saunders ebook

Pre test
1 A manic client begins to make sexual advances toward visitors in the dayroom. When the nurse
firmly states that this is inappropriate and will not be allowed, the client becomes verbally abusive and
threatens physical violence to the nurse. Based on the analysis of this situation, which intervention
would the nurse implement?
Your Answers:
Place the client in seclusion for 30 minutes.
Tell the client that the behavior is inappropriate.
Escort the client to the hospital room, with the assistance of other staff.
Tell the client that telephone privileges are revoked for 24 hours.

2 The nurse is reviewing the etiology of peritonitis. Which of the following would the nurse identify as a
chemical cause of peritonitis?
Your Answers:
Streptococcus infection
Pneumococcus infection
Escherichia coli (E. coli) infection
Bile leakage from the gallbladder

3 The nurse is providing education to a client with pregestational diabetes who is now at 14 weeks'
gestation about measures to take during a hypoglycemic episode. The nurse would instruct the client
to take which initial action?
Answer Options
Consume two to four glucose tablets.
Immediately notify the primary health care provider.
Check the blood glucose level at the first sign of symptoms.
Recheck the blood glucose level 15 minutes after consuming two to four glucose tablets.

4 A client who is undergoing peritoneal dialysis calls the nurse at the renal unit and reports the
presence of severe abdominal pain and diarrhea. The client also informs the nurse that the peritoneal
dialysis returns are brown-tinged in color. Which would the nurse suspect?
Infection
An intact catheter
Bowel perforation
Bladder perforation

5 The nurse is monitoring a postpartum client, who delivered 1 hour ago and received epidural
anesthesia for delivery, for the presence of a vulvar hematoma. Which assessment finding would best
indicate the presence of a hematoma?
Changes in vital signs
Signs of heavy bruising
Complaints of intense pain
Complaints of a tearing sensation
6 The nurse is administering an intravenous dose of methocarbamol to a client with a musculoskeletal
injury. For which adverse effect would the nurse monitor?
Tachycardia
Rapid pulse
Bradycardia
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Hypertension

7 The nurse is preparing to administer a tuberculin skin test to a client via the intradermal route. Which
action would the nurse perform when administering this test to the client?
Inject the medication and place a pressure dressing over the medication site.
Make a circular mark around the injection site after administration of the tuberculin test.
Administer the injection with the needle bevel facing downward at a 10- to 15-degree angle.
Massage the area with an alcohol swab after injection to ensure that the medication is absorbed.

8 Isotretinoin is prescribed for a client with severe acne. Before the administration of this medication,
the nurse anticipates that which laboratory test will be prescribed?
Potassium level
Triglyceride level
Hemoglobin A1c
Total cholesterol level

9 A school nurse is teaching an athletic coach how to prevent dehydration in athletes during football
practice. Which action by the coach during football practice would indicate that further teaching is
needed?
Weighs athletes before, during, and after football practice
Asks the athletes to take a salt tablet before football practice
Schedules fluid breaks every 30 minutes throughout practice
Tells the athletes to drink 16 oz of fluid per pound lost during practice

10 The nurse is checking lochia discharge in a client in the immediate postpartum period. The nurse notes that
the lochia is bright red and contains some small clots. Based on these data, the nurse would make which
interpretation?
The client is hemorrhaging.
The client needs to increase oral fluids.
The client is experiencing normal lochia discharge.
The client's primary health care provider (PHCP) needs to be notified of the finding.

11 The home health nurse is visiting a client for the first time. While assessing the client's medication
history, it is noted that there are 19 prescriptions and several over-the-counter medications that the
client has been taking. Which action would the nurse take first?
Check for medication interactions.
Determine whether there are medication duplications.
Call the prescribing primary health care provider (PHCP) and report polypharmacy.
Determine whether a family member supervises medication administration.

12 A home health care nurse is visiting an older client at home. Furosemide is prescribed for the client,
and the nurse teaches the client about the medication. Which statement, if made by the client,
indicates the need for further teaching?
"I will sit up slowly before standing each morning."
"I will take my medication every morning with breakfast."
"I need to drink lots of coffee and tea to keep myself healthy."
"I will call my primary health care provider if my ankles swell or my rings get tight."
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13 The nurse notes that a 6-year-old child does not recognize that objects exist even when the objects
are outside of the visual field. Based on this observation, which action would the nurse take?
Report the observation to the pediatrician.
Move the objects in the child's direct field of vision.
Teach the child how to visually scan the environment.
Provide additional lighting for the child during play activities.

14 The nurse enters the room of a client who began receiving a blood transfusion 45 minutes earlier to
check on the client. The client is complaining of "itching all over" and has a generalized rash. The
client's temperature has not changed from baseline and the lungs are clear to auscultation. Which
complication of blood transfusion therapy would the nurse determine that this client is most likely
experiencing?
Bacteremia
Fluid overload
Hypovolemic shock
Allergic transfusion reaction

15 A nursing instructor asks the nursing student to describe the definition of a critical path. Which
statement, if made by the student, indicates a need for further teaching regarding critical paths?
"They are developed based on appropriate standards of care."
"They are nursing care plans and use the steps of the nursing process."
"They are developed through the collaborative efforts of members of the health care team."
"They provide an effective way to monitor care and to reduce or control the length of hospital stay for the client."

16 The client diagnosed with depression says to the nurse, "I haven't had an appetite at all for the last
few weeks." Which response by the nurse best assesses the client's nutritional issue?
"The last few weeks?"
"You haven't had an appetite at all?"
"Have patience; it will take time for your appetite to improve."
"When the medication begins to work, your appetite will return."

17 Contact precautions are initiated for a client with a health care–associated (nosocomial) infection
caused by methicillin-resistant Staphylococcus aureus (MRSA). The nurse prepares to provide
colostomy care and would obtain which protective items to perform this procedure?
Gloves and gown
Gloves and goggles
Gloves, gown, and shoe protectors
Gloves, gown, goggles, and a mask or face shield

18 The pediatric nurse educator provides a teaching session to parents regarding the substances that
cause lead poisoning. Which item, if identified by a parent as a known environmental substance that
can cause lead poisoning, indicates a need for further education?
Paint chips
Vinyl blinds
Properly glazed pottery
Solder used in plumbing
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19 The nurse would monitor the client prescribed thioridazine hydrochloride carefully for which
adverse effect?
Weight gain
Photosensitivity
Cardiac dysrhythmias
Extrapyramidal movements

20 The nurse caring for a client diagnosed with inflammatory bowel disease (IBD) recognizes that
which classifications of medications may be prescribed to treat the disease and induce remission?
Select all that Antidiarrheal
Antidiarrheal
Antimicrobial
Corticosteroid
Aminosalicylate
Biological therapy
Immunosuppressant

21 A client has been receiving foscarnet as part of therapy for the treatment of cytomegalovirus (CMV) retinitis
and acquired immunodeficiency syndrome (AIDS). The home care nurse would periodically review results of
which laboratory blood test to assess for adverse effects to this medication?
CD4+ cell count
Lymphocyte count
Albumin concentration
Creatinine concentration

22 The nurse at a well-baby clinic is providing nutrition instructions to the parent of a 1-month-old
infant. What instruction would the nurse give to the parent?
Introduce strained fruits one at a time.
Breast milk or formula is the main food.
Introduce strained vegetables one at a time.
Offer rice cereal mixed with breast milk or formula.

