CAT 2 KAPLAN exam-with 100% verified solutions-2024.docx | Exams Nursing | Docsity (2024)

Download CAT 2 KAPLAN exam-with 100% verified solutions-2024.docx and more Exams Nursing in PDF only on Docsity! CAT 2 KAPLAN exam-with 100% verified solutions-2024 Complete 150 Q&A 1. The nurse assess a client who is in the 24th week of gestation. Which finding is a priority for thenurse to follow-up? 1. Fetal heart rate of 130 to 140 beats/min. 2. Fundal level at 3 fingers below the umbilicus. 3. Fetal movements felt faintly on lower part of abdomen. 4. Client reports backache and leg cramps when sleeping. Ans: 2 2. The nurse administers carisoprodol to the incorrect client. Which strategy should the nurse use toreduce the risk of malpractice litigation? (Select all that apply.) 1. Ask the charge nurse to reassign the client to a different nurse. 2. Notify the health care provider of the medication error immediately. 3. Report the incident to the manager for appropriate follow-up with the client. 4. Print a copy of the incident report to keep in the nurse’s personal records. 5. Explain to the client that the nurse has a heavier assignment than normal. Ans: 2, 3 3. The nurse provides care for a client who is receiving sitagliptin for type 2 diabetes mellitus. Whichassessment finding causes the nurse to suspect the client is experiencing an adverse reaction to themedication? 1. Weight gain. 2. Anemia. 3. Abdominal pain. 4. Edema. Ans: 3 4. The nurse orients a new nurse who inquired about electrical cardioversion. Which statement aboutcardioversion by the nurse is accurate? (Select all that apply.) 1. “Cardioversion is used to treat ventricular fibrillation.” 2. “Pulseless electrical activity (PEA) responds to cardioversion.” 3. “Cardioversion treats atrial fibrillation and atrial flutter.” 4. “An intravenous sedative is required in elective cardioversion.” 5. “Check for life-threatening dysrhythmia during cardioversion.” Ans: 3, 4, 5 5. A wound located on the foot of a client with type 2 diabetes mellitus (DM) is healing. The nurse teaches the client about the prevention of future foot wounds. Which client statement indicates theteaching is effective? (Select all that apply.) 1. “I should not cross my legs.” 2. “I should wear shoes only when I go outside.” 3. “I should apply lotion between my toes after a shower.” 4. “I should inspect the inside of my shoes before I put them on.” 5. “I should use a mirror to examine the bottom of my feet every day.” Ans: 1, 4, 5 6. The nurse prepares discharge instructions for a client who speaks very little English and is recovering from an emergency appendectomy. Which nursing action best helps this client understand wound care instructions? 1. Asking if the client understands the instruction. 2. Demonstrating the procedure and having the client return the demonstration. 3. Asking an interpreter to replay the instructions to the client. 4. Writing out the instructions and having a family member read them to the client. Ans: 2 7. The family sits at the bedside of a client nearing the end-of-life. Which action is appropriate for the nurse to implement? (Select all that apply.) 1. Teach family members about physical signs of impending death. 2. Encourage the management of adverse signs and symptoms. 3. Assess family coping mechanisms to handle impending loss. 4. Avoid spirituality as nurse’s beliefs may not be congruent with the client’s. 5. Leave the family alone as there is no more need for direct nursing care. Ans: 1, 2, 3 8. The nurse performs an intermittent urinary catheterization for a client who is 2 hours post surgery.Which client observation indicates that the procedure was effective? 1. Reports dribbling of urine. 2. Rests quietly. 3. Notes distention above symphysis pubis. 4. Voids 30 mL every 15 minutes. Ans: 2 9. The nurse directs the nursing assistive personnel (NAP) to provide a back massage to a client. Whichaction does the nurse emphasize when giving these directions? 1. Warm the lotion in the microwave before use. 2. Wear clean gloves while performing the massage. 3. Place the bed in the lowest position after the massage. 4. Start the massage at the shoulders and work toward the buttocks. Ans: 3 10. The nurse observes a student nurse provide a client with a subcutaneous injection of heparin. Forwhich student action will the nurse intervene? (Select all that apply.) 1. Pinches the skin and inserts the needle 90 degrees. 2. Places the needle in the sharps container. 3. Administers the injection 1/2 inch from the umbilicus. 4. Aspirates after inserting the needle. 