1. nurse is caring for a school-age child who has sickle-cell anemia
and is experiencing a vaso-occlusive crisis. Which of the following actions should the nurse take? A. Place the child on bed rest. B. Decrease the child's oral fluid intake. C. Administer meperidine to the child. D. Apply cold compresses to the child's joints. 2. A charge nurse is reinforcing teaching with a newly hired licensed practical nurse about scope of practice. Which of the following responsibilities should the nurse include in the teaching?a. Coordinating care b. Providing direct client care c. Assessing a client's health status d. Providing a client with discharge instructions. 3. A nurse Is planning care for a client who has anorexia nervosa and is admitted to an inpatient eating disorder unit. Which of the following is an appropriate intervention? a. Use systematic desensitization to address the client's fears regarding weight gain b. Allow the client to select meal times c. Initiate a relationship built on trust with the client d. Negotiate with the client the opportunity to reweigh. 4. A nurse is admitting a client who is scheduled for an elective surgery. Which of the following actions should the nurse take to verify the status of the client's advance directives? A) Ask the client whether they have advance directives. B) Refer to the client's identification card for the advance directives status. C)Verify the client's advance directives with their health care surrogate. D) Check for a written do not resuscitate prescription in the client's medical record . 5. A nurse is reinforcing discharge teaching with a client who has type 1 diabetes mellitus. Which of the following client statements indicates an understanding of the teaching? A)"I will dispose of insulin needles in a puncture-proof container.". B) I will store opened insulin vials in my refrigerator." C) I will shake the insulin vial before drawing it into the syringe." D) I will expect my regular insulin to appear cloudy. 6. A nurse is contributing to the plan of care for a newborn who is experiencing heroin withdrawal. The nurse should anticipate a prescription for which of the following medications?A) Methadone b) Meperidine c) Hydromorphone d) Fentanyl. 7. A nurse is reinforcing teaching with a client who was diagnosed with diabetes mellitus and requires insulin injections. Which of the following client statements indicates an understanding of the teaching? A) should dispose of my used syringes in the household trash."B ) I will store my current bottle of insulin in the refrigerator."c) "I will hold the needle at a 15° angle to my skin." D) I should use an injection site that is 1 inch from the previous site." 8. A nurse is collecting data from a newly admitted client. Which of the following questions should the nurse ask to assess the client's abstract thinking ability? A) "Who is the current President of the United States?" B ) What does the phrase 'butterflies in my stomach' mean?" "C ) Can you count backward from 20 to 1?" D) Can you draw a clock that shows the hands at 4:30?". 9. A nurse is collecting health history data from a client who has hemorrhoids. Which of the following findings should the nurse expect?A) Chronic constipation b)Excessive dflatulence c) Frequent stools d) Fecal incontinence. 10. A nurse is reviewing client care assignments prior to the beginning of a shift. Which of the following client assignments should the nurse identify as being outside the scope of practice for an LPN? A) A client who has a new onset of chest pain B) A client who has a tracheostomy C)A client who is receiving enteral feedings d)A client who has urinary retention. 11. A nurse is providing preoperative teaching for an adolescent who is scheduled for a cardiac catheterization. Which of the following instructions should the nurse include? A) "You can resume a regular diet 3 days after your procedure." B) "You can take a shower 1 day after your procedure." C) "You can begin exercising 2 days after your procedure." D) "You can return to school 1 week after your procedure." 12. A nurse has obtained a client's oxygen saturation measurement of 88% on 2 liters of oxygen via nasal cannula. Which of the following actions should the nurse take? A) Check the client's heart rate on the oximeter. B) Compare the result with the baseline reading. C) Decrease the amount of oxygen administered. D) Perform another reading while the client ambulates. 13. A nurse is caring for a newborn following a circumcision. Which of the following manifestations indicates the newborn is experiencing pain? A) Lip smacking B) Diaphoresis C) Hypoglycemia D)Transient strabismus. 14. A nurse is reinforcing teaching with a school-age child who has hemophilia about participating in school sports. Which of the following sports should the nurse recommend for the child? (Select all that apply.) A) Soccer b) Basketball c) Gymnastics d)Golf e) Swimming. 15. A nurse is caring for a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following actions should the nurse take? A) Monitor the client's vital signs every 8 hr. B) Reposition the endotracheal tube every 12 hr. C)Place the client in a supine position. D)Perform oral care every 2 hr. 16. A nurse is preparing to remove a peripheral IV for a preschooler. In which order should the nurse complete the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)● Turn off the IV infusion pump and clamp the IV tubing.● Allow the preschooler to assist with removing the transparent dressing over the IV. ● Remove the IV catheter while keeping the catheter hub parallel to the insertion site. ● Inspect the IV catheter tip. ● Apply firm pressure at the IV site. 17. A nurse is assisting with developing a discharge plan for a client who has a new diagnosis of diabetes mellitus. The client is independent and lives alone. Which of the following interventions should the nurse plan to include? A)Provide the client with 1 week's supply of insulin syringes. B)Arrange for a home health nurse to visit the client daily. C) Notify the family of the client's health status. D)Refer the client to a diabetic support group. 