23 The nursing instructor is reviewing the clinical manifestations of gastroesophageal reflux disease
(GERD) in children. The nursing instructor determines that the nursing student understands the
material if the student identifies which manifestation(s) as associated with GERD? Select all that apply.
Weight gain
Chronic cough
Abdominal pain
Hoarse voice
Recurrent pneumonia

24 The nurse is caring for a client with acute pancreatitis and is monitoring the client for paralytic
ileus. Which piece of assessment data would alert the nurse to this occurrence?
Inability to pass flatus
Loss of anal sphincter control
Severe, constant pain with rapid onset
Firm, nontender mass palpable at the lower right costal margin
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25 A 52-year-old male client is seen in the primary health care provider's (PHCP's) office for a physical
examination after experiencing unusual fatigue over the last several weeks. The client's height is 5 ft, 8
in (173 cm) and his weight is 220 lb (99.8 kg). Vital signs are as follows: temperature, 98.6° F (37° C)
orally; pulse, 86 beats/min; and respirations, 18 breaths/min. The blood pressure reading is 184/100
mm Hg. A random blood glucose level is 122 mg/dL (6.8 mmol/L). Which question would the nurse ask
the client first?
"Do you exercise regularly?"
"Are you considering trying to lose weight?"
"Is there a history of diabetes mellitus in your family?"
"When was the last time you had your blood pressure checked?"

26 Which would the nurse do when caring for a client with a chest tube attached to a chest drainage system?
Empty the drainage collection chamber every shift.
Ensure the water level in the water seal chamber is at the 2-cm level.
Maintain the drainage collection device at the level of the client's chest.
Clamp the chest tube before moving the client from the bed to the chair.

27 A client who suffered a brain attack (stroke) is prepared for discharge from the hospital. The primary health
care provider has prescribed range-of-motion (ROM) exercises for the client's right side. What action would the
nurse include in the client's plan of care?
Implement ROM exercises to the point of pain for the client.
Consider the use of active, passive, or active-assisted exercises in the home.
Develop a schedule of ROM exercises every 2 hours while awake even if the client is fatigued.
Encourage the client to be dependent on the home care nurse to complete the exercise program.

28 A nursing student is assisting a school nurse in performing scoliosis screening on the children in
the school. The nurse assesses the student's preparation for conducting the screening. The nurse
determines that the student demonstrates understanding of the disorder when the student states that
scoliosis is characterized by which finding?
Abnormal lateral curvature of the spine
Abnormal anterior curvature of the lumbar spine
Excessive posterior curvature of the thoracic spine
Abnormal curvature of the spine caused by inflammation

29 The nurse is performing an assessment on a client who sustained circumferential burns of both
legs. Which assessment would be the initial priority in caring for this client?
Assessing heart rate
Assessing respiratory rate
Assessing peripheral pulses
Assessing blood pressure (BP)

30 The nurse in a birthing room is monitoring a client with dysfunctional labor for signs of fetal or
maternal compromise. Which assessment finding would alert the nurse to a compromise?
Maternal fatigue
Coordinated uterine contractions
Progressive changes in the cervix
Persistent nonreassuring fetal heart rate
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31 A client at risk for shock secondary to pneumonia develops restlessness and is agitated and
confused. Urinary output has decreased, and the blood pressure is 92/68 mm Hg. The nurse suspects
which stage of shock based on this data?
Stage 1
Stage 2
Stage 3
Stage 4

32 After performing an initial abdominal assessment on a client with nausea and vomiting, the nurse
would expect to note which finding?
Waves of loud gurgles auscultated in all four quadrants
Low-pitched swishing auscultated in one or two quadrants
Relatively high-pitched clicks or gurgles auscultated in all four quadrants
Very high-pitched, loud rushes auscultated especially in one or two quadrants

33 The nurse in the health care clinic is performing a neurological assessment and is testing the motor
function of cranial nerve V (trigeminal nerve). Which technique would the nurse implement to test the
motor function of this nerve?
Ask the client to puff out the cheeks.
Separate the client's jaw by pushing down on the chin.
Place a small amount of sugar on the client's tongue and ask them to identify the taste.
Ask the client to rotate the head forcibly against resistance applied to the side of his or her chin.

34 Fat emulsion is prescribed for the client receiving total parenteral nutrition. The nurse is preparing
to administer the fat emulsion and notes the presence of fat globules in the solution. What would the
nurse do?
Return the solution to the pharmacy.
Shake the solution to dissolve the globules.
Call the primary health care provider (PHCP).
Place the solution in a bath of warm water until the globules dissolve.

35 A 55-year-old client confides in the nurse they are concerned about sexual function. What is the
nurse's best response?
"How often do you have sexual relations?"
"Please share with me more about your concerns."
"You are still young and have nothing to be concerned about."
"You would not have a decline in testosterone until you are in your 80s."

36 Dexamethasone intravenously is prescribed for the client with cerebral edema. The nurse prepares
the medication for administration and plans to perform which action?
Administer the medication by direct injection.
Mix the medication in 1000 mL of 5% dextrose.
Mix the medication in 100 mL of lactated Ringer's solution.
Dilute the medication in lactated Ringer's solution and administer as a direct injection.
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37 Tacrolimus is prescribed for a client who underwent a kidney transplant. Which instruction would
the nurse include when teaching the client about this medication?
Eat at frequent intervals to avoid hypoglycemia.
Take the medication with a full glass of grapefruit juice.
Change positions carefully due to risk of orthostatic hypotension.
Take the oral medication every 12 hours at the same times every day.

