1. The  nurse  cares  for  the  client  diagnosed  as  being  in  the  manic  phase  of  bipolar  disorder.  Which  behavior  indicates  to the nurse the client condition is improving?

a. The client offers suggestions to other clients on the unit

b. The client begins to write a book about life

c. The client sits and eats with other clients on unit

d. The client talks with other clients a group meeting

2. The health care provider orders a continuous intravenous aminophylline infusion for a two year old client. It is most important for the nurse to intervene for which situation?

a. The  client  heart  rate  is  100  bpm

b. The  clients  blood  pressure  is  100/60  mmHg

c. The  clients  serum  theophylline  level  is  25  mcg/mL

d. The client is sleepy

3. The nurse teaches the client about the schedule cardiac catheterization. Which statement, if made by the client to the nurse, indicates that the teaching was effective?

a. “I understand that there is little or no risk associated with this procedure.”

b. “I  may  experience  a  little  pounding  sensation  in  my  chest  during  the  procedure.”

c. “I will be in and out of the procedure room in about 30 minutes.”

d. “I will be able to walk in the hall soon after the procedure is completed.”

4. During the second stage of labor, the client’s partner asks the nurse, “Can I go get a cup of coffee from the cafeteria?” Which response by the nurse is best?

a. “I  will  get  you  a  cup  of  coffee.”

b. “It would be best if you stayed here at this time.”

c. “Ask your partner if it is acceptable to leave.”

d. “Why do you want to leave the room?”

5. The  nurse  discovers  that  client  lying  face  down  on  the  floor.  Which  action  does  the  nurse  take  first?

a. Assess the patency of the client’s airway b. Determine whether the client is responsive

c. Check the client’s carotid pulse

d. Reposition the client onto the back

6. A  nurse  works  3  weeks  at  a  100-bed  suburban  hospital  after  working  several  months  at  a  40-bed  rural  hospital.  The nurse prefers the total client care delivery system that was used at the rural hospital, rather then the team leading system of client care that is used at the suburban hospital. Which action does the nurse take?

a. Works with in the system at the hospital to change the type of client care delivery

b. Discuss his thoughts about the type of client care delivery system with the nurses supervisor

c. Asks the nurses peers why this type of client care delivery system is used

d. Suggests a change in the type of client care delivery system to the director of nursing

7. The nurse cares for the client diagnosed with a left traumatic below knee amputation (BKA) with a tourniquet in place. The client also has a tear from the perineum to the rectum. Which action is the nurse take first?

a. Apply anti-shock trousers

b. Assesses the clients level of consciousness

c. Remove the tourniquet

d. Check the client’s blood pressure and pulse

8. During morning rounds, the client diagnosed with schizophrenia tells the nurse, “I know you are conspiring with my spouse to keep me locked away.” Which statement by the nurse is the most appropriate?


a. “What makes you think your spouse is trying to hide your existence?”

b. “Are you saying that you think your spouse doesn’t love you?”

c. “I  can  see  that  you  are  frightened  about  being  here  but I  am  a  nurse  in  a  hospital.”

d. “I’m  not  conspiring  with  your  spouse.  I  first  met  your  spouse  when  you  are  admitted  to  the  hospital.”

9. During a routine prenatal visit, the nurse auscultates the fetal heart rate (FHR). If the fetal position is left sacrum posterior (LSP), at which site does the nurse expect to find the fetal heart (FHT)?

a. Below umbilicus, on the mothers right

b. Below umbilicus, on the mothers left c. Above umbilicus, on the mothers left

d. Above umbilicus, on the mothers right

10. The nurse makes environmental rounds on the client care unit. Which problem does the nurse addressed first?

a. A wheel of the medication cart is broken

b. The needle disposal unit in unoccupied room is full c. The call light and occupied isolation room is broken

d. The ice machine and the visitors lounge is leaking water on the floor

11. The nurse observes a nursing assistive personnel (NAP) enter the room of the client diagnosed with tuberculosis (TB) to provide morning care. Which observation, if you made by the nurse, does not require an intervention?

