Adult Health
Mental Health
Child Health
Critical Care
Maternal & Newborn Health
100
The nurse is reviewing the laboratory results of a client with renal failure. Which laboratory data requires immediate follow-up?
A. Blood urea nitrogen 50 mg/dL [10-20 mg/dL]
B. Serum potassium 6 mEq/L (mmol/L) [3.5-5.0 mEq/L]
C. Arterial blood pH 7.30 [7.35-7.45]
D. Hemoglobin 10.3 g/dL (1.03 g/L) [F: 12-16 g/dL (7.4 -9.9 mmol/L) M: 14-18 g/dL (8,7-11.2 mmol/L)]
B. Serum potassium 6 mEq/L (mmol/L) [3.5-5.0 mEq/L]
100
The nurse is caring for a client in the emergency department (ED) experiencing delirium tremens. The nurse should take which initial action?
A. assess the client's pain level
B. implement seizure precautions
C. obtain a prescription for chlordiazepoxide
D. assess the client using the Glasgow Coma Scale (GCS)
B. implement seizure precautions
100
The nurse is caring for a client receiving digoxin. It would be a priority for the nurse to monitor the client's
A. potassium.
B. calcium.
C. sodium.
D. phosphorus.
A. Potassium
100
The nurse is reviewing the arterial blood gas (ABG) of a client. Which of the following is the correct interpretation for the ABG?
- pH: 7.59
- PCO2: 30
- HCO3: 24
A. Metabolic acidosis
B. Respiratory acidosis
C. Metabolic alkalosis
D. Respiratory alkalosis
D. respiratory alkalosis
100
The nurse is caring for a client who delivered a set of twins one hour ago via Cesarean section. What are the expected findings during the fundal assessment?
A. The fundus is hard, midline, and 1-2 fingerbreadths above the umbilicus
B. The fundus need not be assessed because of the C-section
C. The fundus is to the right of the umbilicus and soft
D. The fundus is hard, midline, and at the level of the umbilicus
D. The fundus is hard, midline, and at the level of the umbilicus
200
The occupational health nurse was called to see a client who sustained injuries from a light bulb explosion. On assessment, the nurse notes that a piece of glass was lodged in the client's eye. The initial nursing intervention should be which of the following?
A. Attempt to carefully remove the glass from the eye
B. Reassure the client that everything is okay
C. Administer a sedative for pain relief
D. Advise the client to remain in a sitting position until a specialist arrives
D. Advise the client to remain in a sitting position until a specialist arrives
200
A client is scheduled to undergo electroconvulsive therapy (ECT). The nurse understands which of the following actions must be performed before the client's electroconvulsive therapy (ECT) procedure?
A. Assess the client for contrast dye allergy
B. Administer an anticonvulsant medication
C. Apply a blood pressure cuff to the client
D. Check if the client is currently on metformin
C. Apply a blood pressure cuff to the client
200
The nurse encounters an infant with irritability from acute otitis media while working in the pediatric clinic. The nurse should know that the infant is at much higher risk than an adult for otitis media due to which of the following?
A. Immature cardiac sphincter
B. Feeding in a semi-Fowler position
C. Introduction of solid foods
D. Narrower, shorter, and more horizontal Eustachian tubes
D. Narrower, shorter, and more horizontal Eustachian tubes
200
The intensive care unit (ICU) nurse is caring for a client with septic shock. The assessment shows bleeding from the peripheral intravenous site, gum bleeding, and hematuria. Based on the assessment, the nurse should take which action?
A. Assess if the client is receiving heparin products
B. Review the client's most recent lactic acid level
C. Assess the client's oxygen saturation
D. Notify the primary healthcare provider (PHCP)
D. Notify the primary healthcare provider (PHCP)
200
You are a nurse in the L&D department of the local hospital. You are caring for a newborn born at term with APGAR scores of 8 and 10. Before discharge from the hospital, you should ensure that the newborn has received:
A. Hep A (hepatitis A) vaccine
B. Hep B (hepatitis B) vaccine
C. RV (Rotovirus) vaccine
D. DTaP (diphtheria, tetanus, and pertussis) vaccine
B. Hep B (hepatitis B) vaccine
300
The nurse is caring for a client with type 1 diabetes mellitus who develops hyperglycemia between 5:00 and 6:00 AM as a result of the nighttime release of growth hormone. The nurse should recognize that this condition is consistent with...
A. dawn phenomenon.
B. Somogyi effect.
C. hyperosmolar hyperglycemic syndrome (HHS).
D. diabetic ketoacidosis (DKA).
A. Dawn Phenomenon
300
The nurse is caring for a client who is experiencing psychosis. The client states, "You all are trying to kill me!" Which of the following responses would be most appropriate for the nurse to make to the client?
A. “What you are experiencing is not real.”
B. “Are you hearing voices?”
C. "You are safe here, please be calm.”
D. “What makes you think we are trying to kill you?”
D. "What makes you think we are trying to kill you?"
300
The nurse is working with a child who has a learning disability. The child is ten years old and has trouble reading and interpreting words, letters, and symbols. What is the most likely diagnosis?
A. Phonologic processing deficit
B. Dyslexia
C. Tourette’s syndrome
D. Apraxia
B. Dyslexia
300
The nurse is caring for a client receiving mechanical ventilation with positive end-expiratory pressure (PEEP). The nurse should monitor the client for which complication?
