Question #1. The nurse has just received shift report and is preparing to make rounds. Which client should be seen first?
A. The client who has a history of a cerebral aneurysm with an oxygen saturation rate of 99%
B. The client who was admitted 1 hour ago with shortness of breath
C. The client who is three days post–coronary artery bypass graft with a temperature of 100.2°F
D. The client who is being prepared for discharge following a femoral popliteal bypass graft
Answer B is correct. The client admitted 1 hour ago with shortness of breath should be seen first because this client might require oxygen therapy. The client in answer A with a low-grade temperature can be assessed after the client with shortness of breath. The client in answer C can also be seen later. This client will have some
Question #2. The client has an order for heparin to prevent post-surgical thrombi.
Immediately following a heparin injection, the nurse should:
A. Aspirate for blood
B. Check the pulse rate
C. Massage the site
D. Check the site for bleeding
Answer D is correct. After administering any subcutaneous anticoagulant, the nurse should check the site for bleeding. Answers A and C are incorrect because aspirating and massaging the site are not done. Checking the pulse is not necessary, as in answer B.
Question #3. The nurse is assisting in the care of a patient with diverticulosis. Which of the following assessment findings would necessitate a report to the doctor?
A. Bowel sounds of 5–20 seconds
B. Intermittent left lower-quadrant pain
C. Constipation alternating with diarrhea
D. Hemoglobin 26% and hematocrit 32
Answer D is correct. Low hemoglobin and hematocrit might indicate intestinal bleeding. Answers A, B, and C are normal lab values.
Question #4. The nurse is assessing the abdomen. The nurse knows the best sequence to perform the assessment is:
A. Palpation, inspection, auscultation
B. Auscultation, palpation, inspection
C. Inspection, auscultation, palpation
D. Inspection, palpation, auscultation
Answer C is correct. The nurse should inspect first, then auscultate, and finally palpate. If the nurse palpates first the assessment might be unreliable. Therefore, answers A, B, and D are incorrect.
Question #5. The nurse is making assignments for the day. Which client should be assigned to the nursing assistant?
A. The 18-year-old with a fracture to two cervical vertebrae
B. The infant with meningitis
C. The elderly client with a thyroidectomy 4 days ago
D. The client with a thoracotomy 2 days ago
Answer C is correct. The most stable client is the client with the thyroidectomy 4 days ago. Answers A, B, and D are incorrect because the other clients are less stable and require a registered nurse.
Question #6. The client is admitted to the postpartum unit with an order to continue the infusion of Pitocin. Which finding indicates that the Pitocin is having the desired effect?
A. The fundus is deviated to the left.
B. The fundus is firm and in the midline.
C. The fundus is boggy.
D. The fundus is two finger breadths below the umbilicus.
Answer B is correct. Pitocin is used to cause the uterus to contract and decrease
bleeding. A uterus deviated to the left, as stated in answer A, indicates a full bladder. It is not desirable to have a boggy uterus, making answer C incorrect. This lack of muscle tone will increase bleeding. Answer D is incorrect because the position of the uterus is not related to the use of Pitocin.
Question #7. A 70-year-old male who is recovering from a stroke exhibits signs of unilateral neglect. Which behavior is suggestive of unilateral neglect?
A. The client is observed shaving only one side of his face.
B. The client is unable to distinguish between two tactile stimuli presented simultaneously.
C. The client is unable to complete a range of vision without turning his head side to side.
D. The client is unable to carry out cognitive and motor activity at the same time.
Answer A is correct. The client with unilateral neglect will neglect one side of the body. Answers B, C, and D are not associated with unilateral neglect.
Question #8. The nurse is assigned to care for an infant with physiologic jaundice. Which action by the nurse would facilitate elimination of the bilirubin?
A. Decreasing caloric intake
B. Maintaining the infant’s body temperature at 98.6°F
C. Minimizing tactile stimulation
D. Increasing the infant’s fluid intake
Answer D is correct. Bilirubin is excreted through the kidneys, thus the need for increased fluids. Maintaining the body temperature is important but will not assist in eliminating bilirubin; therefore, answer B is incorrect. Answers A and C are incorrect because they do not relate to the question.
Question #9. A 24-year-old female client is scheduled for surgery in the morning. Which of the following is the primary responsibility of the nurse?
A. Taking the vital signs
B. Obtaining the permit
C. Explaining the procedure
D. Checking the lab work
Answer A is correct. The primary responsibility of the nurse is to take the vital signs before any surgery. The actions in answers B, C, and D are the responsibility of the doctor and, therefore, are incorrect for this question.
Question #10. The doctor orders 2% nitroglycerin ointment in a 1-inch dose every 12 hours. Proper application of nitroglycerin ointment includes:
A. Rotating application sites
B. Limiting applications to the chest
C. Rubbing it into the skin
D. Covering it with a gauze dressing
Answer A is correct. Sites for the application of nitroglycerin should be rotated, to prevent skin irritation. It can be applied to the back and upper arms, not to the lower extremities, making answer B incorrect. Answer C is contraindicated to the question, and answer D is incorrect because the medication should be covered with a prepared dressing made of a thin paper substance, not gauze.