a. The NAP enters the room while wearing goggles and a hair covering

b. That NAP enters the room while wearing a mask and sterile gloves

c. The NAP enters the room while wearing a gown and clean gloves

d. The NAP enters the room while wearing a particulate respirator and a gown

12. The  nurse  teaches  the  client about  ferrous  sulfate.  Which  statement  by  the  client  indicates  to  the  nurse  that  the client understands the education?

a. “I  should  take  this  medication  when  I  take  my  antacid.” b. “I  should  take  this  medication  with  orange  juice.”

c. “I should increase my intake of foods that contain calcium.”

d. “I should take this medication at bedtime.”

13. The nurse gives discharge instructions about home care for orchitis to the client. Which statement indicates to the nurse that teaching has been successful?

a. “I should make an appointment to have a circumcision.” b. “It will help if I use a scrotal support.”

c. “I  should  restrict  my  athletic  activities  for  about  6  weeks.”

d. “I need to stay in bed for at least 10 days.”

14. The nurse cares for the client having a left total hip arthroplasty period in which position does the nurse placed the client after surgery?

a. Legs abducted with the toes pointing upward

b. Legs adducted with a bed cradle in place

c. Flat on the bed with a foot board in place

d. Legs elevated on two pillows with the knees flexed

15. The  adolescent  receives  10  units  of  intermediate-acting  insulin  every  morning  at  0700.  If  the  client  requires  the insulin dosage reduced, the nurse expects the client to present with which symptom?

a. Declines lunch at 1200

b. Reports hunger at 0900

c. Experiences confusion at 1600

d. Becomes sleepy at 2100

16. The nurse discovers the client in the bathroom attempting self-harm. Which action does the nurse take first?


a. Removes the client from the bathroom and escorts the client to the bedroom b. Stays with the client and continually monitors for self-destructive behaviors

c. Initiates a discussion with the client concerning reasons for self-harm

d. Distracts the client from trying to hurt self by talking about the family.

17. The nurse admits a 2-month-old infant for surgical correction of hypospadias. Which assessment does the nurse complete?

a. Check this scrotal sac and palpate the testes b. Inspect the position of the urinary meatus

c. Obtained a urine sample for analysis

d. Measure intake and output hourly

18. The patient of an 18 month old toddler ask the nurse, (Which toy is most appropriate for my child?) The nurse from recommend which toy?

a. A story book

b. A stuffed animal

c. A colorful mobile

d. A large yo-yo

19. The  nurse  cares  for  the  client  prior  to  cataract  surgery. The  nurse  administers  the  preoperative  medication.  Ten minutes later, the nurse finds the client on the floor at the foot of the bed. Which action does the nurse takes initially?

a. a. Notifies the healthcare provider, and receive new orders

b. b. Complete accident report documenting the fall c. c. Stays with the client and calls for assistance

d. d. Moves the client back onto the bed providing support to the cervical area

20. The nurse teaches the client what to expect during a cardiac catheterization. Which statement if made by the client, indicates further teaching is necessary?

a. “I may feel a fluttering sensation in my chest during the test.”

b. “I may kill chest pain during the test.”

c. “I  may  have  chest  pain  for  several  days  following  the  test.”

d. “I  may  have  some  pain  at  the  catheter  insertion  site.”

21. The parents of the 18 month old toddler with a fractured femur visits with the child in the hospital. The parents say they  must  go  home,  the  child  screams,  cries,  and  hits  the  parents.  Which  statement  does  the  nurse  suggest  the parents tell the child?

a. “We will return in a little while.”

b. “We  will  come  back  at  1000  hours.”

c. “We will return when the sun comes up.”

d. “We will come back as soon as we can.”