38 The nurse is reviewing the assessment data of a client admitted to the mental health unit. The nurse
notes that the admission nurse documented that the client is experiencing anxiety as a result of a
situational crisis. The nurse plans care for the client, determining that this type of crisis could be
caused by which event?
Witnessing a murder
The death of a loved one
A fire that destroyed the client's home
A recent rape episode experienced by the client

39 A 56-year-old client with heart failure is taking digoxin for treatment of the health problem. The
nurse auscultates the client's apical heart rate before administering digoxin and notes that the heart
rate is 52 beats/min. The nurse would make which interpretation of this information?
Normal, because of the client's age
Abnormal, requiring further assessment
Normal, as a result of the effects of digoxin
Normal, because this is the reason the client is receiving digoxin

40 The nurse is assessing a client who has been admitted to the coronary care unit. The client seems
to fluctuate in the ability to focus during the day. On the basis of this assessment, which client
problem would the nurse suspect?
Dementia as a result of isolation
Dementia as a result of substance intoxication
Acute confusion as a result of hospital-induced psychosis
Interruption in the family as a result of alcohol withdrawal

41 The nurse is reviewing the pediatrician’s orders for a child diagnosed with Hirschsprung’s disease.
Which diet would the nurse anticipate to be prescribed for the child?
Clear liquid
Low calorie
High protein
Limited fruit and vegetable

42 A client with osteoarthritis is receiving diclofenac sodium. The nurse would be concerned about the
administration of this medication if the client's history and physical included a diagnosis of which
condition?
Graves' disease
Peptic ulcer disease
Coronary artery disease
Benign prostatic hypertrophy
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43 The nurse is testing the spinal reflexes of a client during neurological assessment. Which
assessment by the nurse would help to determine the adequacy of the spinal reflex?
Cough reflex
Withdrawal reflex
Munro-Kellie reflex
Accommodation reflex

44 When working with the client who has two family members with a history of substance abuse, the
nurse would identify which assessment data as a primary biological factor?
The client is a 25-year-old.
The client is employed as a firefighter.
The client is of non-American descent.
The client has two family members who have abused.

45 The nurse has a prescription to administer foscarnet intravenously to a client with acquired
immunodeficiency syndrome (AIDS). What would the nurse plan to do before administering this
medication?
Obtain a sputum culture.
Obtain folic acid as an antidote.
Place the solution on a controlled infusion pump.
Ensure that liver enzyme levels have been drawn as a baseline.

46 A diagnosis of Hodgkin's disease is suspected in a 12-year-old child. Several diagnostic studies are
performed to determine the presence of this disease. Which diagnostic test result will confirm the
diagnosis of Hodgkin's disease?
Elevated vanillylmandelic acid urinary levels
The presence of blast cells in the bone marrow
The presence of Epstein-Barr virus in the blood
The presence of Reed-Sternberg cells in the lymph nodes

47 A client suspected of cholelithiasis is admitted to the hospital. Upon assessment, the nurse notes that the
client is jaundiced. Which diagnostic imaging would be most important for the client to obtain?
X-ray
Discogram
Dual energy x-ray
Endoscopic retrograde cholangiopancreatography

48 A client has experienced an episode of pulmonary edema. The nurse determines that the client's
respiratory status is improving after this episode if which breath sounds are noted?
Rhonchi
Wheezes
Crackles in the bases
Crackles throughout the lung fields
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49 The nurse has provided dietary instructions to the parent of a child with celiac disease. The nurse
determines that the parent understands the instructions when the parent states to include which food
in the child's diet?
Corn
Wheat cereal
Rye crackers
Oatmeal biscuits

50 The nurse is preparing for suctioning an unconscious client who has a tracheostomy. The nurse
would perform which actions for this procedure? Select all that apply.
Keeping a supply of suction catheters at the bedside
Auscultating breath sounds to determine the need for suctioning
Hyperoxygenation the client before, during, and after suctioning
Intermittently suctioning during insertion of the suction catheter
Placing suction on the catheter for at least 30 seconds to ensure that all secretions are removed

51 The nurse is preparing the client's morning insulin isophane dose. The nurse notices a clumpy
precipitate inside the insulin vial. What is the most appropriate nursing action related to this finding?
Draw the dose from a new vial.
Draw up and administer the dose.
Shake the vial in an attempt to disperse the clump.
Warm the vial under running water to dissolve the clump.

52 A home care nurse is visiting a client with a diagnosis of pernicious anemia that developed as a
result of gastric surgery. The nurse instructs the client that in this disorder, because the stomach
lining produces a decreased amount of a substance known as the intrinsic factor, the client will need
which medication?
An antacid
An antibiotic
Vitamin B6 injections
Vitamin B12 injections

53 The nurse would make which statement to a pregnant client found to have a gynecoid pelvis?
"Your type of pelvis has a narrow pubic arch."
"Your type of pelvis is the most favorable for labor and birth."
"Your type of pelvis is a wide pelvis, but it has a short diameter."
"You will need a cesarean section because this type of pelvis is not favorable for a vaginal delivery."

54 The nurse would implement which interventions for a child older than 2 years with type 1 diabetes
mellitus who has a blood glucose level of 60 mg/dL (3.4 mmol/L)? Select all that apply.
Administer regular insulin.
Encourage the child to ambulate.
Give the child a teaspoon of honey.
Provide electrolyte replacement therapy intravenously.
Wait 30 minutes and confirm the blood glucose reading.
Prepare to administer glucagon subcutaneously if unconsciousness occurs.
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55 The nurse is providing dietary teaching for a client with a diagnosis of chronic gastritis who is at
risk for vitamin B12 deficiency. The nurse instructs the client to include which foods rich in vitamin
B12 in the diet? Select all that apply.
Meat
Corn
Liver
Apples
Bananas

56 A child is seen in the health care clinic for a complaint of fever. On data collection, the nurse notes
that the child is pale, tachycardic, and has petechiae. Aplastic anemia is suspected. The nurse would
prepare the child to obtain which specimen that could confirm the diagnosis?
Platelet count
Granulocyte count
Red blood cell count
Bone marrow biopsy

57 A client is admitted with a recent history of severe anxiety following a home invasion and robbery.
During the initial assessment interview, which statement by the client would indicate to the nurse the
possible diagnosis of post-traumatic stress disorder? Select all that apply.
"I'm afraid of spiders."
"I keep reliving the robbery."
"I see that face everywhere I go."
"I don't want anything to eat now."
"I might have died over a few dollars in my pocket."
"I have to wash my hands over and over again many times."