A. The client who has a history of a cerebral aneurysm with an oxygen saturation rate of 99%
B. The client who was admitted 1 hour ago with shortness of breath
C. The client who is three days post–coronary artery bypass graft with a temperature of 100.2°F
D. The client who is being prepared for discharge following a femoral popliteal bypass graft
Answer B is correct. The client admitted 1 hour ago with shortness of breath should be seen first because this client might require oxygen therapy. The client in answer A with a low-grade temperature can be assessed after the client with shortness of breath. The client in answer C can also be seen later. This client will have some
Question #2. The client has an order for heparin to prevent post-surgical thrombi.
Immediately following a heparin injection, the nurse should:
A. Aspirate for blood
B. Check the pulse rate
C. Massage the site
D. Check the site for bleeding
Answer D is correct. After administering any subcutaneous anticoagulant, the nurse should check the site for bleeding. Answers A and C are incorrect because aspirating and massaging the site are not done. Checking the pulse is not necessary, as in answer B.
Question #3. The nurse is assisting in the care of a patient with diverticulosis. Which of the following assessment findings would necessitate a report to the doctor?
A. Bowel sounds of 5–20 seconds
B. Intermittent left lower-quadrant pain
C. Constipation alternating with diarrhea
D. Hemoglobin 26% and hematocrit 32
Answer D is correct. Low hemoglobin and hematocrit might indicate intestinal bleeding. Answers A, B, and C are normal lab values.
Question #4. The nurse is assessing the abdomen. The nurse knows the best sequence to perform the assessment is:
A. Palpation, inspection, auscultation
B. Auscultation, palpation, inspection
C. Inspection, auscultation, palpation
D. Inspection, palpation, auscultation
Answer C is correct. The nurse should inspect first, then auscultate, and finally palpate. If the nurse palpates first the assessment might be unreliable. Therefore, answers A, B, and D are incorrect.
Question #5. The nurse is making assignments for the day. Which client should be assigned to the nursing assistant?
A. The 18-year-old with a fracture to two cervical vertebrae
B. The infant with meningitis
C. The elderly client with a thyroidectomy 4 days ago
D. The client with a thoracotomy 2 days ago
Answer C is correct. The most stable client is the client with the thyroidectomy 4 days ago. Answers A, B, and D are incorrect because the other clients are less stable and require a registered nurse.
Question #6. The client is admitted to the postpartum unit with an order to continue the infusion of Pitocin. Which finding indicates that the Pitocin is having the desired effect?
A. The fundus is deviated to the left.
B. The fundus is firm and in the midline.
C. The fundus is boggy.
D. The fundus is two finger breadths below the umbilicus.
Answer B is correct. Pitocin is used to cause the uterus to contract and decrease
bleeding. A uterus deviated to the left, as stated in answer A, indicates a full bladder. It is not desirable to have a boggy uterus, making answer C incorrect. This lack of muscle tone will increase bleeding. Answer D is incorrect because the position of the uterus is not related to the use of Pitocin.
Question #7. A 70-year-old male who is recovering from a stroke exhibits signs of unilateral neglect. Which behavior is suggestive of unilateral neglect?
A. The client is observed shaving only one side of his face.
B. The client is unable to distinguish between two tactile stimuli presented simultaneously.
C. The client is unable to complete a range of vision without turning his head side to side.
D. The client is unable to carry out cognitive and motor activity at the same time.
Answer A is correct. The client with unilateral neglect will neglect one side of the body. Answers B, C, and D are not associated with unilateral neglect.
Question #8. The nurse is assigned to care for an infant with physiologic jaundice. Which action by the nurse would facilitate elimination of the bilirubin?
A. Decreasing caloric intake
B. Maintaining the infant’s body temperature at 98.6°F
C. Minimizing tactile stimulation
D. Increasing the infant’s fluid intake
Answer D is correct. Bilirubin is excreted through the kidneys, thus the need for increased fluids. Maintaining the body temperature is important but will not assist in eliminating bilirubin; therefore, answer B is incorrect. Answers A and C are incorrect because they do not relate to the question.
Question #9. A 24-year-old female client is scheduled for surgery in the morning. Which of the following is the primary responsibility of the nurse?
A. Taking the vital signs
B. Obtaining the permit
C. Explaining the procedure
D. Checking the lab work
Answer A is correct. The primary responsibility of the nurse is to take the vital signs before any surgery. The actions in answers B, C, and D are the responsibility of the doctor and, therefore, are incorrect for this question.
Question #10. The doctor orders 2% nitroglycerin ointment in a 1-inch dose every 12 hours. Proper application of nitroglycerin ointment includes:
A. Rotating application sites
B. Limiting applications to the chest
C. Rubbing it into the skin
D. Covering it with a gauze dressing
Answer A is correct. Sites for the application of nitroglycerin should be rotated, to prevent skin irritation. It can be applied to the back and upper arms, not to the lower extremities, making answer B incorrect. Answer C is contraindicated to the question, and answer D is incorrect because the medication should be covered with a prepared dressing made of a thin paper substance, not gauze.
