1 >>A patient is agitated and continues to try to get out of bed. The nurse tries unsuccessfully to reorient him. What should the nurse do next? ?
- (A) Apply a vest restraint.
- (B) Move the patient to a quieter room
- (C) Ask another nurse to care for the patient.
- (D) Provide comfort measures.
2 >>The nurse is teaching a child and family about firearm safety. The nurse should instruct the child to take which step first if he sees a gun at a friend’s house? ?
- (A) Leave the area.
- (B) Do not touch the gun.
- (C) Stop where he is.
- (D) Tell an adult
3 >>Which factor(s) in the patient’s past medical history place(s) him at risk for falling? Select all that apply. ?
- (A) Orthostatic hypotension
- (B) Appendectomy
- (C) Dizziness
- (D) Orthostatic hypotension and Dizziness
4 >>During a presentation at a nursing staff meeting, the unit manager speaks very slowly with a monotone. She uses medical and technical terminology to convey her message. Dressed in business attire, the manager stands erect and smiles occasionally while speaking. Which elements of her approach are likely to cause the staff to lose interest in what she has to say? Select all answers that apply. ?
- (A) Slow speech
- (B) Monotone
- (C) Slow speech and Monotone
- (D) Formal dress
5 >>A mother comes to the emergency department after receiving a phone call informing her that her son was involved in a motor vehicle accident. When she approaches the triage desk, she frantically asks, “How is my son?” Which response by the nurse is best? ?
- (A) “He’s being examined now; he’s awake and talking. We’ll take you to see him soon.”
- (B) “Don’t worry, I’m sure he’ll be fine; we have an excellent trauma team caring for him.”
- (C) “Everything will be okay; please take a seat and I’ll check on him for you.”
- (D) “Your son is strong and has youth on his side; I’m sure he’ll be fine.”
6 >>A local church organizes a group for people who are having difficulty coping with the death of a loved one. Which type of group has been organized? ?
- (A) Work-related social support group
- (B) Therapy group
- (C) Task group
- (D) Community committee
7 >>A patient is admitted to the medical surgical floor with a kidney infection. The nurse introduces herself to the patient and begins her admission assessment. Which goal is most appropriate for this phase of the nurse-patient relationship? The patient will be able to: ?
- (A) Describe how to operate the bed and call for the nurse.
- (B) Discuss communication patterns and roles within the family.
- (C) Openly express his concerns about the hospitalization.
- (D) State expectations related to discharge.
8 >>The nurse suspects that a patient is being physically abused at home. What is the best environment in which to discuss the possibility of abusive events? ?
- (A) The patient’s shared semiprivate room
- (B) The hallway outside the patient’s room
- (C) An empty corner at the nurse’s station
- (D) A conference room at the end of the hall
9 >>Which situation requires intrapersonal communication? ?
- (A) Staff meetings
- (B) Positive self-talk
- (C) Shift report
- (D) Wound care committee meeting
10 >>Which of the following clients should have an apical pulse taken? A client who is: ?
- (A) Febrile and has a radial pulse of 100 bpm
- (B) A runner who has a radial pulse of 62 bpm
- (C) An infant with no history of cardiac defect
- (D) An elderly adult who is taking antianxiety medication
11 >>Which of the following clients would have the most difficulty maintaining thermoregulation? ?
- (A) Young child playing soccer during the summer
- (B) Middle-aged adult snow skiing
- (C) Young adult playing golf on a hot day
- (D) Older adult raking leaves on a cold day
12 >>A client who has experienced prolonged exposure to the cold is admitted to the hospital. Which method of taking a temperature would be most appropriate for this client? ?
- (A) Axillary with an electronic thermometer
- (B) Oral with a glass thermometer
- (C) Rectal with an electronic thermometer
- (D) Tympanic with an infrared thermometer
13 >>Which of the following clients has indications of orthostatic hypotension? A client whose blood pressure is: ?
- (A) 118/68 when standing and 110/72 when lying down
- (B) 140/80, HR 82 bpm when sitting and 136/76, HR 98 bpm when standing
- (C) 126/72 lying down and 133/80 when sitting, and reports shortness of breath
- (D) 146/88 when lying down and 130/78 when standing, and reports feeling dizzy
14 >>The nurse assesses the client’s pedal pulses as having a pulse volume of 1 on a scale of 0 to 3. Based on this assessment finding, it would be important for the nurse to also assess the: ?
- (A) Pulse deficit
- (B) Blood pressure
- (C) Apical pulse
- (D) Pulse pressure
15 >>The nurse assesses clients’ breath sounds. Which one requires immediate medical attention? A client who has: ?
- (A) Crackles
- (B) Rhonchi
- (C) Stridor
- (D) Wheezes
16 >>Which of the following clients is experiencing an abnormal change in vital signs? ?
- (A) Blood pressure (BP) was 132/80 mm Hg sitting and is 120/60 mm Hg upon standing
- (B) Rectal temperature is 97.9°F in the morning and 99.2°F in the evening
- (C) Heart rate was 76 before eating and is 60 after eating
- (D) Blood pressure (BP) was 132/80 mm Hg sitting and is 120/60 mm Hg upon standing and Heart rate was 76 before eating and is 60 after eating
17 >>A client who is receiving epidural analgesia complains of nausea and loss of motor function in his legs. The nurse obtains his blood pressure and notes a drop in his blood pressure from the previous reading. Which complication is the patient most likely experiencing? ?
- (A) Infection at the catheter insertion site
- (B) Side effect of the epidural analgesic
- (C) Epidural catheter migration
- (D) Spinal cord damage
18 >>Ibuprofen (Motrin) ?
- (A) Celecoxib (Celebrex)
- (B) Aspirin (Ecotrin)
- (C) Indomethacin (Indocin)
- (D) Celecoxib (Celebrex)
19 >>The nurse administers codeine sulfate 30 mg orally to a patient who underwent craniotomy 3 days ago for a brain tumor. How soon after administration should the nurse reassess the patient’s pain? ?
- (A) Immediately
- (B) In 10 minutes
- (C) In 15 minutes
- (D) In 60 minutes
20 >>Which action should the nurse take when preparing patient-controlled analgesia for a postoperative patient? ?
- (A) Caution the patient to limit the number of times he presses the dosing button.
- (B) Ask another nurse to double-check the setup before patient use.
- (C) Instruct the patient to administer a dose only when experiencing pain.
- (D) Provide clear, simple instructions for dosing if the patient is cognitively impaired.