22. The nurse supervises a nursing assistive personnel (NAP) caring for the client after abdominal surgery. Which observation requires an intervention by the nurse?

a. a.  The  NAP  massages  the  client’s  leg  using  long,  firm  strokes

b. b. The NAP massages the client arms using smooth, gentle strokes

c. c. The NAP assist the client to put the joints through range of motion exercises

d. d. The NAP positions the client side-lying and applies lotion to the back

23. The nurse cares for the client diagnosed with anorexia nervosa. Which goal is the highest priority initially?

a. Stabilize the clients weight

b. Encourage the client to gain insight about body image c. Maintain the clients fluid and electrolyte balance


d. Increase the clients caloric intake

24. The  nurse  administers  medications  to  the  client  diagnosed  with  bipolar  disorder.  The  client  approaches  the  nurse  and begins to throw things. Which action does the nurse take?

a. Get another nurse to assist with the client

b. Give the client the medications, so the client will calm down

c. Admonishes the client, and suggested the client collect self d. Sits down and asks the client what is bothering the client

25. The nurse prepares to assess the blood pressure of the six year old child following an accident. A blood pressure cuff of appropriate size is unavailable. Which action does the nurse take?

a. Uses another site appropriate for the size of the bailable cost to obtaining reading

b. Wait until proper equipment is available before proceeding to check the blood pressure

c. Use a smaller blood pressure cuff and checked to reading in both arms

d. Uses a larger cost, and add 10 mm Hg to the systolic reading

26. The healthcare provider orders tobramycin for a 3-year-old child. The nurse enters the clients room to administer the medication and discovers that the child does not have an identification bracelet. Which action by the nurse is the most appropriate?

a. Ask a coworker to identify the child before giving the medication b. Ask the parents at the child’s bedside to state their child’s name

c. Hold the medication until an identification bracelet can be obtained from the admitting office

d. Ask the child to save the child’s first and last name

27. The nurse changes the dressing on a client two days after a bowel resection. After opening a sterile pack and putting on the sterile gloves at the clients bedside, the nurse notes the dressing needed for the dressing change are missing. Which action does the nurse take next?

a. Remove the gloves, obtained the missing dressings, and replaces the clubs to continue with the procedure

b. Closes the pack, obtained the missing dressing and new gloves, and reopen the pack to continue with procedure

c. Presses the call light, ask the nurse assistive personnel to bring the missing dressings to the clients room, and then continues with the procedure

d. Remains in place at the clients bedside while the nursing assistive personnel obtains the missing dressings, and then continues with the procedure

28. 29. The client receives parenteral nutrition (PN) via the internal jugular vein. Which action does the nurse take if the next container of PN solution is not available when it is needed?

a. Slows down the PN infusion until the new solution is available

b. Hangs  a  container  of  0.9%  NaCl  until  the  new  solution  is  available c. Hangs  a  container  of  10%  D/W  until  the  new  solution  is  available

d. Uses a heparin lock until the new solution is available

29. The  nurse  cares  for  the  client  with  a  history  of  chronic  alcohol  abuse,  nutritional  problems,  and  confabulation.  In planning for the clients nursing care, which action is the first priority of the nurse?

a. Restrict visitors to minimize environmental stimuli

b. Provide a high-calorie, high- protein diet as ordered

c. Start a intravenous line of D5W with thiamine as ordered

d. Monitor behaviors for documentation of confabulation

30. The nurse cares for the school- aged Child diagnosed with cystic fibrosis (CF). The healthcare provider orders aerosol therapy. The nurse knows which is the expected outcome?

a. The child’s appetite improves

b. The child displays no evidence of infection


c. The child manages respiratory secretions without difficulty

d. The child’s activity level increases

31. Which situation suggests a nurse is addicted to the use of alcohol or habit-forming medications?

a. The nurse questions a client’s medication order left by a healthcare provider

b. The nurse volunteers to “Float” to another unit at the hospital

c. The nurse cannot be found on the unit for half an hour during the assigned shift

d. The nurse questions a client about paying before administering a narcotic analgesic

32. The nurse assesses the intravenous (IV) site on the left forearm of the child. Which finding causes the nurse to rule out the occurrence of infiltration of the IV?