58The nurse in charge of a nursing unit is asked to select the hospitalized clients who can be
discharged so that hospital beds can be made available for victims of a community disaster. Select the
clients who can be safely discharged. Select all that apply.
A client experiencing sinus rhythm
A client receiving oral anticoagulants
A client with chronic atrial fibrillation
A client experiencing third-degree heart block
A client who has not voided since before surgery

59 Which is a priority problem for a child with severe edema caused from nephrotic syndrome?
Risk for constipation
Risk for skin breakdown
Inability to regulate body temperature
Consumption of more calories or nutrients than the body requires

60 The nurse is providing a dietary session to a group of clients about the vitamin content of various
foods. The nurse would tell the clients that which food item is highest in vitamin A?
Eggs
Milk
Tomatoes
Green leafy vegetables
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61 The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term newborn on
admission to the nursery. The nurse suspects fetal alcohol syndrome and is aware that which
additional sign would be consistent with this syndrome?
Length of 19 inches
Abnormal palmar creases
Birth weight of 6 lb, 14 oz (3120 g)
Head circumference appropriate for gestational age

62 The nurse is caring for a client who is mechanically ventilated and is monitoring for complications
of mechanical ventilation. Which assessment finding, if noted by the nurse, indicates the need for
follow-up?
Muscle weakness in the arms and legs
A temperature of 98.6° F (37° C), decreased from 99.0° F (37.2° C)
A blood pressure of 90/60 mm Hg, decreased from 112/78 mm Hg
A heart rate of 80 beats/minute, decreased from 85 beats/minute

63 A client with a 38-week twin gestation is admitted to a birthing center in early labor. One of the
fetuses is a breech presentation. Which intervention is least appropriate in planning the nursing care
of this client?
Measure fundal height.
Attach electronic fetal monitoring.
Prepare the client for a possible cesarean section.
Visually examine the perineum and vaginal opening.

64 The nurse is providing directions to a client about how to test a stool for occult blood. The nurse
cautions the client that which could cause a false-negative result?
Iodine
Colchicine
Ascorbic acid
Acetylsalicylic acid

65 The nurse is planning care for a child with hemolytic-uremic syndrome who has been anuric and
will be receiving peritoneal dialysis treatment. The nurse would plan to implement which measure?
Restrict fluids as prescribed.
Care for the arteriovenous fistula.
Encourage foods high in potassium.
Administer analgesics as prescribed.

66 A depressed client who appeared sullen, distraught, and hopeless a few days ago now suddenly appears
calm, relaxed, and more energetic. Which is the nurse's best initial action with regard to the client's altered
demeanor?
Continue to assess the client's behaviors and document clearly in the chart.
Report to the psychiatrist that the client is adapting to the unit and is feeling safe.
Notify the health team of these observations and alert them to the suspicion that the client is contemplating
suicide.
Engage the client in one-to-one supervision, share with the client the observations that have been assessed,
and ask whether the client is thinking about suicide.
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67 The nurse is giving report to an assistive personnel (AP) who will be caring for a client who has
hand restraints (safety devices) applied. How frequently would the nurse instruct the AP to remove the
restraints to allow for muscle activity?
Every 2 hours
Every 3 hours
Every 4 hours
Every 6 hours

68 A client who sustained an inhalation injury arrives in the emergency department. On initial
assessment, the nurse notes that the client is very confused and combative. The nurse determines that
the client is most likely experiencing which condition?
Pain
Fear
Anxiety
Hypoxia

69 The nurse is providing medication instructions to a client with multiple sclerosis receiving baclofen.
Which information would the nurse include in the instructions?
Watch for urinary retention as a side effect.
Stop taking the medication if diarrhea occurs.
Restrict fluid intake while taking this medication.
Notify the primary health care provider if fatigue occurs.

70 A client with a potential for violence is exhibiting aggressive gestures, making belligerent
comments to the other clients, and is continuously pacing in the hallway. Which comment by the nurse
would be therapeutic at
"What is causing you to behave so agitated?"
"Why are you intent on upsetting the other clients?"
"Please stop so I don't have to put you in seclusion."
"You are going to be restrained if you do not change your behavior."

71 The nurse is caring for a client in labor and notes that minimal variability is present on a fetal heart
rate (FHR) monitor strip. Which conditions are most likely associated with minimal variability? Select
all that apply.
Early labor
Amniotomy
Tachycardia
Fetal hypoxia
Metabolic acidemia
Congenital anomalies

72 A pulmonary artery catheter is inserted into a client during cardiac surgery. The nurse is monitoring
the right atrial pressure (RAP). Which finding requires immediate nursing intervention?
4 mm Hg
6 mm Hg
8 mm Hg
12 mm Hg
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73 The nurse is performing an assessment on a 2-year-old child with Hirschsprung's disease who is
accompanied by a parent. Which finding would the nurse expect to note on assessment?
Diaphoresis
Hernia-like stomach bulge
Report of increased appetite
Report of a chronic pattern of constipation

74 The nurse planning care for a military veteran needs to prioritize nursing interventions targeted at
managing which condition, if present, that commonly occurs in this population?
Hypertension
Hyperlipidemia
Substance abuse disorder
Post-traumatic stress disorder

75 The nurse provides instructions regarding home care to the parents of a 3-year-old child
hospitalized with hemophilia. Which statement, if made by the parent, indicates a need for further
instructions?
"We will supervise our child closely."
"We will pad corners of the furniture."
"We will avoid having our child receive immunizations."
"We will remove household items that can easily fall over."
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Post test
1 The nurse is providing home care instructions to the parent of a child receiving radiation therapy.
Which statement by the parent indicates a need for further teaching?
"I would dress my child in loose-fitting clothing."
"I won't need to limit the amount of sun that my child gets."
"My child may experience fatigue and need more rest periods."
"I need to try to provide food and fluids to prevent dehydration."

2 The student nurse is presenting a clinical conference regarding human immunodeficiency virus (HIV)
in children. Which information would the student include?
HIV cannot be spread by hugging, holding, or touching other people.
HIV can be transmitted from open wounds but only if there is skin-to-skin contact.
HIV is only able to be transmitted from an infected parent to the baby through breast/chest milk.
HIV infection cannot be transmitted if a person uses an intrauterine device as birth control.

3 The nurse is assisting to defibrillate a client in ventricular fibrillation. Which intervention is a priority
after placing the pads on the client's chest and before discharging the device?
Ensure that the client has been intubated.
Set the defibrillator to "synchronize" mode.
Administer an amiodarone bolus.
Confirm the cardiac rhythm.