5. Massages the site. Ans: 3, 4, 5 2. Blood pressure reading of 152/90 mm Hg. 3. Pain reported as severe in the left knee and ankle. 4. Blood urea nitrogen (BUN) level of 40 mg/dL. Ans: 4 22. A preschool-age client experiences a sudden cardiac arrest. Which action will the nurse take whenperforming cardiopulmonary resuscitation (CPR)? 1. Deliver 12 breaths per minute. 2. Compress the sternum with both hands at a depth of 2 inches (4 to 5 cm). 3. Use the heel of one hand for sternal compressions. 4. Use two fingers for sternal compressions. Ans: 3 23. A client takes a statin as prescribed. Which action does the nurse implement to identify if the clientis experiencing any side effects of the medication? 1. Measure height and weight. 2. Check recent cholesterol level. 3. Inquire about the consistency of stool. 4. Assess for muscle tenderness. Ans: 4 24. The nurse provides care for a client with the following arterial blood gas (ABG) results: pH 7.29, pCO231 mmHg, and HCO3 19 mEq/L. Which electrolyte alteration does the nurse monitor for based onthis client data? 1. Hypocalcemia. 2. Hypernatremia. 3. Hypomagnesemia. 4. Hyperkalemia. Ans: 4 25. The nurse provides care for a client diagnosed with an acute stroke. Which intervention does thenurse delegate to the nursing assistive personnel (NAP)? (Select all that apply.) 1. Screen the client for thrombolytic therapy. 2. Take vital signs based on stroke protocol. 3. Measure and record urinary output. 4. Assist with positioning the client as needed. 5. Evaluate the client’s motor strength every hour. Ans: 2, 3, 4 26. The health care provider prescribes intramuscular pain medication for a child recovering from anappendectomy. Which is the most appropriate action for the nurse to take? 1. Advocate for the child to see if the medication can be given by an alternate route. 2. Disinfect the injection site and allow it to dry completely. 3. Administer a topical anesthetic at the intended injection site. 4. Administer the medication by the intravenous route. Ans: 1 27. The nurse provides care to victims of a disaster. Which client will the nurse assess first? 1. An 8-month-old client with a laceration over the left eye, a blood pressure of 84/50 mm Hg, and a pulse of 105 beats/min. 2. A 6-year-old client with crush injuries to both legs, fixed and dilated pupils, and an absent pulse. 3. A 20-year-old client with a traumatic left below the knee amputation, a blood pressure of 70/46 mm Hg, and a pulse of 124 beats/min. 4. A 28-year-old client with a hematoma on the forehead, a Glasgow Coma Scale of 11, and is crying. Ans: 3 28. The nurse notes the client’s electrocardiogram (ECG) tracing shows a prolonged PR interval, a wideQRS complex, and tall peaked T waves. Which action does the nurse take next? 1. Palpate the peripheral pulses. 2. Check the serum potassium. 3. Raise the head of the bed. 4. Obtain serum troponin level. Ans: 2 29. The nurse provides care for a client on bed rest. The nurse determines that the client’s right calf isswollen, red, and tender to touch. Which nursing action is most appropriate? 1. Check the client for Homan sign. 2. Massage the area. 3. Notify the health care provider. 4. Teach the client to dangle legs. Ans: 3 30. The nurse prepares to teach a client about measures to prevent falls at home. Which point will thenurse include in the teaching plan? 1. Place a small area rug on the bathroom floor in front of the bathtub. 2. Avoid using step stools. 3. Allow damp areas on the floor to air dry. 4. Do not attempt to do anything beyond reach. Ans: 4 31. The nurse auscultates heart sounds in a school-age client. Where does the nurse place thestethoscope to listen to the aortic area of the heart? 1. Second left intercostal space. 2. Second right intercostal space. 3. Fifth intercostal space left midclavicular line. 4. Fifth right and left intercostal spaces. Ans: 2 32. The nurse teaches a class on suicide prevention to high school students. Which risk factor isaccurate with regard to suicide in adolescent clients? (Select all that apply.) 1. Possessions that are given to friends. 2. A low-grade point average. 3. Statements like, “I may not be around anymore.” 4. Access to a gun at home. 5. Frequent thoughts of suicide. Ans: 1, 3, 4, 5 33. The nurse prepares discharge instructions for an overweight client with gastroesophageal reflux disease (GERD). Which instruction does the nurse include in the teaching plan? (Select all that apply.) 1. Elevate the head of the bed. 2. Decrease caffeine intake. 3. Evaluate weight loss strategies. 4. Increase fluid intake at meals. 