A. Decreased mean arterial pressure (MAP)
B. Increased preload
C. Increased partial pressure of oxygen
D. Increased gas exchange
A. Decreased mean arterial pressure (MAP)
300
A client presents to the obstetrics floor at 39 weeks gestation with irregular contractions. After you get the client situated in a labor, delivery, and recovery room, you notice the client's health care provider (HCP) enter the room to evaluate the client. Following the evaluation, the HCP exits the room, and shortly there after, you enter. During your discussion, the client states the HCP "went to order oxytocin." In anticipation of that order, you understand this client's oxytocin will be administered via which route of administration?
A. Intramuscular administration
B. Intravenous administration via mainline infusion using an infusion pump
C. Intravenous administration via piggyback using an infusion pump
D. Oral administration
C. Intravenous administration via piggyback using an infusion pump
400
An emergency department nurse is taking care of a 68-year-old female after she fell. The paramedics said that she was on the bathroom floor for approximately 10 hours. The nurse is straight catheterizing the patient for a urine sample when she notices the amount of urine reaches 800 mL. The urine is still flowing heavily. What action should the nurse take and why?
A. Drain the patient’s bladder entirely and place a small amount in a urine specimen cup. This patient needs a urine sample to check for rhabdomyolysis.
B. Continue draining the bladder fully, then place a Foley catheter to monitor for sufficient urine output.
C. Stop draining the patient’s bladder because the patient is at risk for developing bladder spasms.
D. Stop draining the patient’s bladder and consult the physician for further instructions.
C. Stop draining the patient’s bladder because the patient is at risk for developing bladder spasms.
400
An LPN is working in a group home for adolescents who are recovering from substance abuse. She is assigned to work with a 16-year-old girl who is trying to quit smoking marijuana. While talking with the girl, she uses motivational interviewing to help her work towards her goals. Which of the following statements by the LPN would be the best?
A. “Would it be alright if we talk about your pot use now?”
B. “What good things do you have going for you in your life?”
C. “What changes can you make in your marijuana use this week?”
D. “Who can help you quit marijuana?”
C. "What changes can you make in your marijuana use this week?"
400
A 12-year-old child is scheduled for an appendectomy. The child’s mother has already signed the consent form and the child is about to be wheeled by the nurse to the operating room when her father arrives. It is made known to the nurse that the child’s parents are divorced and have joint legal custody. Which action by the nurse is most appropriate?
A. Have the father sign a new consent form.
B. Cancel the operation.
C. Proceed with the child’s operation.
D. Notify the physician.
C. Proceed with the child's operation
400
The nurse is planning a staff development conference about mechanical ventilator modes. Which of the following information should the nurse include?
A. Assist-control allows spontaneous breathing at the client's rate and tidal volume between the ventilator breaths
B. Synchronized intermittent mandatory ventilation applies positive airway pressure throughout the respiratory cycle to prevent alveolar collapse
C. Pressure support ventilation delivers a set airway pressure and is used for spontaneously breathing clients
D. Continuous positive airway pressure is used to provide full ventilator support for clients not taking spontaneous breaths
C. Pressure support ventilation delivers a set airway pressure and is used for spontaneously breathing clients
400
The nurse is caring for a newborn immediately following birth. Which of the following actions by the nurse will prevent radiant heat loss in the newborn?
A. Drying the newborns skin with a towel
B. Placing the newborn on a padded, covered surface
C. Using warmed, humidified oxygen
D. Positioning the bassinet away from windows
D. Positioning the bassinet away from windows
500
The nurse reviews the client's continuous telemetry monitor and observes the following. As the nurse reviews the client's current medications, which prescribed medication is most likely causing this tracing? See the image below.
A. Losartan
B. Nitroglycerin transdermal patch
C. Enalapril
D. Verapamil
D. Verapamil
500
While rounding in the mental health unit, you are learning about specific phobias. You should be aware that ailurophobia is an unreasonable fear of:
A. Social interactions
B. Clowns
C. Crowds
D. Cats
D. Cats
500
The nurse is caring for an infant with the below tracing on the electrocardiogram (ECG). The nurse should plan to take which initial action? See the image below.
A. Instruct the infant to beardown.
B. Prepare a bag filled with ice and water.
C. Assess the infant's axillary temperature.
D. Obtain the infant's carotid pulse.
B. Prepare a bag filled with ice and water
500
The nurse is caring for a client who recently had an arterial blood gas (ABG) drawn. The nurse knows that the following ABG:
pH 7.44, CO2 52, HCO3 42 would be interpreted as:
A. Compensated metabolic alkalosis
B. Uncompensated metabolic acidosis
C. Compensated respiratory acidosis
D. Uncompensated respiratory alkalosis
A. Compensated metabolic alkalosis
500
The nurse is screening clients at risk of sudden infant death syndrome (SIDS). The nurse correctly identifies which client is at the highest risk for SIDS? An infant who is:
A. a preterm 4-month-old female who sleeps supine and is formula fed
B. a preterm 12-month-old male who sleeps prone and is formula fed
C. a term 6-month-old male who sleeps supine and is formula fed
D. a preterm 3-month-old male who sleeps lateral and is breastfed
D. A preterm 3-month-old male who sleeps lateral and is breastfed