4 A 13-year-old child is diagnosed with Ewing's sarcoma of the femur. After a course of radiation and
chemotherapy, it was decided that leg amputation is necessary. After the amputation, the child
becomes very frightened because of aching and cramping felt in the missing limb. Which nursing
statement is most appropriate to assist in alleviating the child's fear?
"The pain medication that I give you will take these feelings away."
"This aching and cramping is normal and temporary and will subside."
"This pain is not real pain, and relaxation exercises will help it go away."
"This normally occurs after the surgery, and we will teach you ways to deal with it."

5 The nurse is monitoring the amount of lochia drainage in a client who is 2 hours postpartum and
notes that the client has saturated a perineal pad in 15 minutes. What action would the nurse take
initially?
Document the finding.
Encourage the client to ambulate.
Encourage the client to increase fluid intake.
Contact the obstetrician (OB) to report this finding.

6 The nurse is giving medication instructions to a client who is receiving baclofen as maintenance
therapy. Which client statement about the maintenance dose of baclofen indicates that education was
effective?
"I will take 15 mg 4 times daily."
"I will take 30 mg 4 times daily."
"I will take 25 mg of this medication 4 times daily."
"I will take 40 mg of this medication 4 times daily."
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7 The nurse is giving instructions to a client with cholecystitis about food to exclude from the diet.
Which food item identified by the client indicates that the educational session was successful?
Fresh fruit
Brown gravy
Fresh vegetables
Poultry without skin

8 The nurse is reviewing the white blood cell (WBC) count and differential on a client and notes that the
results indicate a left shift. What are the possible indications for these laboratory results? Select all
that apply.
The total number of WBCs
An increased number of bands
The presence of an acute infectious process
An increased number of mature neutrophils
An increased number of immature neutrophils

9 The nurse is caring for a terminally ill client. The nurse has developed a close relationship with the
family of the client. Which interventions would the nurse plan to employ? Select all that apply.
Making decisions for the family
Encouraging family discussion of feelings
Accepting the family's expressions of anger
Allowing spiritual practices identified by the family
Preserving the family's sense of self-direction and control

10 The nurse has been closely observing a client who has been displaying aggressive behaviors. The
nurse observes that the behavior displayed by the client is escalating. Which nursing intervention is
most helpful to this client at this time? Select all that apply.
Initiate confinement measures.
Acknowledge the client's behavior.
Assist the client to an area that is quiet.
Maintain a safe distance from the client.
Allow the client to take control of the situation.

11 The nurse is caring for a client whose urine output was 25 mL per hour for 2 consecutive hours. The
nurse reviews the primary health care provider's prescriptions and plans care, knowing that which
client-related factor would increase the amount of blood flow to the kidneys?
Physiological stress
Release of norepinephrine
Release of low levels of dopamine
Sympathetic nervous system stimulation

12 The nurse is creating a plan of care for the client who is upset following the loss of a job and is
verbalizing concerns regarding the ability to meet financial obligations. Which problem is the basis of
the client's concerns?
Anxiety
Confusion about social roles
Inability to meet role expectations
Impairment of interactions among family members
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13 Glimepiride is prescribed for a client with diabetes mellitus. The nurse instructs the client that
which food items are most acceptable to consume while taking this medication? Select all that apply.
Alcohol
Red meats
Whole-grain cereals
Low-calorie desserts
Carbonated beverages

14 Which statement by the client best reflects the development of an effective coping response style
and effective processing of information for a hospitalized client participating in Alcoholics Anonymous
(AA)?
"I know I'm ready to be discharged. I feel as if I can say no and leave a group of friends if they are drinking. No
problem."
"I'll keep all my appointments and go to all my AA groups; I'll do everything I'm supposed to. Nothing will go
wrong that way."
"I'm looking forward to leaving here. I will miss all of you. So, I'm happy and I'm sad, I'm excited, and I'm
scared. I know that I have to work hard to be strong and that not everyone will be as helpful as you people."
"This group has really helped a lot. I know it will be different when I go home. But I'm sure that my family and
friends will all help me in the same way the people in this group have. They'll all help me. I know they will. They
won't let me go back to old ways."

15 The nurse teaches a client who is going to have a plaster cast applied to treat a fracture about the
procedure. Which statement by the client indicates a need for further teaching?
"The cast will give off heat as it dries."
"I can bear weight on the cast in one-half hour."
"The cast edges may be trimmed with a cast knife."
"A stockinette will be placed over the leg area to be casted

16 The home care nurse is visiting an older client whose spouse died 6 months ago. Which behaviors
by the client indicate effective coping? Select all that apply.
Neglecting personal grooming
Looking at old snapshots of family
Participating in a senior citizens program
Visiting the spouse's grave once a month
Decorating a wall with the spouse's pictures and awards received

17 The nurse is assigned to care for four clients. In planning client rounds, which client would the
nurse assess first?
A postoperative client preparing for discharge with a new medication
A client requiring daily dressing changes of a recent surgical incision
A client scheduled for a chest x-ray after insertion of a nasogastric tube
A client with asthma who requested a breathing treatment during the previous shift
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18The nurse is collecting data on a child who reports difficulty in seeing the words that the teacher
writes on the whiteboard during school. The child reports sitting in the back of the classroom, far from
the whiteboard. Which eye disorder would the nurse suspect?
Myopia
Presbyopia
Nystagmus
Strabismus

19 The nurse manager is planning to implement a change in the nursing unit from team nursing to
primary nursing. The nurse anticipates that there will be resistance during the change process. Which
primary technique would the nurse use in implementing this change?
Introduce the change gradually.
Use coercion to implement the change.
Manipulate the participants in the change process.
Confront the individuals involved in the change process.

20 The nurse is planning to formulate a psychotherapy group. Several clients are interested in
attending the session. The nurse plans the group, based on which management principle?
Members need to be of the same gender.
The group will decide the focus of the sessions.
The group would be limited to no more than 10 members.
The focus of the group will determine when the group will meet.

21 The nurse is caring for an older client whose spouse died approximately 6 weeks ago. The client
says, "There is no one left who cares about me. Everyone that I have loved is now gone." Which
nursing response allows for continued communication about the client's state of mind?
"That doesn't sound like the real you talking!"
"I'm sure you have someone if you think hard enough."
"It sounds as though you are feeling all alone right now."
"I don't believe that, and I really don't think you do either."

22 The home care nurse visits a client who has delivered a healthy newborn infant via vaginal delivery.
An episiotomy was performed, and the client has developed a wound infection at the episiotomy site.
The nurse provides instructions to the client regarding care related to the infection. Which statement, if
made by the client, indicates a need for further instruction?
"I need to take the antibiotics as prescribed."
"I need to take warm sitz baths to promote healing."
"I need to apply warm compresses to provide comfort."
"I need to isolate the infant for 48 hours after beginning the antibiotics."