5. Eat a small bedtime snack. Ans: 1, 2, 3 34. The nurse reviews care needs for a shift assignment. Which client task will the nurse delegate tonewly hired nursing assistive personnel (NAP)? (Select all that apply.) 1. Client diagnosed with a fractured hip being discharged tomorrow. 2. Client receiving blood after a total abdominal hysterectomy that was admitted to the care area 10 minutes ago. 3. Client diagnosed with a fractured tibia who had surgery 2 days ago. 4. Client diagnosed with cellulitis to the lower leg. 5. Client who had a resection of the prostate this morning with a 3-way indwelling urinary catheter for irrigation. Ans: 1, 3, 4 35. The nurse prepares to administer fondaparinux to a client. Which laboratory test result will thenurse monitor in the client receiving this medication? 1. International normalized ratio. 2. Prothrombin time. 3. Creatinine level. 4. Partial thromboplastin time. Ans: 3 46. The nurse provides care for a client diagnosed with head trauma. The client experiences a seizure.Which actions will the nurse implement? (Select all that apply.) 1. Keep the client in a side-lying position. 2. Monitor the client's ability to maintain a patent airway. 3. Arouse the client frequently to assess neurological status. 4. Provide environmental stimuli to help the client awaken. 5. Place suction equipment and an oral airway at the client's bedside. Ans: 1, 2, 5 47. The nurse admits a child with fever, malaise, headache, and a vesicular rash on the scalp, face, andtrunk. Which transmission-based precaution does the nurse implement for this child? 1. Contact precautions. 2. Airborne and contact precautions. 3. Airborne and droplet precautions. 4. Droplet precautions. Ans: 2 48. The nurse provides care for a client diagnosed with deep vein thrombosis. The client receiveswarfarin therapy. Which laboratory test result indicates to the nurse that treatment is successful? 1. International normalized ratio 1 to 2. 2. Partial thromboplastin time 1.5 times the control. 3. International normalized ratio 2 to 3. 4. Partial thromboplastin times 2.5 times the control. Ans: 3 49. The nurse provides care for a client receiving chemotherapy and radiation who has several bruises.Which nursing intervention will be part of the care plan to prevent further injury? (Select all that apply.) 1. Shave with an electric razor. 2. Allow the client to be up without supervision as tolerated. 3. Avoid enemas and suppositories. 4. Administer stool softeners. 5. Place an indwelling catheter. Ans: 1, 3, 4 50. Which activity appropriately demonstrates the nurse’s role as client advocate? (Select all thatapply.) 1. Defending client participation in decisions affecting them. 2. Protecting clients from incompetent or unethical practice. 3. Safeguarding the client’s autonomy and independence. 4. Telling clients, they must take all medications prescribed by health care providers. 5. Communicating client needs to the interdisciplinary team. Ans: 1, 2, 3, 5 51. The nurse reviews ways to prevent client medication errors with a student nurse. Which responseby the student indicates that additional teaching is necessary? (Select all that apply.) 1. “ I will prepare medications for each client separately." 2. “ I should compare the medication administration record against the drug label at least two times before giving the medication to a client.” 3. “ I should trust the health care provider and not question a medication or dose ordered.” 4. “ I will document all medications as soon as I give them.” 5. “ I should use at least two patient identifiers whenever administering medications.” Ans: 2, 3 52. The nurse reviews prescriptions from a health care provider for a client’s care. Which prescriptionwill the nurse question before implementing? 1. Monitor intake and output. 2. Begin a 2 L/day fluid restriction. 3. Start heparin infusion by 0800 hours. 4. Continue intravenous fluids D5W at 150 mL/hour. Ans: 3 53. The nurse provides care for a client newly diagnosed with a benign brain tumor. The nurse teachesthe client about the diagnosis. Which property of benign tumors should the nurse include in the teaching? 1. They are poorly differentiated. 2. They metastasize to other organs. 3. They grow at an aggressive rate. 4. They can cause tissue destruction. Ans: 4 54. The nurse auscultates the heart of a client experiencing increasing shortness of breath. Whichfinding causes the nurse the most concern? 1. S1 heart sound. 2. S2 heart sound. 3. S3 heart sound. 