puncture. The nurse should provide the client with
comfort measures to relieve pain. Bleeding to the site is common due to arterial flow. The nurse
should ensure that pressure is applied to the site for at least 5 minutes. An arterial puncture is
performed on either the radial or ulnar arteries. Bruising to the antecubital area is not expected.
Concepts tested

Question 4290
A nurse is providing care to a client who has completed hemodialysis treatment. Which
assessment finding indicates a complication that should be reported to the healthcare provider?
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A Weight loss of 1 kilogram
B Absence of a bruit
C Blood pressure of 99/50 mmHg
D Bleeding at the access site

Question Explanation
Correct Answer is B
Rationale: A bruit to the AV fistula is a normal finding. The absence of a bruit may indicate
decreased blood flow to the area. Weight loss is common due to the removal of fluid during
hemodialysis. A blood pressure of 100/50 mmHg is on the lower side of normal. A decrease in
blood pressure is not uncommon after hemodialysis. The nurse should monitor the client’s vital
signs closely. Bleeding at the access site is not uncommon, particularly if anticoagulants were
given during therapy. The nurse should apply pressure to the site and monitor for uncontrolled
bleeding.
Concepts tested

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