23 A client in labor is receiving oxytocin by intravenous infusion to stimulate uterine contractions.

Which finding indicates that the rate of infusion needs to be decreased?
Increased urinary output
A fetal heart rate of 180 beats/min
Three contractions occurring in a 10-minute period
Adequate resting tone of the uterus palpated between contractions
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24The home care nurse is reviewing the record of a client newly diagnosed with glaucoma who is
scheduled for a home visit. The nurse notes that the primary health care provider (PHCP) has
prescribed atropine sulfate and pilocarpine hydrochloride eye drops. The nurse would contact the
PHCP before the home visit for which reason?
Clarify the prescription for the atropine sulfate.
Clarify the prescription for the pilocarpine hydrochloride.
Determine the date of the scheduled follow-up PHCP visit.
Determine the extent of the intraocular pressure caused by the glaucoma.

25 The nurse determines that a client is having a transfusion reaction. After the nurse stops the
transfusion, which action would be taken next?
Remove the intravenous (IV) line.
Run a solution of 5% dextrose in water.
Run normal saline at a keep-vein-open rate.
Obtain a culture of the tip of the catheter device removed from the client.

26 The nurse is initiating one-rescuer cardiopulmonary resuscitation on an adult client. The nurse
would place the hands in which position to begin chest compressions?
On the lower half of the sternum
On the upper half of the sternum
On the lower third of the sternum
On the upper third of the sternum

27 A hemodialysis client with a left arm fistula is at risk for arterial steal syndrome. The nurse would
assess for which manifestations of this complication?
Warmth, redness, and pain in the left hand
Ecchymosis and audible bruit over the fistula
Edema and reddish discoloration of the left arm
Pallor, diminished pulse, and pain in the left hand

28 The nurse is assessing a client who was admitted 24 hours ago for a fractured humerus. Which
findings would alert the nurse to the potential for alcohol withdrawal delirium?
Hypotension, ataxia, hunger
Stupor, lethargy, muscular rigidity
Hypotension, coarse hand tremors, lethargy
Hypertension, changes in level of consciousness, hallucinations

29 The nurse has a written prescription to discontinue an intravenous (IV) line. The nurse obtains
which item from the unit supply area for use in applying pressure to the site after removing the IV
catheter?
Band-Aid
Alcohol swab
Sterile 2 × 2 gauze
Povidone-iodine swab
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30A client with renal cell carcinoma of the left kidney is scheduled for nephrectomy. The right kidney
appears normal at this time. The client is anxious about whether dialysis will ultimately be needed. The
nurse would plan to use which information in discussions with the client to alleviate anxiety?
There is a strong likelihood that the client will need dialysis within 5 to 10 years.
There is absolutely no chance of needing dialysis because of the nature of the surgery.
One kidney is adequate to meet the needs of the body as long as it has normal function.
Dialysis could become likely, but it depends on how well the client complies with fluid restriction after surgery.

31 A client is diagnosed with external otitis. Which finding would the nurse expect to note on
assessment of the client?
A wider-than-normal ear canal
A pearly gray tympanic membrane
Redness and swelling in the ear canal
An excessive amount of cerumen lodged in the ear canal

32 The nurse is performing an assessment on a client who suspects being pregnant and is checking
the client for probable signs of pregnancy. The nurse would assess for which probable signs of
pregnancy? Select all that apply.
Ballottement
Chadwick's sign
Uterine enlargement
Positive pregnancy test
Fetal heart rate detected by a nonelectronic device
Outline of fetus via radiography or ultrasonography

33 The nurse provides education to the client with hyperthyroidism about potassium iodide before
medication administration. The client is scheduled for a subtotal thyroidectomy. Which response by
the client indicates understanding?
"It replaces thyroid hormone."
"It prevents iodine absorption."
"It increases thyroid hormone."
"It suppresses thyroid hormone."

34 Following kidney transplantation, cyclosporine is prescribed for a client. Which laboratory result would
indicate an adverse effect from the use of this medication?
Your Answers:
Hemoglobin level of 14.0 g/dL (140 mmol/L)
Creatinine level of 0.6 mg/dL (53 mcmol/L)
Blood urea nitrogen level of 25 mg/dL (8.8 mmol/L)
Fasting blood glucose level of 99 mg/dL (5.5 mmol/L)

35 The nurse is preparing to administer a tuberculin skin test to a client via the intradermal route.
Which action would the nurse perform when administering this test to the client?
Inject the medication and place a pressure dressing over the medication site.
Make a circular mark around the injection site after administration of the tuberculin test.
Administer the injection with the needle bevel facing downward at a 10- to 15-degree angle.
Massage the area with an alcohol swab after injection to ensure that the medication is absorbed.
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36 The nurse is providing instructions about taking iron supplements to a pregnant client. The nurse
determines that the client understands the instructions if the client states that they will take the
supplements with which drink?
Tea
Milk
Coffee
Orange juice

37 A client is prescribed trimethoprim-sulfamethoxazole for a recurrent urinary tract infection (UTI).

The nurse would give the client which instruction regarding this medication?
Expect rashes or skin changes as a result of therapy.
Discontinue the medication when symptoms subside.
Take most doses early in the day when fluid intake is greatest.
Take each dose with 8 oz of water, and drink extra water each day

38 A client has a prescription to begin an infusion of 1000 mL of 5% dextrose in lactated Ringer's

solution. The client has an intravenous (IV) cannula inserted, and the nurse prepares the solution and
IV tubing. Arrange the actions in the order that they would be performed. All options must be used.
Select the correct sequence number for each item:
1. Uncap the distal end of the tubing.
2. Close the roller clamp on the IV tubing.
3. Open the roller clamp and fill the tubing.
4. Attach the distal end of the tubing to the client.
5. Spike the IV bag and half-fill the drip chamber.
3,1,4,5,2

39The home care nurse has taught a client with heart failure and a problem of inadequate cardiac
output about helpful lifestyle adaptations to promote health. Which statement by the client best
demonstrates an understanding of the information provided?
"I will try to exercise vigorously to strengthen my heart muscle."
"I will eat enough daily fiber to prevent straining during bowel movement."
"I will drink 3000 to 3500 mL of fluid daily to promote good kidney function."
"Drinking 2 to 3 oz of liquor each night will promote blood flow by enlarging blood vessels."