4. S4 heart sound. Ans: 3 55. The nurse educator plans an educational program to review transmission-based precautions withunit staff. Which substance is included on the list of potential sources of infection as outlined by theCenters for Disease Control and Prevention (CDCP)? (Select all that apply.) 1. Blood. 2. vagin*l secretions. 3. Sputum. 4. Non-intact skin. 5. Sweat. Ans: 1, 2, 3, 4 56. A young adult military veteran who served time in the Gulf War reports headache, sore throat,shortness of breath, a rash, and nausea when exposed to paint and certain air fresheners. Which condition does the nurse suspect is most likely causing the client’s symptoms? 1. Post-traumatic stress disorder. 2. Allergy-induced asthma. 3. Multiple chemical sensitivities. 4. Claustrophobic reaction. Ans: 3 57. The nurse provides care to a school-age child suspected of being sexually abused. Whichassessment data best supports this suspicion? 1. Difficulty walking. 2. Bald spots on scalp. 3. Fear of parents. 4. Welts on buttocks. Ans: 1 58. The nurse provides care for a hospitalized client. The client’s room is located close to the nursesstation. The client tells the nurse, “I don’t know how anyone can get any rest around here, it is so noisy.” The nurse reports these concerns to the nursing supervisor. Which change to the nursing unitshould the nursing supervisor implement? (Select all that apply.) 1. Encourage staff to change shoes to clogs to reduce noise. 2. Reduce the volume of phones and pagers. 3. Turn off all lights in the hallways. 4. Keep conversations quiet. 5. Close the client’s room door if possible. Ans: 2, 4, 5 59. The nurse working in a community hospital’s emergency department provides care to a client withchest pain. Which level of care is the nurse providing? 1. Preventive care. 2. Tertiary care. 3. Restorative care. 4. Continuing care. Ans: 2 60. While administering an intravenous push medication to a client, the nurse notes that the color ofthe medication changed in the tubing. Which type of response will the nurse identify occurred with this medication? 1. Incompatibility. 2. Additive effect. 70. The nurse identifies the nursing diagnosis of Stress Urinary Incontinence related to weakenedpelvic musculature for a client. Which goal is most appropriate for this client? 1. Engage in a bladder retraining program. 2. Reduce the frequency of urinary incontinence episodes through exercises. 3. Use adaptive clothing for quick removal. 4. Undergo urodynamic testing to assess urine speed and volume. Ans: 2 71. The nurse provides care for a client with a nasogastric (NG) tube attached to wall suction. The nurse notes large amounts of gastric secretions in the suction canister. Which arterial blood gas (ABG)result does the nurse expect to observe? 1. PaCO2 50 mmHg, pH 7.20. 2. PaCO2 40 mmHg, pH 7.40. 3. HCO3 28 mEq/L (28 mmol/L), pH 7.50. 4. HCO3 20 mEq/L (20 mmol/L), pH 7.30. Ans: 3 72. The nurse plans to assess a client with acquired immune deficiency syndrome (AIDS). Whichquestion provides the least amount of information to plan this client's care? 1. What method of birth control do you use? 2. Do you use intravenous drugs? 3. How many sexual partners do you have? 4. How old were you when you became sexually active? Ans: 4 73. A client recovers from general anesthesia. Which medication will the nurse identify as causingrespiratory depression? (Select all that apply.) 1. Ketorolac. 2. Hydromorphone hydrochloride. 3. Ibuprofen. 4. Codeine sulfate. 5. Hydrocodone. Ans: 2, 4, 5 74. The nurse provides care to a client diagnosed with acute exacerbation of chronic obstructivepulmonary disease (COPD). Which goal is most appropriate to include in the nursing care plan? 1. Improve gas exchange. 2. Perform activities of daily living without dyspnea. 3. Obtain flu and pneumonia vaccinations. 4. Sleep for 8 hours without interruption. Ans: 1 75. A client with injuries from a motor vehicle accident is unconscious from a severe head injury. The client's identity is unknown, but the client needs emergency surgery to stabilize fractures. Which action is the best for the nurse to take when obtaining informed consent for the operative procedure? 1. Ask the emergency services team to sign the informed consent. 2. Obtain an emergency court order for the surgical procedure. 3. Transport the client to the operating room for surgery. 4. Ask the police to identify the client and locate the family. Ans: 3 76. The nurse attends a staff development conference on transfusion reactions. Which statement bythe nurse indicates the need for further teaching? 1. “I will keep the intravenous line open with normal saline after I stop the transfusion.” 2. “I will obtain a urine specimen to determine the presence of hemoglobin.” 