The nurse notes that a client intervention has a deadline occurring in 3 days. What
should this information indicate to the nurse?
1. The action should be observed every 3 days
2. The action should be completed every 3 days
3. The action should be documented every 3 days
4. The action will no longer be necessary in 3 days
The nurse is caring for a client with a fever of 101.8F oral. Which other vital signs
should the nurse anticipate would be affected?
Standard Text: Select all that apply.
1. Pulse rate
2. Respiratory rate
3. Diastolic blood pressure
4. Systolic blood pressure
5. Oxygen saturation
The nurse is caring for a client with a traumatic brain injury who has questionable
cerebral cortex activity. Which finding is a definitive diagnosis for brain death?
1. Apnea
2. No gag reflex
3. No corneal reflex
4. No response to noxious stimuli
Which method is most appropriate for the nurse to use when teaching a client to walk
with a cane?
1. Holding the cane on the stronger side of the body and moving the cane forward, then
moving the weak leg forward
2. Holding the cane on the weaker side and moving the weak leg forward, then
following with the cane
3. Holding the cane on the stronger side, stepping forward with the weak leg, and then
moving the cane forward as the stronger leg moves forward
4. Holding the cane on the weaker side, stepping forward with the weak leg, and then
moving the cane forward as the stronger leg moves forward
The nurse is preparing to administer an intradermal medication. Which item will form
to indicate the medication was injected at the proper depth?
1. Diluent
2. Wheel
3. Wheal
4. Blister
The nurse is caring for a client with an indwelling catheter. When emptying the urine
collection bag, the nurse notes the urine is cloudy with moderate amounts of
sedimentation and a foul odor. Based on these assessment findings, what should the
nurse suspect?
1. Urethral irritation
2. Bladder atrophy
3. Urinary tract infection
4. Kidney infection
The nurse is providing care for a client with terminal breast cancer. The client’s children
ask if their mother will exhibit any signs and symptoms prior to death. When
responding to the family, which statements regarding the expected clinical
manifestations of impending death will the nurse include?
Standard Text: Select all that apply.
1. “Your mother’s jaw may sag.”
2. “Your mother may have difficulty speaking.”
3. “Your mother may have trouble swallowing.”
4. “Your mother may feel hot to the touch.”
5. “Your mother may begin to breathe only through her nose.”
The nurse is providing care for a client requiring mechanical ventilation. When the
nurse enters the room at the beginning of the shift, the client’s monitor displays a heart
rate of 64 and oxygen saturation of 88%. Which nursing action is the priority?
1. Increasing the oxygen concentration and quickly assessing the client
2. Removing the client from the ventilator and hyperoxygenating and hyperventilating
the client
3. Assessing the client for airway obstruction
4. Checking ventilator settings
The nurse is reviewing the status of assigned clients. Which observation should the
nurse identify as appropriate for a client to be discharged?
1. Client with heart disease understands the discharge process
2. Client with multiple sclerosis wants to stay in the hospital “forever”
3. Client with asthma wants to use a previous form of inhaled medication
4. Client recovering from knee surgery is apprehensive about going home alone
The nurse is caring for a client being weaned from the ventilator, and wants to improve
the client’s ability to communicate. Which item should the nurse request an order for
from the health care provider?
1. Cuffed tracheostomy tube
2. Uncuffed tracheostomy tube
3. Fenestrated tracheostomy tube
4. Obturator
A staff nurse position has been posted for the radiology department. Which nurse is the
most qualified for this position?
1. Nurse with 10 years of experience in the intensive care unit
2. Nurse with 6 months of experience in the post anesthesia care unit
3. Nurse with 7 years of experience working in the hemodialysis center
4. Nurse with 4 years of experience in the outpatient ambulatory center
A client’s blood pressure is 180/120 mm Hg. How will the client’s neurologic system
adapt to this increase in blood pressure?
1. Arteries in the brain dilate
2. Cerebrospinal fluid increases
3. Arteries in the brain constrict
4. Cerebrospinal fluid decreases
The nurse working in the intensive care unit is assigned a client requiring mechanical
ventilation. When responding to the ventilator alarm, the nurse sees a high-pressure
alarm. Which nursing action is the priority?
1. Silencing the alarm
2. Removing the client from the ventilator and using a bag-valve device to oxygenate
the client until the respiratory therapist can be summoned
3. Emptying the collected water from the ventilator tubing
4. Assessing the client
The health care provider prescribes 10 grains of medication. If the medication is
calculated in milligrams, how many milligrams should the nurse administer to equal 10
grains?
____ mg
Standard Text: Record the answer rounding to the nearest whole number.
The nurse on a medical’surgical unit is caring for a client who complains of chest pain.
Assessment findings include a blood pressure of 72/40, pulse rate of 40, and respiratory
rate of 32. Which action by the nurse is the priority in this situation?
1. Calling a code
2. Calling the rapid response team
3. Calling the client’s primary health care provider
4. Calling the emergency department (ED) and requesting they send a health care
provider