A nurse is caring for a client who sustained full thickness burns over 70% of the total body surface

area 6
days ago. Which of the following findings should the nurse report to the provider?
a. Glasgow Coma Scale score of 9
c. Temperature of 37.9 C (100.2 F)
b. Pain level of 6 on a scale from 0 to 10
d. Urine output of 40 mL/hr
e.
f. The nurse should report a Glasgow Coma Scale score of 9 because this indicates a neurological deficit.
g. A pain level of 6 on a scale from 0 to 10 is an expected finding for a client who has full thickness burns
over 70% of the total body surface area. A temperature of 37.9 C (100.2 F) is an expected finding for a
client whose core temperature is adapting to a hypermetabolic state.
h. A urine output of 40 mL/hr is within the expected reference range.
i.
j.
k. A nurse is planning teaching for a client who has acute kidney failure. Which of the following overthe-counter medications should the nurse recommend as safe for this client?
a. Naproxen
c. Magnesium hydroxide
b. Calcium carbonate
d. Gentamicin
e.
f. Calcium carbonate is safe for clients who have acute kidney failure.
g. Naproxen can cause nephrotoxicity and is not safe for a client who has acute kidney failure. Naproxen
can cause nephrotoxicity and is not safe for a client who has acute kidney failure. Gentamicin is
nephrotoxic and not safe for clients who have acute kidney failure.
h.
i.
j. A nurse is caring for a client following a lumbar puncture. Which of the following actions should
the nurse take?
a. Place a pillow under the client's knees.
b. Maintain the client in a dorsal recumbent position.
c. Restrict fluids for 2 hr.
d. Assist the client to ambulate after 30 min.
k.
l. Maintain the client in a dorsal recumbent position.
Should not place a pillow under the client's knees because it can impede circulation. Should encourage
fluid intake to replace lost cerebrospinal fluid. Should be maintained in a supine position for 1 to 12hr
following the procedure.
m.
n.
o. When administering RBCs to a client, which of the following actions should the nurse take?
a.
b.
c.
d.

Prime the administration set with lactated Ringer's solution.

Stay with the client during the first 30 min of the infusion.
Wait until the RBCs warm to room temperature before infusing.
Start a 22-gauge peripheral intravenous line.

p.
q.
The nurse should stay with the client for at least 30min, as most transfusion reaction manifest during
the infusion of the first 50 to 100mL of the blood product.
Blood should be administered with 0.9% sodium chloride solution and never with lactated Ringer's solution or
with a solution that contains dextrose. Blood products should be administered as soon as possible after
obtaining them from the blood bank to decrease the risk of bacterial growth. Blood components are viscous and
needle should be an 18 or 19 gauge.
r.

s.
t.
A nurse in a long term care facility is caring for four clients. Which of the following clients should be
moved to a private room?
a. A client with botulism.
b. A client with shingles.
e.
f.

c. A client with hepatitis.

d. A client with chlamydia.

A client who has shingles requires airborne precautions and therefore requires a private room.
g. A client who has botulism, hepatitis or chlamydia can share a room with another client who has the same
infectious process.
h.

i.
j.

A nurse is reviewing the laboratory results of a client who has aplastic anemia. Which of the
following findings indicates a potential complication?
a. RBC count 5.2 million/mm3
c. Platelet count 380,000 mm3
3
b. WBC count 2,000/mm
d. Potassium level 4 mEq/L
e.
f.
WBC count 2,000/mm3
g. This value is below the expected reference range and indicates a risk for severe immunosuppression.
h. All other values are within the expected reference range.
i.
j.
k. A nurse is caring for a client who has a leg cast and is returning demonstration on the proper use of
crutches while climbing stairs. (Move the steps into the box on the right, placing them in the
selected order of performance. All steps must be used.)
Place body weight on the crutches.
Advance the unaffected leg onto the stair.
Shift weight from the crutches to the unaffected leg.
Bring the crutches and the affected leg up to the stair.
l.
m.
n. A nurse is caring for a client who had a nephrostomy tube inserted 12 hr ago. Which of the
following findings should the nurse report to the provider?
a. The client's urinary output has increased.
b. The client is reporting back pain.
c. The client's urine color is red tinged.
d. The client's temperature is 37.7 C (100 F).
o.
p. The nurse should report back pain, which can indicate that the nephrostomy tube is dislodged or clogged.
The nurse should notify the provider also if there is a decrease in urinary output. Red tinged urine is an
expected finding for the first 12 to 24hr hollowing a nephrostomy tube insertion. A low grade fever is
expected in the first 24 hr.
q.
r.
s. A nurse is caring for a client in the PACU who has hypothermia. For which of the following
complications should the nurse monitor?
a. Hypertension
c. Cardiac tamponade
b. Metabolic alkalosis
d. Flail chest
e.
f. Hypothermia can cause vasoconstriction leading to hypertension.