3. “I will discard the blood bag and transfusion set in a waterproof bag.” 4. “I will notify the blood bank if a client has a transfusion reaction.” Ans: 3 77. A client diagnosed with a terminal disease questions the nurse about the purpose of diagnostictests. Which action should the nurse take next? 1. Encourage the client to have the testing performed to validate the diagnosis. 2. Contact the radiology department to reschedule the diagnostic tests. 3. Inform the health care provider that the client is refusing diagnostic tests. 4. Ask the health care provider to discuss the diagnostic tests with the client. Ans: 4 78. The nurse observes a student assess an older client with dehydration. Which assessment requiresthe nurse to intervene? 1. Measures orthostatic blood pressure. 2. Reviews serial daily weight readings. 3. Checks skin turgor on the hand. 4. Reviews serum sodium values. Ans: 3 79. The nurse provides care for a client receiving external radiation to the chest wall. Which action bythe nurse is best? 1. Perform a thorough assessment and ongoing monitoring of the client’s skin. 2. Isolate the client from people with infections such as the cold virus. 3. Prevent the client from eating or drinking for 2 hours after radiation. 4. Dispose of the client’s excretions in a specific lead-lined container. Ans: 1 80. The nurse teaches a group of students about measures to reduce the risk for medical device-related accidents. Which point does the nurse include in the teaching? (Select all that apply.) 1. Bend electric cords for storage. 2. Be alert for wet surfaces near electric cords. 3. Handle medical equipment with care. 4. Avoid using equipment that is unfamiliar. 5. Use two-prong electrical plugs when possible. Ans: 2, 3, 4 81. The nurse provides care for a 65-year-old client with no high-risk factors. The nurse evaluates theclient’s immunization status. Which of the client’s immunizations should the nurse determine are current? (Select all that apply.) 1. Last tetanus booster at age 60. 2. Has not received the hepatitis A vaccine. 3. Received the herpes zoster vaccine at age 60. 4. Has not received the hepatitis B vaccine. 5. Receives a flu shot every year. Ans: 1, 3, 5 82. The nurse provides care for a client who reports a sexual and physical assault by a friend. Whichaction should the nurse take first? 1. Place a referral for a psychiatric provider consult. 2. Call the hospital chaplain to offer prayer and support. 3. Clean the client’s wounds and provide a clean gown. 4. Stay with the client during the physical examination. Ans: 4 83. The nurse teaches the parent of a child diagnosed with celiac disease. Which statement does thenurse identify as an indication that the parent understands the teaching? 1. “I will give my child barley soup for lunch.” 2. “I will make my child sandwiches on rye bread." 3. “I will make my child popcorn as a snack.” 4. “I will give my child oatmeal for breakfast." Ans: 3 84. The nurse provides care to a client with a terminal illness and discusses withdrawal of care. The family expresses concern related to discontinuation of the therapy. Which statement by the nurse ismost appropriate? 1. “I understand your concerns. We will give the client enough morphine to promote a painless death.” 2. “You will need to talk to the lawyer. I am not legally allowed to participate in the withdrawal of life support.” 3. “I realize this is a difficult decision. Discontinuation of therapy will allow the client to diea more natural death.” Ans: 4, 5 95. The client states to the nurse, “I am a lacto-vegetarian.” Which food will the nurse expect the clientto eat? (Select all that apply.) 1. Fish. 2. Milk. 3. Eggs. 4. Cheese. 5. Yogurt. Ans: 2, 4, 5 96. The nurse provides care for a client in the post-operative anesthesia care unit (PACU). The client’svital signs are respirations 16 breaths per minute, pulse 90 beats per minute, and blood pressure 110/68 mm Hg. The pulse oximeter shows 87% with 2 L of oxygen per nasal cannula. Which nursing diagnosis is a priority? 1. Impaired gas exchange. 2. Ineffective airway clearance. 3. Ineffective peripheral tissue perfusion. 4. Ineffective breathing pattern. Ans: 1 97. The nurse is teaching a group of nursing assistive personnel (NAP) about infection controlpractices. Which statement by a NAP indicates that the teaching is effective? 1. “I’ll be sure to clean the least soiled areas first.” 2. “I’ll place soiled bed linens on the floor.” 