18. A nurse is observing an assistive personnel (AP) apply antiembolic stockings for a client. The nurse should identify that which of the following actions by the AP indicates an understanding of the procedure?A)Elevates the client's legs before applying the stockings B) Instructs the client to dorsiflex their feet while applying the stockings C) Massages the client's legs before applying the stockings. D) Folds the top of the stockings over after applying them. 19. A nurse is caring for a client who had a transurethral resection of the prostate and now is receiving continuous bladder irrigation. Which of the following actions should the nurse take? (Select all that apply.) A)Document urine color. B)Monitor the client for reports of bladder spasms. C) Check the drainage tubing for obstructions. D)Maintain the client in a left side-lying position. E) Use clean technique for intermittent irrigation. 20. A nurse is caring for a client who is using a non-rebreather mask for oxygen delivery. The nurse should identify which of the following as an indication that the equipment is functioning properly? A) Air is heard escaping from around the mask. B)The flow control meter dial is at the correct setting.C) The attached reservoir bag is inflated. D)The exhalation ports are covered during inspiration and expiration. 21. A nurse is reinforcing teaching about complete and incomplete proteins with a client who has a prescription for a high-protein diet. The nurse should identify which of the following foods as sources of complete proteins? (Select all that apply.) A)Salmon B)Hard-boiled eggs C)Cottage cheese D)Whole wheat bread E) Steamed spinach. 22. A nurse in an urgent care clinic is collecting data from a client who reports having diarrhea for the past 3 days. Which of the following findings indicates hypokalemia? A) Pitting edema B)Diplopia C) Muscle weakness D) Hyperactive bowel sounds. 23. A nurse is collecting data from a client who has a gastrostomy tube and is experiencing diarrhea. Which of the following factors should the nurse identify as a potential cause of the diarrhea? A)The formula infusion rate of the feeding was too slow. B)The formula was given immediately following removal from the refrigerator.C) The feeding tube was partially obstructed during the infusion. D)The client is experiencing delayed gastric emptying. 24. A nurse is caring for an adolescent who has an allergy to penicillin. Which of the following prescriptions should the nurse clarify with the provider? A)Doxycycline B)Vibramycin C) Cefazolin D)Gentamicin. 25. A nurse is caring for an infant who is drinking a cow's milk formula and has bloody stools. Which of the following recommendations should the nurse make to the infant's guardian? A)Switch to a soy-based formula. B)Switch to a goat's milk formula. C)Switch to an unpasteurized milk formula. D) Switch to a condensed milk formula. 26. A nurse is reinforcing teaching about a safety plan for a client who reports partner violence. Which of the following instructions should the nurse include? A)"Call a shelter in another county." B)Leave your partner immediately." "C)Keep a packed bag by your front door." D)Rehearse your escape route." 27. A nurse is collecting data from a client who has asthma. Which of the following prescribed medications should the nurse administer first for severe wheezing? A)Bronchodilators B)Beta blocker C)Inhaled steroids D) Anti‐inflammatory agent. 28. A nurse is reinforcing discharge teaching about limiting sodium intake with a client who has a new diagnosis of cardiomyopathy. Which of the following client responses indicates an understanding of the teaching? A)I can have mustard on my sandwiches." B) I can season foods with celery salt." C) I can have a frozen juice bar for dessert." D) I can drink vegetable juice with my meals." 29. A nurse is reinforcing teaching with the guardian of a preschooler who has a new diagnosis of enterobiasis. Which of the following information should the nurse include in the teaching? A) One dose of medication is all that will be necessary." B) Everyone who lives in the home will need medication." C) Allow the child to take tub baths instead of showers." D) Wash all clothes and bed linens in cold water." 30. A nurse is reinforcing teaching about confidentiality with a client. Which of the following statements should the nurse include in the teaching? A)Your nurse will provide information about the risks and benefits of surgical procedures." B)Only health care staff providing care will see your medical record." C) The provider must grant you access to your personal health information." D)You have to authorize our providers to prescribe treatments for your condition. 31. A nurse is caring for a client who has a cast on their left lower leg. Which of the following actions should the nurse take? A) Massage areas around the edge of the client's cast with lotion. B) Avoid elevating the extremity when the client is resting in bed. C) Give the client a dull object to scratch the skin under the cast. D)Tell the client to expect numbness in their toes. 32. A nurse is collecting a sputum specimen from a client for culture and sensitivity. Which of the following actions should the nurse take?A) Collect 2 mL of sputum in an emesis basin. Instruct the client to rinse with an antiseptic.B) mouthwash prior to specimen collection. C) Swab the oropharynx with a sterile swab. D) Refrigerate the specimen until the time of transport to the laboratory. 33. A nurse is reviewing the medical record for a client who is at 38 weeks of gestation, tested positive for group B streptococcus ß-hemolytic, and is allergic to penicillin. The nurse should identify that which of the following medications is contraindicated for this client? 1. Ampicillin 2.Erythromycin 3.Cefazolin 4.Clindamycin. 34. A nurse is preparing to insert a nasogastric tube for a client who has a prescription for gastric decompression. Which of the following supplies should the nurse obtain prior to the procedure? A) Oil-based lubricant B)Enteric feeding C)pump Sterile gloves D)pH strips. 35. A nurse is assisting with the care of an adolescent who is scheduled for surgery. Which of the following actions should the nurse plan to take?A) Provide a tour of the perioperative area prior to surgery. B)Explain that anesthesia is a special type of sleep. C) Wait until after surgery to explain the importance of coughing and deep breathing. D) Keep medical equipment out of the client's sight.
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