g. Metabolic acidosis can result from hypothermia due to shivering. Cardiac tamponade & flail chest are not
complications or hypothermia.
h.
i.
j. A newly licensed nurse is caring for a client diagnosed with methicillin-resistant Staphylococcus
aureus (MRSA). Which of the following statements by the nurse indicates a need for further
training?
a. "I will use a mask if there is a potential for a splash from body fluids."
b. "I will wear a gown to protect against cross-contamination of my clothing."
c. "I will leave assessment equipment in the room to use on this client."
d. "I will need to move the client to a room with negative air flow."
k.
l. A client who has MRSA does not require a negative pressure airflow room because the mode of
transmission is not airborne.
The nurse should follow standard precautions and were a mask whenever there is a risk of splashing of
body fluids. Should follow contact precautions, and wear a gown to prevent cross contamination and use
dedicated equipment when assessing the client to prevent cross contamination with other clients.
m.
n.
o. A nurse is assessing a client who is taking carvedilol for heart failure. Which of the following
findings should the nurse report to the provider?
a. Fatigue
c. Orthostatic hypotension
b. Diarrhea
d. Weight gain
e.
f. Weight gain in a client who has heart failure indicates that the medication is not effective and the client's
condition is worsening.
Fatigue, diarrhea, and orthostatic hypotension are expected findings.
g.
h.
i. A nurse is caring for a client who has been having frequent premature ventricular contractions. The
client's potassium level is 3.8 mEq/L. Which of the following medications should the nurse administer?
a. Lisinopril
c. Lidocaine
b. Potassium chloride
d. Norepinephrine
e.
f. The nurse should administer lidocaine, an antidysrhythmic for short term treatment of ventricular
dysrhythmias.
g. Lisinopril is an ACE inhibitor that does not have antidysrhythmic properties. The client's potassium level
is within the expected reference range; therefore, the nurse should not anticipate administering potassium
chloride. Norepinephrine is a vasoconstrictor, which the nurse should not administer to treat ventricular
dysrhythmias.
h.
i.
j. A nurse is caring for a client who is in pulseless ventricular tachycardia. The nurse should recognize
that which of the following assessment findings requires defibrillation?
a. The client is unconscious.
b. The client has a respiratory rate of 8/min.
c. The client is cyanotic.
d. The client's blood pressure cannot be measured.
k.
l. Lack of consciousness indicates that the client has become unstable and requires emergency defibrillation.
m.
n.
o. A nurse is reviewing the laboratory findings of a client who had a myocardial infarction 6 hr ago.
Which of the following is an expected finding for this client?
a. Calcium 9.5 mg/dL
b. HDL 65 mg/dL

c. Troponin I 8 ng/mL
d. Alanine aminotransferase 35 units/L
p.
q. This value is above the expected reference range for Troponin I and is a specific marker of myocardial
infarction.
r.
s.
t. A nurse is caring for a client who is having a febrile reaction while receiving a blood transfusion.
The nurse should administer which of the following medications?
a. Cephalexin
c. Furosemide
b. Acetaminophen
d. Diphenhydramine
e.
f. The nurse should plan to administer an antipyretic such as acetaminophen for a febrile reaction to a blood
transfusion.
Diphenhydramine for a mild allergic reaction. Furosemide, a loop diuretic, for circulatory overload. IV
antibiotic such as cephalexin for sepsis due to receiving contaminated blood from a transfusion.

g. A nurse is providing teaching for a client who has a gastric ulcer and a new prescription for
omeprazole. The nurse should instruct the client that the medication provides relief by which of
the following actions?
c. Coating the stomach lining
a. Neutralizing gastric acid
d. Suppressing gastric acid
b. Reducing growth of ulcer-causing
production
bacteria

e.
f. Omeprazole is a proton pump inhibitor, which relieves symptoms of gastric
ulcers by suppressing gastric acid production.
g.
h.
i. A nurse is administering meperidine IM in the right deltoid of a client. The nurse aspirates and
pulls back blood in the syringe. Which of the following actions should the nurse take?
a. Obtain a new needle and continue administering the medication as
prescribed.
b. Withdraw the syringe and reinsert it in a different location.
c. Continue with the injection after pulling back on the needle slightly.
d. Dispose of the medication.
j.
k. The presence of blood indicate improper placement of the needle, and the
solution and needle are now contaminated. The nurse should dispose of the
medication according to facility protocol, and obtain a new dose of medication,
syringe, and needle.
l.