Fundamentals
A client is scheduled for surgery. The nurse should:
A. Encourage smoking until day of surgery
B. Verify informed consent is signed
C. Withhold all medications the morning of surgery
D. Encourage the client to eat a heavy meal
Answer: B
Rationale: Confirming informed consent is the nurse's responsibility before surgery
Which fetal heart rate pattern would require immediate intervention during labor?
A. Early decelerations
B. Variable decelerations
C. Accelerations
D. Late decelerations
Answer: D
Rationale: Late decelerations indicate uteroplacental insufficiency and require immediate nursing intervention.
A 6-month-old is admitted with gastroenteritis and has sunken fontanelles and dry mucous membranes. What should the nurse expect?
A. Administer oral fluids
B. Begin IV rehydration
C. Give antidiarrheals
D. Encourage fruit juices
Answer: B
Rationale: Signs of moderate to severe dehydration require IV fluids for rehydration.
A client with type 2 diabetes has cool, clammy skin and is confused. What is the priority action?
A. Administer glucagon
B. Give juice or glucose
C. Check blood sugar
D. Call the provider
Answer: B
Rationale: Hypoglycemia signs—treat immediately with quick-acting carbohydrates before checking BG.
A client is prescribed digoxin. Which vital sign must be checked before administration?
A. Respiratory rate
B. Apical pulse
C. Blood pressure
D. Temperature
Answer: B
Rationale: Digoxin slows the heart rate. Apical pulse should be checked; hold if <60 bpm (adult).
What is the priority nursing action if a client suddenly becomes unresponsive?
A. Call a code or rapid response
B. Check for pulse and breathing
C. Start chest compressions immediately
D. Give oxygen
Answer: B
Rationale: Confirm airway, breathing, and circulation before further actions.
Which finding in a 12-hour-old newborn should be reported to the provider?
A. Respiratory rate of 58
B. Blood glucose of 35 mg/dL
C. Positive rooting reflex
D. Acrocyanosis
Answer: B
Rationale: A blood glucose <40 mg/dL in a newborn indicates hypoglycemia and requires intervention.
What is the best site for an IM injection in a 9-month-old?
A. Deltoid
B. Dorsogluteal
C. Vastus lateralis
D. Abdomen
Answer: C
Rationale: Vastus lateralis is safest for infants under 12 months.
A client with a head injury has clear drainage from the nose. What action is most appropriate?
A. Test for glucose
B. Wipe away drainage frequently
C. Apply pressure
D. Place on oxygen
Answer: A
Rationale: Clear drainage may be CSF—test for glucose to confirm possible skull fracture.
Which of the following is a common side effect of opioids like morphine?
A. Diarrhea
B. Insomnia
C. Constipation
D. Increased respirations
Answer: C
Rationale: Opioids slow gastrointestinal motility, often causing constipation.
Which vital sign change is concerning in a post-op client?
A. BP 130/80
B. HR 120
C. Temp 98.6°F
D. RR 18
Answer: B
Rationale: Tachycardia may indicate pain, bleeding, or infection post-op—needs assessmen
A nurse is caring for a client who delivered 1 hour ago. Which finding requires immediate attention?
A. Saturating a perineal pad in 10 minutes
B. Small blood clots on the pad
C. Fundus firm and at the umbilicus
D. Chills and shivering
Answer: A
Rationale: Heavy bleeding (pad saturated in 10 minutes) is a sign of postpartum hemorrhage and must be addressed urgently.
A child with epiglottitis is drooling and sitting in tripod position. What is the priority nursing action?
A. Start IV antibiotics
B. Prepare for intubation
C. Suction the airway
D. Administer nebulized epinephrine
Answer: B
Rationale: Drooling and tripod position suggest airway obstruction. Prepare for intubation—do not examine throat.
A client with a DVT is started on heparin. What lab result should be monitored?
A. INR
B. Platelet count
C. aPTT
D. Hemoglobin
Answer: C
Rationale: aPTT is used to monitor heparin’s effectiveness and safety.
A client taking warfarin (Coumadin) reports eating spinach daily. What is the nurse's best response?
A. "Spinach helps your body recover, continue as usual."
B. "Green leafy vegetables help thin the blood."
C. "You should avoid green leafy vegetables completely."
D. "Spinach is high in vitamin K and can decrease the effectiveness of your medication."
Answer: D
Rationale: Vitamin K can antagonize the effects of warfarin, decreasing its effectiveness.
5. While taking an adult patient's pulse, a nurse finds the rate to be 140 beats/min. What should the nurse do next?
a. Check the pulse again in 2 hours.
b. Check the blood pressure.
c. Record the information.
d. Report the rate to the primary care provider.
Answer : D
A rate of 140 beats/min in an adult is an abnormal pulse and should be reported to the primary care provider or the nurse in charge of the patient.
Which assessment finding in a 2-day postpartum client should be reported?
A. Uterus firm and midline
B. Lochia rubra with small clots
C. Fundus deviated to the right
D. Mild uterine cramping while breastfeeding
Answer: C
Rationale: A deviated fundus often indicates a full bladder, and can cause bleeding
What vaccine is contraindicated in a child with a severe egg allergy?
A. DTaP
B. Hepatitis B
C. MMR
D. Influenza (live attenuated)
Answer: D
Rationale: Live attenuated flu vaccines may be contraindicated with egg allergy. MMR is generally safe unless severe anaphylaxis.
A client has a potassium level of 2.8 mEq/L. What is the most appropriate intervention?
A. Encourage potassium-rich foods
B. Administer IV potassium slowly
C. Hold all diuretics
D. Administer oral sodium
Answer: B
Rationale: Severe hypokalemia (<3.0) requires IV potassium replacement under monitoring.
Which medication requires the nurse to monitor the client for cough, hyperkalemia, and hypotension?
A. Furosemide
B. Lisinopril
C. Metoprolol
D. Amlodipine
Answer: B
Rationale: Lisinopril is an ACE inhibitor; common side effects include dry cough and increased potassium levels.
The nurse assesses clients' breath sounds. Which one requires immediate medical attention? A client who has:
1) Crackles
2) Rhonchi
3) Stridor
4) Wheezes
Answer:
3) Stridor
Rationale:
Stridor is a sign of respiratory distress, possibly airway obstruction. Crackles and rhonchi indicate fluid in the lung; wheezes are caused by narrowing of the airway. Crackles, rhonchi, and wheezes indicate respiratory illness and are potentially serious but do not necessarily indicate respiratory distress that requires immediate medical attention.
A client is in active labor. Which fetal heart rate (FHR) change requires immediate action?
A. Baseline of 140 bpm
B. Accelerations with movement
C. Variable decelerations
D. Moderate variability
Answer: C
Rationale: Variable decelerations suggest cord compression and require interventions like repositioning.
What is the best method to give oral medication to a 15-month-old?
A. In a bottle of milk
B. Mixed with applesauce
C. Use a calibrated oral syringe
D. Ask child to take from a spoon
Answer: C
Rationale: An oral syringe provides accurate dosing and is safe for young children.
A client with liver cirrhosis is confused and drowsy. What lab value supports this finding?
A. Elevated bilirubin
B. High ammonia level
C. Low albumin
D. Elevated ALT
Answer: B
Rationale: High ammonia causes hepatic encephalopathy, leading to confusion and CNS depression.
A client prescribed morphine sulfate for pain has a respiratory rate of 8/min. What is the priority action?
A. Reassess in 30 minutes
B. Administer oxygen
C. Administer naloxone
D. Elevate the head of the bed
Answer: C
Rationale: Respiratory depression is a life-threatening adverse effect of opioids. Naloxone is the antidote.