40 The nurse is planning to test the sensory function of the olfactory nerve (cranial nerve 1). The nurse
would gather which items to perform the test?
Tuning fork and audiometer
Cloves, peppermint, and soap
Flashlight, pupil size chart, and millimeter ruler
Safety pin, hot and cold water in test tubes, and cotton wisp

41 A client has been admitted to the hospital for gastroenteritis and dehydration. The nurse determines
that the client has received adequate volume replacement if the blood urea nitrogen (BUN) level drops
to which value?
3 mg/dL (1.08 mmol/L)
15 mg/dL (5.4 mmol/L)
29 mg/dL (10.44 mmol/L)
35 mg/dL (12.6 mmol/L)
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42 The nurse is caring for a 4-year-old child diagnosed with Kawasaki disease. The nurse notices that
the child’s urinary output is decreasing, the child’s heart rate has increased from a baseline of 90 beats
per minute at rest to 130 beats per minute at rest, and a new gallop is noted on cardiac auscultation.
Which complication would the nurse suspect?
Pneumonia
Myocarditis
Heart failure
Coronary artery dilatation

43 The nurse has provided instructions for measuring blood glucose levels to a client newly diagnosed
with diabetes mellitus who will be taking insulin. The client demonstrates understanding of the
instructions by identifying which method as the best method for monitoring blood glucose levels?
"I will check my blood glucose level every day at 5:00 p.m."
"I will check my blood glucose level 1 hour after each meal."
"I will check my blood glucose level 2 hours after each meal."
"I will check my blood glucose level before each meal and at bedtime

44 The nurse is performing a physical assessment on a client during the first prenatal visit to the clinic.
The nurse takes the client's temperature and notes that it is 37.3° C (99.2° F). Based on this finding,
which nursing action is most appropriate?
Document the temperature.
Notify the primary health care provider.
Retake the temperature by the rectal route.
Inform the client that the temperature is elevated and antibiotics may

45 A client is examined in the hospital emergency department after taking an overdose of

acetylsalicylic acid. The client has rapid breathing, nausea and vomiting, and lethargy. The primary
health care provider prescribes arterial blood specimens for blood gas analysis to be drawn. Aspirin
toxicity is suspected when the blood gas results are reported as which value?
pH 7.50, Pco2 60 mm3 Hg, HCO3 30 mEq/L (30 mmol/L)
pH 7.44, Pco2 30 mm3 Hg, HCO3 21 mEq/L (21 mmol/L)
pH 7.29, Pco2 29 mm3 Hg, HCO3 19 mEq/L (19 mmol/L)
pH 7.33, Pco2 52 mm3 Hg, HCO3 28 mEq/L (28 mm

46 An infant receives a diphtheria, tetanus, and acellular pertussis (DTaP) immunization at a well-baby
clinic. The parent returns home and calls the clinic to report that the infant has developed swelling and
redness at the site of injection. Which intervention would the nurse suggest to the parent?
Monitor the infant for a fever.
Bring the infant back to the clinic.
Apply a hot pack to the injection site.
Apply a cold pack to the injection site.
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47 The home care nurse's assignment is to visit a postpartum client at home 24 to 48 hours after
discharge. What would the nurse expect to note in a healthy client who is breast/chest-feeding the
newborn infant?
The parent has cracked nipples and feeds the infant with a supplemental bottle.
The parent complains of engorgement, and the infant demonstrates difficulty in latching onto the breast/chest.
The parent is breast/chest-feeding the infant with the infant's head turned toward the breast and the body flat in
the client's arms; the parent has sore nipples, and the infant has a suck blister.
The parent is breast/chest-feeding with the infant in a tummy-to-tummy position without signs of cracked
nipples; the baby demonstrates bursts of sucking, followed by a pause and swallow.

48 The ambulatory care nurse is working with a 22-year-old client who has been diagnosed with pelvic
inflammatory disease (PID). The nurse incorporates which item in a teaching plan for this client?
Avoid frequent douching.
Undergarments made of nylon are best.
Intrauterine devices are a good birth control method.
It is necessary to change sanitary pads only every 8 hours.

49 The nurse provides a list of instructions to a client being discharged to home with a peripherally
inserted central catheter (PICC). The nurse determines that the client needs further instruction if the
client makes which statement?
"I need to wear a MedicAlert tag or bracelet."
"I need to restrict my activity while this catheter is in place."
"I need to have a repair kit available in the home for use if needed."
"I need to keep the insertion site protected when in the shower or

50 A client has begun to use a methylxanthine bronchodilator. What beverage would the nurse plan to
teach the client to avoid while taking this medication?
Coffee
Orange juice
Mineral water
Cranberry juice

51 The nurse has received the client assignment for the day. Which client would the nurse care for
first?
A client asking to leave against medical advice (AMA)
A client who is a fall risk and needs assistance to the bathroom
A client needing medication before breakfast because it is a timed dose
A client recently admitted after a motor vehicle accident still in cervical spine precautions

52 A client with chronic kidney disease has completed a hemodialysis treatment. The nurse would use
which standard indicators to evaluate the client's status after dialysis?
Vital signs and weight
Potassium level and weight
Vital signs and blood urea nitrogen level
Blood urea nitrogen and creatinine levels
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53 A client who has had a stroke (brain attack) has residual dysphagia. When a diet prescription is
initiated, the nurse would take which actions? Select all that apply.
Giving the client thin liquids
Thickening liquids to the consistency of oatmeal
Placing food on the unaffected side of the mouth
Allowing plenty of time for chewing and swallowing
Leaving the client alone so that the client will gain independence by feeding self

54 The nurse is reviewing the laboratory and diagnostic test results of a 5-year-old child scheduled to
be seen in the clinic. The nurse notes that the primary health care provider (PHCP) documented that
diagnostic studies revealed the presence of Reed-Sternberg cells. The nurse prepares to assist the
PHCP to discuss which initial procedure with the parents?
Chemotherapy
Surgical biopsy
High-dose radiation
Intravenous antibiotics

55 Laboratory studies are performed for a child suspected to have iron-deficiency anemia. The nurse
reviews the laboratory results, knowing that which result indicates this type of anemia?
Elevated hemoglobin level
Decreased reticulocyte count
Elevated red blood cell count
Red blood cells that are microcytic and hypochromic

56 The nurse is reviewing with the parent the immunization schedule for a child with human
immunodeficiency virus (HIV) infection. Which instruction would the nurse provide to the parent?
Immunizations will not be given to the child with HIV infection.
The immunization schedule is altered because of the HIV infection.
The child and any siblings will need to receive inactivated polio vaccine.
The child with HIV infection will start immunizations when 3 years old.