a. The  fluid  in  that  IV  tubing becomes  pink  tinged  when  the  tubing  is  pinched

b. The end of the needle can be palpated in the vein in the left forearm

c. The amount of fluid infused through the IV site is a half- hour behind schedule

d. The skin on the left arm distal to the IV insertion site is cool and dry

33. The nurse cares for the client diagnosed with a left tibia fracture. The client has a long – leg walking cast applied. Several hours later, the client states, “I can’t feel my toes.” It is most important for the nurse to take a which action?

a. Ask the client to wiggle the toes

b. Observe the foot for edema

c. Assess the clients femoral pulse

d. Check the skin temperature of the foot

34. The charge nurse notes that during a staff meeting designed to discuss client care concerns, a nurse that is a non- native speaker of English remains silent. Which action does the charge nurse take?

a. Require all the nurses at the meeting to verbalize their thoughts about the topic under discussion b. Allow extra time during the meeting for questions and summarize the discussion of the group

c. Take the none-native nurse a side after the meeting and restate the major conclusions of the discussion

d. Check with the non-native nurse before the conclusion of the discussion to see if the discussion topics were understood

35. The nurse cares for the client with a chest tube attach to a three-chamber water sealed drainage system. While attempting to get out of bed, the client accidentally disconnect the chest tube from the water-seal drainage system. Which action does the nurse take first?

a. Inserts the end of the chest tube in a container of sterile saline solution

b. Clamps the chest tube near the water- seal drainage system

c. Applies a dressing to the chest tube insertion site

d. Obtains a new water- seal drainage system

36. The  nurse  teaches  the  client, scheduled  for  a  total  right  hip  arthroplasty,  preoperatively.  Teaching  includes postoperative exercises. Which exercise, if perform by the client, indicates further teaching is necessary?

a. The client performs straight leg lifts

b. The client performs plantar and dorsiflexion  exercises

c. The client demonstrates quadriceps and gluteal  setting

d. The client demonstrate active range of motion exercises of the ankle

37. The nurse cares for the client receiving peritoneal dialysis. Which finding, if observed by the nurse during the procedure, indicate a malfunction in the system?

a. There is a leak of fluid onto the dressing in the bed

b. The client reports rectal pain on infusion of the dialysate

c. More dialysate is returned then was infused

d. The clients blood pressure decreases


38. The  client  scheduled  for  a  vaginal  hysterectomy tells  the  nurse,  “I  want  to  read  my  medical  record.”  Which  action does the nurse take?

a. Asks  the  clients  health  care  provider  if  the  client  can  read  the  medical  record.

b. Relays the clients request to read medical medical record to the nurses supervisor

c. Gives the medical record to the client, and remains with the client while the client reads it

d. Tells the client the medical record is the property of the hospital

39. The  nurse  cares  for  a  client  diagnosed  with  primary  adrenocorticol  insufficiency.  The  nurse  expects  to  observe  which laboratory finding?

a. Decreased sodium and glucose; increased potassium

b. Decrease sodium and potassium; increased glucose

c. Increased sodium and potassium; decreased  glucose

d. Increased sodium and glucose; decreased  potassium

40. The nurse works with the client who has a history of alcoholism. Which statement, if made by the client to the nurse, indicates that the client has gained some insight into alcoholism?

a. “I know I can stop drinking if I put my mind to it.”

b. “For the sake of my family, I will never drink again.”

c. “I  know  this  is  a  lifelong  problem,  and  I’ll  need  continued  support.”

d. “I know that Alcoholics Anonymous (AA) is available in case the problem gets worse.”