3. “I’ll discard liquids by pouring them over the sink.” 4. “I’ll carry soiled items close to me to prevent them from dropping.” Ans: 1 98. The nurse provides care to a client receiving intravenous heparin. Which laboratory test resultcauses the nurse to be most concerned? 1. Platelet count 50 mm3/L (50×109/L). 2. Sodium level 130 mEq/L (130 mmol/L). 3. Potassium level 3.2 mEq/L (3.2 mmol/L). 4. Partial thromboplastin time 70 seconds. Ans: 1 99. The nurse is teaching a client diagnosed with end stage renal disease about hemodialysis. Whichstatement indicates that teaching has been effective? 1. “I should have a treatment once a week.” 2. “I might have muscle cramps after a treatment.” 3. “The treatment could make my blood clot faster.” 4. “The treatments reduce my risk of getting infections.” Ans: 2 100. The supervisor observes the nurse delegate a dressing change on a client with a fever, positive blood cultures, and a blood pressure of 86/42 mm Hg to the LPN/LVN. Which action will the supervisortake next? 1. Encourage the LPN/LVN to complete the dressing change as assigned. 2. Assign another LPN/LVN who is more comfortable with dressings to complete the dressing change. 3. Discuss with the nurse that the dressing change should not be delegated to the LPN/LVN. 4. Ensure that the nurse follows up with the LPN/LVN after the dressing change is complete. Ans: 3 101. The nurse prepares to instruct a client diagnosed with diabetes mellitus on self- injection ofinsulin. Which gauge and needle length does the nurse teach the client to choose? 1. 23-gauge syringe with a 1 inch needle. 2. 28-gauge syringe with a 0.5 inch needle. 3. 18-gauge syringe with a 1 1/2 inch needle. 4. 20-gauge syringe with a 2 inch needle. Ans: 2 102. A newly admitted client experiences a cardiac arrest and does not have a "do not resuscitate" order. Nursing assistive personnel (NAP) relate that the client stated to family earlier the desire to not be resuscitated. Which action will the nurse perform next? 1. Respect the client's wishes and do not perform cardiopulmonary resuscitation. 2. Tell the health care provider the client asked to be have a "do not resuscitate" order. 3. Determine who has the durable medical power of attorney. 4. Start cardiopulmonary resuscitation. Ans: 4 103. The nurse provides care for a client diagnosed with a duodenal ulcer. The clientasks how a stomach infection can cause a duodenal ulcer. Which response by the nurse is best? 1 “Bacteria in the duodenum deteriorate the area, causing an ulceration.” 2 “The bacteria enter the lining of the intestines and changes the protective layer.” 3 “There is no explanation for how this occurs in a vast majority of people.” 4 “Medication for the stomach infection causes the duodenal lining to break down.” Ans: 2 104. The nurse receives reports on several clients. Which client will the nurse assess first? 1 9-month-old client with a barking cough, not eating or drinking, with an oxygensaturation of 92% on room air. 2 14-month-old client with an oral temperature of 1020 F, green nasal drainage, and is pulling at the ears. 3 6-month-old client with a harsh cough, mild audible wheezes, and retractionsnoted in the ribs. 4 2-year-old client with a sore throat, sitting upright, refusing to swallow, anddrooling. Ans: 4 105. During an assessment the nurse suspects that an injured child is a victim of physical abuse. Which action is the nurse’s primary legal responsibility in this situation? 1 Refer the family to the hospital social worker. 2 Call the hospital attorney to report the suspicion. 3 Report the case to the local law enforcement authorities. 4 Document the physical assessment of the child accurately and thoroughly. Ans: 3 106. A client relieves severe abdominal pain that radiates to the back by sitting forward with theknees bent. Which laboratory test will the nurse expect to be prescribed for this client? 1 Creatinine. 2 Serum amylase. 3 Creatinine kinase. 4 Blood urea nitrogen. Ans: 2 107. The nurse provides care for a client who is confused and reports a headache. The client'svital signs are as follows: temperature 101.0°F (38.3°C), BP 150/64 mm Hg, pulse 58 beats/min, and irregular respirations of 12 breaths/min. Which action does the nurse take next? 1 Lower the head of the bed to a flat position. 115. The nurse provides care for a client newly admitted to the post-operative anesthesia care unit (PACU). The client is drowsy with a respiratory rate of 8 and an oxygen saturation of 86%. Which action does the nurse take first? 1 Place the client in a supine position. 2 Assess lung sounds. 3 Remove the oral airway. 