57 Amoxicillin/clavulanate potassium 500 mg orally every 6 hours is prescribed for a child with an
upper respiratory infection. The medication is supplied as 200 mg/5 mL. How many milliliters will be
administered in each dose? Fill in the blank.
12.5 ml

58 A breast-feeding/chest-feeding parent of an infant with lactose intolerance asks the nurse about
dietary measures. What foods would the nurse tell the parent are acceptable to consume while breast-
feeding/chest feeding? Select all that apply.
1% milk
Egg yolk
Dried beans
Hard cheeses
Green leafy vegetables
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59 The nurse is preparing a pregnant client for a transvaginal ultrasound examination. The nurse
would tell the client that which will occur?
Some pain will be felt during the procedure.
A side-lying position is needed for the procedure.
Some pressure may be felt when the vaginal probe is moved.
It is necessary to drink 2 quarts of water before the procedure to attain a full bladder.

60 The client experiencing a great deal of stress and anxiety is being taught to use self-control therapy.
Which statement by the client indicates a need for further teaching about the therapy?
"This form of therapy can be applied to new situations."
"An advantage of this technique is that change is likely to last."
"Talking to oneself is a basic component of this form of therapy."
"It provides a negative reinforcement when the stimulus is produced

61 The nurse is providing dietary instructions to the client with anemia. The client tells the nurse that
the iron pills are very expensive and that it will be difficult to pay for the pills and buy the proper food.
What is the most appropriate nursing response?
"You will have to find a way to afford both."
"You will be fine as long as you take the iron pills."
"Why don't you ask your family to help you out financially?"
"Would you like for me to check into some other options for you?"

62 The nurse has conducted teaching with a client in an arm cast about the signs and symptoms of
compartment syndrome. The nurse determines that the client understands the information if the client
states that they would report which early symptom of compartment syndrome?
Cold, bluish-colored fingers
Numbness and tingling in the fingers
Pain that increases when the arm is dependent
Pain that is out of proportion to the severity of the fracture

63 A child is seen in the health care clinic, and the nurse suspects the presence of pinworm infection
(enterobiasis). The nurse instructs the parent as to how to obtain a cellophane tape rectal specimen.
Which statement by the parent indicates an understanding of the correct procedure to obtain the
specimen?
"I need to collect the specimen after I give my child a bath."
"I need to collect the first bowel movement of the day and place it in a sealed container."
"I need to place a piece of transparent cellophane tape lightly over the anal area as soon as my child awakens
and bring it to the clinic for examination."
"I need to place a piece of transparent cellophane tape lightly over the anal area after my child has a bowel
movement and bring it to the clinic for examination."

64 The nurse is interviewing a middle-aged woman with a history of fibrocystic disorder of the breasts.
Which statements made by the client indicate a need for further teaching? Select all that apply.
"I might experience pain in my underarm region."
"My symptoms will decrease just before menstruation."
"After I experience menopause, my symptoms may lessen."
"Taking oral contraceptives now will increase my symptoms."
"Upon self-breast examination, I may detect lumpiness in the upper, outer area of my breasts.
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65 A client develops an anaphylactic reaction after receiving morphine. The nurse would plan to
institute which actions? Select all that apply.
Administer oxygen.
Quickly assess the client's respiratory status.
Document the event, interventions, and client's response.
Keep the client supine regardless of the blood pressure readings.
Leave the client briefly to contact a primary health care provider (PHCP).
Start an intravenous (IV) infusion of D5W and administer a 500-mL bolus.

66 A primary health care provider (PHCP) is about to remove a chest tube from a client. After the
dressing is removed and the sutures have been cut, the nurse assisting the PHCP would ask the client
to perform which procedure?
Take a deep breath.
Exhale immediately.
Breathe in and out quickly.
Take a deep breath and hold it.

67 The nurse is reviewing the medical record of a newly assigned client and notes that the client is
receiving cyclobenzaprine hydrochloride for the treatment of muscle spasms. The nurse questions the
prescription if which disorder is noted in the admission history?
Hypothyroidism
Chronic bronchitis
Recurrent pneumonia
Angle-closure glaucoma

68 A neurologist prescribed ticlopidine to the client with thrombotic stroke. The nurse provides
instructions to the client and spouse regarding the medication. Which statement made by the client
indicates that education was effective?
"I'll take the medicine with meals."
"If I do not feel well, I should skip the medication."
"I won't have another stroke if I take this medicine faithfully."
"If I have any gastrointestinal side effects, I should call the neurologist."

69 A 2-year-old child has been admitted to the hospital for management of pneumonia. The child is
placed in an oxygen tent. Taking into consideration the child's age and developmental level and the
treatment being administered, which statement is appropriate for the nurse to make to the parents?
"Your child can play in the tent with blocks and plush stuffed animals."
"You can sit next to your child and hold hands through the tent, but your child needs to remain inside of it."
"At your child's age, separation anxiety is high, so bringing in the wool blanket that your child usually sleeps
with is a good idea."
"Before you leave for the night, it is a good idea to rock your child to sleep. Your child can be out of the tent for
up to 60 minutes without any consequences."

70 Which action would the nurse take to test cranial nerve XI, the spinal accessory nerve?
Ask the client to clench the teeth.
Ask the client to read the letters in a line on a Snellen chart.
Ask the client to shrug the shoulders against the nurse's resistance.
Ask the client to close the eyes, occlude one nostril, and identify a specific odor such as coffee.
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71 The nurse is assessing a newborn after circumcision and notes that the circumcised area is red
with a small amount of bloody drainage. Which nursing action is most appropriate?
Apply gentle pressure.
Reinforce the dressing.
Document the findings.
Contact the primary health care provider (PHCP).

72 The nurse is taking the history of a client with occupational lung disease (silicosis). The nurse
would ask the client whether the client wears which item during periods of exposure to silica particles?
Mask
Gown
Gloves
Eye protection

73 The nurse is reviewing the laboratory test results for a client and notes that the serum sodium level
is 150 mEq/L (150 mmol/L). The nurse understands that this value would be noted in which condition?
Heart failure
Addison's disease
A severe burn injury
Adrenal insufficiency

74 The emergency department nurse is assessing a client with suspected appendicitis with complaints
of right lower quadrant pain, nausea, vomiting, and anorexia. Which diet orders would the nurse
anticipate?
Regular diet
Full liquid diet
Clear liquid diet
Nothing by mouth (NPO)

75 The nurse is preparing a client with depression for electroconvulsive therapy, which is scheduled
for the next morning. Which interventions would be included in the preprocedural plan? Select all that
apply.
Have the client void.
Obtain an informed consent.
Administer tap water enemas.
Avoid discussing the procedure.
Remove dentures and contact lenses.
Withhold food and fluids for 6 hours.