41. The parent arrives from overseas to visit. The child discovers the parent depressed, disheveled, and suspicious of family  members.  The  nurse  include  which  nursing  order  in  the  care  plan?

a. Encourage  family  involvement  in  clients  treatment.

b. Involve the local international community and the clients care

c. Set limits on family visits until the client is stable

d. Assign the client to structured group activity

42. The home health nurse changes dressings four times a week for the client diagnosed with stage III pressure ulcer. The hospital admitting nurse notes that the dressing was not applied as ordered. Which action is most important for the nurse to take?

a. Contact the nursing supervisor in the hospital to report the discrepancy

b. Contact the home health nurse who has been caring for the client to report the discrepancy

c. Contact the home health supervisor to report the discrepancy

d. Document the discrepancy between what was ordered and the condition of the dressing

43. The  nurse  gives  a  client  morphine  10mg  intramuscularly  (IM).  After  administering  the  medication,  the  nurse  notes  the order for morphine was deleted by the healthcare provider the previous day and replaced with an order of hydromorphone 4mg IM. Which documentation is best?

a. “Morphine 10mg given IM into left ventrogluteal area for report of a domino pain. Healthcare provider notified.”

b. “Morphine 10 mg given IM for reports the pain. Hydromorphone 4 mg IM ordered. Incident report completed.”

c. “Morphine  10  mg  given  IM  for  reports  of  abdominal  pain  instead  of  hydromorphone  4mg  IM.  Incident reported  to  healthcare  provider.”

d. “Morphine given for report of incisional pain. Vital signs unchanged. Client resting resting comfortably. States pain is relieved.”

44. 45. The spouse of the 60 – year – old client brings the client to the clinic. The spouse states that during the last week  the  client  has  become  confused  and  has  been  drinking  large  quantities  of  water.  Lab  values  indicate:  blood glucose  1,215  mg/dL  (67.43  mmol/L),  see  osomolality  400  mOsmol/kg  H2O  (400  mmol/kg  H2O),  potassium  4.5  mEq/L


(4.5  mmol/L),  sodium  145  mEq/L  (145  mmol/L),  and  serum  negative  for  ketones.  The  nurse  expects  the  healthcare provider to initially order which treatment?

a. 0.45% NaCl IV and isophane insulin IV

b. D5 0.9% NaCl IV and isophane insulin SQ

c. D5W IV and regular insulin SQ

d. 0.9%  NaCl  IV  and  regular  insulin  IV

45. The parents bring their 9-month-old child to the clinic. Which observation by the nurse indicates a delay in development?

a. The child begins to cry when the nurse approaches

b. The child can sit unsupported

c. The child uses a Palmer grasp to hold objects

d. The child can clap the hand when asked to do so

46. An hour and a half after admission to the nursery, the nurse observe spontaneous jerky movements of the lambs and infant born to a mother with just station on diabetes mellitus (GDM). Based on these signs, which condition does the nurse expect in the infant?

a. Hyperbilirubinemia

b. Cold stress c. Hypoglycemia

d. Neurological impairment

47. The nurse cares for the client with an above-knee (AKA) amputation performed four days ago. The nurse teaches the client  about  care  of  the  residual  limb  prior  to  being  fitted  with  a  temporary  prosthesis.  Which  intervention  is  most important for the nurse to include an instruction?

a. Expose the residual limb to air 30 minutes daily

b. Elevate the residual limb on pillows at night

c. Wrap the residual limb with an elastic bandage during the day

d. Inspect the residual limb daily

48. To ensure a safe hospital environment for a 2-year-old toddler, which intervention does the nurse implement?

a. Arranges for one of the parents to stay with the client

b. Pads the rails of the clients crib

c. Places the client and they use bed

d. Remove equipment from the bedside table

49. The nurse cares for the client diagnosed with a loss of ability to use language following a stroke. Which action does the nurse take?

a. Involve the family members as translators

b. Utilize both verbal and nonverbal communication

c. Write out all information on an erasable board

d. Focus efforts on reducing the clients frustration when communicating

50. The nurse assesses the client who has a chest tube and a three-chamber water-seal drainage system connected dissection. Which occurrence requires an intervention by the nurse?