4 Raise the head of the bed to semi-Fowler’s. Ans: 4 116. The nurse provides teaching to a client diagnosed with tuberculosis about the most common means of transmitting the tubercle bacillus to others. Which method of transmissionwill the nurse include in the teaching? 1. Droplet nuclei 2. Contaminated food 3. Hands 4. Eating utensils Ans: 1 117. The nurse provides care for a newly admitted client diagnosed with Alzheimer disease.Which action from the nurse is appropriate? 1 Ask the client the date and the day of the week. 2 Assign a different nurse to provide care for each day to introduce the client to thestaff. 3 Ask the family to step out of the room while the nurse assesses the client. 4 Place the client in a private room away from the nurses’ station. Ans: 1 118. The nurse provides care for a client diagnosed with chronic constipation and diverticulosiswho was recently admitted to the hospital with a rectal impaction. The nurse teaches the clientabout strategies to manage constipation. Which statement made by the client indicates to the nurse a need for further teaching? 1 “I will begin an exercise program and exercise daily.” 2 “I will eat foods like corn, popcorn, or sunflower seeds to increase my fiber.” 3 “I will drink about 2 liters of fluid a day.” 4 “I will give myself as much privacy as I can when having a bowel movement.” Ans: 2 119. The nurse prepares to discard a partial dose of hydromorphone. Which action by thenurse is most correct? 1 Asks a second nurse to witness the discarding. 2 Discards the medication and documents the discarding in the control record. 3 Asks a second nurse to witness the discarding and countersign the control record. 4 Asks a second nurse to countersign the control record. Ans: 3 120. The nurse provides care for a client who has received gentamicin intravenously for thepast 6 days. Which finding indicates the client is experiencing adverse effects? 1 Heart rate of 92 beats per minute. 2 Urine output of 110 mL for 8 hours. 3 White blood cell (WBC) count of 12,000 per mm3. 4 Blood pressure (BP) of 149/78 mm Hg. Ans: 2 121. The nurse provides care for a client who exhibits shortness of breath and a pulse oximeter reading of 87% on 2 liters oxygen via nasal cannula. The client’s respiratory rate is 28breaths/min. The nurse assesses rales in both lower lobes bilaterally. Which nursing diagnosisdoes the nurse assign the highest priority? 1 Decreased cardiac output. 2 Fluid volume excess. 3 Impaired gas exchange. 4 Ineffective tissue perfusion. Ans: 3 122. The nurse provides care for the client who had an extracorporeal shock-wave lithotripsyto treat a kidney stone. Which observation requires intervention by the nurse? 1 Urine output is 10 to 15 mL per hour. 2 Urine is pinkish in color. 3 Urine contains sand-like particles. 4 Urine has red blood cells of >2. Ans: 1 123. The nurse learns that the twin sibling of a toddler with a Staphylococcus skin infection has developed the same infection. Which behavior by the children is most likely to have caused the transmission of this infection? 1 Using the same pacifiers. 2 Coughing on each other. 3 Sharing eating utensils. 4 Bathing with one another. Ans: 4 124. A client recovering from anesthesia receives a dose of intravenous nalaxone. Whichresponse indicates to the nurse that the medication is effective? 1 Blood pressure is 88/50 mm Hg. 2 Heart rate is 55 beats/min. 3 Respiratory rate is 13 breaths/min. 4 Pulse oximeter is 86% on 2 liters per nasal cannula. Ans: 3 125.Upon entering the room, the nurse notices the client is visibly short of breath. Whichnursing action does the nurse perform first? 1 Obtain the client’s oxygen saturation. 2 Place the client in a high-Fowler position. 3 Assess the client’s lung sounds. 4 Notify the health care provider of the client's assessment data. Ans: 2 126. The nurse develops a dietary teaching plan for a pregnant client. Which information willthe nurse include? 1 Protein requirements will triple. 2 The need for calories will increase by 1200 kcal/day. 3 There is an increased need for iron. 4 Sodium needs will decrease. Ans: 3 127. A client was found on the floor lying in a pool of blood next to the client’s bed at 0500. Themedical examiner determined that the client died 3 to 4 hours before being found by the nurse. Hospital policy states that hourly rounding is done in all client care areas. Which charge will thefamily use when seeking legal action against the hospital and the nurse? 1 Negligence. 2 Slander. 3 Battery. 4 Abandonment of care. Ans: 1 1 Fluid volume deficit related to excess urine output. 2 Hyponatremia related to increased sodium excretion. 3 Risk for fluid overload related to low urine output. 