a. The  collection  container  contains  100  mL  of  serosanguineous  fluid

b. There is continuous bubbling in the section control chamber c. There is continuous bubbling in the water-seal chamber

d. The fluid in the chest tube fluctuates with the clients respirations

51. The clients adult children bring their 70-year-old parent, in the early stages of Alzheimer’s disease, to the medical clinic. Which symptom does the nurse expect the client to exhibit?

a. The client walks with a slow, staggering gate


b. The client cannot remember what the client had for breakfast that morning

c. The client reports generalized body aches

d. The client cannot remember the clients children’s names

52. The nurse takes care of the client admitted to rule out epilepsy. Which action is the highest priority for the nurse?

a. Protect the client from injury

b. Accurately document any seizures the client might have

c. Monitor the client from medication side effects

d. Provide for client assessment and teaching

53. The nurse observes cardiopulmonary resuscitation (CPR) Being performed on an 8-months-old client. The nurse intervenes if which observation is made by the nurse?

a. The client’s nose and mouth are covered by the rescuers mouth b. The clients neck is hyperextended

c. The depth of chest compressions is about 1 1/2 inches deep

d. The rate of chest compressions is 100 per minute

54. The  client  at  32  weeks  gestation  visits  the  healthcare  provider.  While  the  nurse  palpates  the  woman’s  abdomen,  the woman  suddenly  says,  “I  feel  dizzy.  I  feel  as  if  I’m  going  to  faint.”  The  nurse  identifies  which  condition  causes  the clients response?

a. Maternal anxiety causing peripheral vasoconstriction

b. Postural hypotension resulting from a change of position

c. Inappropriate Leopold’s maneuvers compressing blood flow to the fetus d. Hypotensive syndrome causing a reduction in cardiac output

55. The nurse teaches the client newly diagnosed with type I diabetes. Which statement by the nurse best explains the rationale for rotating injection sites for this client?

a. “You  may  damage  the  tissues  causing  erratic  absorption  of  insulin  if  you  don’t  rotate  sites.”

b. “You may develop an infection if you use the same area too frequently

c. “You may damage to the superficial nerves in the skin and lose sensation if you use the same area to frequently.”

d. “your  thighs  will  eventually  becomes  sore  if  you  don’t  change  injection  sites.”

56. The nurse performs a venipuncture using an intravenous (IV) catheter for a client scheduled for surgery. Which technique does the nurse use?

a. Pierces the skin and the vein in one swift motion

b. Inserts the catheter through the skin and the 30° angle

c. Releases the tourniquet after cleaning the skin alcohol

d. Insert the catheter through the skin with the devil down

57. The nurse cares for the adolescent scheduled for surgery to repair extensive facial scarring sustained any motor vehicle accident. The nurse assesses the clients understanding of the operation. Which response, if made by the client to the nurse, indicated the client has the capacity for abstract thinking?

a. “When I was in the hospital right after the accident, the nurse who took care of me showed me what the skin graft with look like on a doll.”

b. “The first thing I am going to do when I finish with this operation is begin saving for my own car.”

c. “I’m scared that my face will look worse after the surgery than it does now. This operation sounds horrible.” d. d. “The healthcare provider talked to me about the different techniques involved and the risk of the skin

graft  being  rejected.”

58. The new patient holds the two week old neonate E erect with the feet touching the table top. The baby responds by flexing and extending the legs. The parent says to the nurse, “look my baby is trying to walk!” Which response, if made by the nurse to the parent, is best?


a. “Your  baby  is  demonstrating the  dance  or  step  reflex.  It  will  be  replaced  by  deliberate  movement  in  about  2 to  3  weeks.”

b. “Your baby won’t start to walk until the baby is about a year old. The baby is just performing random movements.”

c. “Your baby is advanced for two weeks of age. This type of movement is not usually seen into the baby is two months old.”

d. “Your baby is not trying to walk. That is physically impossible at this age.”

59. The  nurse  teaches  the  school  age  to  how  to  use  crutches correctly.  Which  action  by  the  client  requires  intervention  by the nurse?

a. The client rest win the client become short of breath or diaphoretic when walki