4 Hyperglycemia related to reduced insulin production. Ans: 1 138. The nurse provides care for a post-operative client with an abdominal incision. The clientreports feeling the wound give way, and the nurse visualizes a separation in the incision. Which risk factor can contribute to the client’s condition? 1 Vomiting. 2 Uncontrollable pain. 3 Early ambulation after surgery. 4 Splinting with coughing. Ans: 1 139. A nursing assistive personnel (NAP) asks the nurse when contact precautions should beused for client care. Which response by the nurse is best? 1 “Use contact precautions for a client who has a disease transmitted by tiny airborne droplet nuclei.” 2 “Use contact precautions for a client who has a disease transmitted by blood- borne pathogens.” 3 “Use contact precautions for a client who has a disease transmitted by inhalinglarge particle droplets.” 4“Use contact precautions for a client who has a disease transmitted by touching a contaminated object.” Ans: 4 140. The nurse instructs a client with asthma about the treatment plan. Which statement fromthe nurse teaches the client how to evaluate a response to therapy at home? 1 “Keep a daily diary to record symptoms and interventions.” 2 “Measure your chest circumference every week.” 3 “Note your symptoms when you don’t take your home medications.” 4 “Use proper technique and sequence with the metered dose inhaler.” Ans: 1 141. The nurse suspects that a client receiving hospice care is in the depression stage of theKubler- Ross coping with loss model. Which client action causes the nurse to make this determination? 1 The client ignores family members. 2 The client throws clothes on the floor. 3 The client states repeatedly “this can’t be happening to me.” 4 The client states the desire to see a grandchild get married. Ans: 1 142. The nurse observes a client walk with a cane. The nurse reevaluates the size of the canebeing used. Which observation caused the nurse to make this decision? 1 The client moves the weaker leg with the cane. 2 The client bends the elbow at a 90-degree angle. 3 The client holds the cane on the stronger side. 4 The client places the stronger leg ahead of the cane. Ans: 2 143. The nurse provides care for a group of clients in a mental health facility. Which task doesthe nurse delegate to the nursing assistive personnel (NAP)? (Select all that apply.) 1 Observe a client with bulimia for 30 minutes after each meal. 2 Help a client with depression to complete a craft project. 3 Assist a client to identify coping skills to manage stress. 4 Lead a group therapy session for clients with bipolar disorder. 5 Complete an Abnormal Involuntary Movement Scale for a client. Ans: 1, 2 144. A client with a blood type of B Rhesus factor (Rh) negative is prescribed a blood transfusion. Which type of donated blood will the nurse expect to be provided for this client? 1 B+. 2 AB-. 3 A+. 4 O-. Ans: 4 145. The nurse provides care for a pediatric client diagnosed with otitis media. Which statement by the parent will cause the nurse to immediately intervene? 1 “I will continue giving my child antibiotics, even after symptoms resolve.” 2 “I clean drainage from my child’s outer ear canal with cotton swabs.” 3 “ 4 “I have been giving my child ibuprofen.” Ans: 3 146. The nurse notes that a client has a 2 cm area of skin breakdown on the coccyx. Whichaction will the nurse take first? 1 Stage the wound. 2 Apply a dry gauze dressing to the wound. 3 Notify the health care provider. 4 Place lamb’s wool under affected the area. Ans: 1 147. The nurse teaches a group of nursing students about infection. Which condition does thenurse list as a primary defense against infection? 1 Inflammation. 2 Elevated temperature. 3 Lethargy. 4 Intact skin. Ans: 4 148.Prior to delegating a client's surgical dressing change to an LPN/LVN, the nurse notes thedressing is saturated with blood. What action will the nurse take next? 1 Instruct the LPN/ LVN to complete the dressing change. 2 Reinforce the dressing. 3 Remove the dressing to assess the incision. 4 Notify the health care provider. Ans: 3 149. The nurse provides care to a client with deep vein thrombosis (DVT). Which medicationrequires monitoring of the activated partial thromboplastin time (aPTT)? 1 Enoxaparin. 2 Heparin. 3 Rivaroxaban. 4 Warfarin. Ans: 2 150. The nurse provides care for a client who received an inhalation anesthetic agent duringsurgery. Which assessment finding requires the nurse to intervene immediately? 1 Blood pressure 144/80 mm Hg. 2 Urine output 30 mL/hour. 3 Generalized muscle rigidity. 4 Increased cardiac output. Ans: 3