NP3 DRILL 1 4G

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Choose the correct answer.

Which of the following statements by a client indicates adequate understanding of post-
test care after a femoral approach is used for cerebral angiography? *
1 point

“I cannot move my neck.”

“I need to wear a neck brace.”
“I need to keep my leg
straight.”
“I need to keep my arm straight.”

After receiving a client who has had a femoral approach for cerebral angiography, the
nurse notices the puncture site is oozing bright red blood. Which is the most appropriate
action of the nurse?*
1 point

Document the findings.

Apply pressure to the
site. Monitor for changes.
Inform the physician.

A client has had a right femoral approach for cerebral angiography. The right groin
dressing is clean, dry, and intact, with no bruising or swelling at the site. The nurse
notices the client’s right foot has become cool, and the pedal pulse is no longer
palpable, or obtained with a doppler. Which is the most appropriate action of the
nurse?
*
1 point

Monitor for changes.

Apply pressure to the
site. Document the
findings.
Notify the physician.

A client with which of the following conditions is at risk for developing a low magnesium
level?*
1 point
alcoholism
pericarditis
prostatitis
lymphoma

Which of the following arterial blood gas values represents respiratory acidosis?*
1 point

pH = 7.60 , pCO2 = 38 mm Hg, HCO3 = 30 mEq/L

pH = 7.20, pCO2 = 36 mm Hg, HCO3 = 18 mEq/L
pH = 7.80, pCO2 = 32 mm Hg, HCO3 = 32 mEq/L
pH = 7.20 , pCO2 = 50 mm Hg, HCO3 = 24 mEq/L

Which of the following is an appropriate diet for the client with acute pancreatitis?*
1 point

low
cholesterol
clear liquids
regular
nothing by mouth

A client is taking a full liquid diet following gastric surgery. The nurse evaluates the
health teaching to be successful when the family brings in which of the following for the
client to eat?*
1 point

chopped vegetables
custard
pureed
fruits soft
cake

While doing a physical assessment on a client, the nurse suspects that the client has
poor nutritional status. Which of the following would confirm the nurse’s observations?*
1 point

flaccid soft muscles

firm, smooth pink nails
erect posture
moist buccal cavity mucous membranes

Which blood type is known as the universal donor?*

1 point

O
A
AB
B
A client that was started on a transfusion of packed red blood cells begins to complain
of chest tightness, anxiety, and shortness of breath. What should the nurse do first? *
1 point

Check the oxygen saturation.

Check the vital signs.
Monitor the client.
Stop the transfusion.

An elderly client admitted for dehydration and electrolyte imbalance states “Get these
bugs off of me.” The nurse would respond:*
1 point

“I’ll just brush them away for

you.” “I do not see any bugs.”
“Your electrolyte imbalance is making you feel this
way.” “There are no bugs here. You are imagining
them.”

The physical examination and evidence collection is completed on a sexual assault

victim. The victim is sitting motionless and appears dazed and unaware of the
surroundings. The nurse would interpret the behavior as:*
1 point

indications of a severe mental disorder.

normal behavior following a traumatic event.
signs that the person should be hospitalized.
signaling the need for suicide precautions.

Common causes of hyperkalemia include the following except:*

1 point

poor urine output for days.

p o t s diuretics.
re n a l
s iu m -
in s uf
w a s ti n g
f ic ie n c y .
administration of IV solutions with large doses of potassium chloride in each solution.

A client, 68 years old, has a calcium deficit. Her serum calcium level is 3.6mEq/L. The
client’s serum calcium level is:*
1 point

low average.
normal.
severely
low. slightly
low.

Nurse Troy writes, “Knowledge deficit regarding prevention of crisis” on the nursing care
plan of a client, an 18-year-old male with sickle cell anemia. After a client has been
taught to avoid situations that can precipitate a crisis, which of the following actions
would indicate a need for follow-up education?*
1 point

applying for a driver’s permit

staying up until 3:00 A.M. to study for a test
applying antiseptic to a cut on his finger
planning a vacation at a beach resort

In a patient suspected of having aplastic anemia, the nurse should plan to: *
1 point

assess for renal disease and administer prescribed folic acid.

teach the patient which foods have a high iron content and administer prescribed
iron. advice the client to sleep every time
take a thorough history of medication and chemical exposures.

The physician orders 25 milligrams of diphenhydramine hydrochloride (Benadryl) prior

to a blood transfusion for a patient. The nurse knows this product is often given prior to

a blood transfusion because:*

1 point

it will make the patient drowsy, and he will sleep during the blood
transfusion. it will prevent sneezing and accidental dislodgement of the IV.
it will prevent the transmission of hepatitis.
it decreases the chance of an allergic reaction to the blood.

A patient asks a nurse what’s the definition of total parenteral nutrition (TPN). The nurse
responds by saying:*
1 point

“An inexpensive way to give protein and vitamins.”

I t i s a c n v e ie n t m e t h o o f
“ A n IV so
o lu t ion t h a t p r o v id de s
p ro v id i n g
a d e q u a t e nutrition.”
trition.” “TPN is part of long-
term patient care.”

How can total parenteral nutrition (TPN) be of primary value in a patient receiving
chemotherapy who has stomatitis and severe diarrhea?*
1 point

These symptoms will resolve if the patient does not take oral
nutrition. TPN will prevent nosocomial infections.
It will prevent dehydration.
It will provide nutrition.

Which of the following stages of NREM sleep is thought to restore the body physically? *
1 point
NREM
IV REM
NREM II
NREM III

The nurse should use which assessment tool to evaluate Mr. James Reid nutritional
patterns?*
1 point

anthropometric measurements
height and weight measurements
lipid profile
24-hour diet recall

Which type of jaundice is due to increased destruction of erythrocytes?*

1 point

obstructive
hepatocellular
hemolytic
Both 2 and 3 are correct

When assessing a patient admitted with a bleeding gastric ulcer, the nurse should
expect to find which of the following stool characteristics?*
1 point

clay
colored
black, tarry
bright red
coffee-ground color

The nurse is providing postoperative care to a patient who has had a craniotomy.
Which of the following observations would require immediate attention?*
1 point

pale, warm skin and a temperature of 99°F

increased blood pressure and decreased pulse
rate negative glucose reading in nasal mucus
continued unresponsiveness to verbal stimuli

Upon assessment, the nurse notes hepatomegaly, ascites, dependent edema, and
jugular neck vein distention. The nurse understands that which of the following
mechanisms accounts for these symptoms?*
1 point

backward effects of right ventricular

failure end-stage left ventricular failure
end-stage cirrhosis of the liver
backward effects of lymphatic obstruction

Which of the following arterial blood gas values represents metabolic alkalosis?*
1 point

pH = 7.20 , pCO2 = 36 mm Hg, HCO3 = 18 mEq/L

6 , 3 8 ,
pH = 7. 10
0, p CO2 = 5 0 mm Hg,
Hg H
H C O 3 = 30 m E q /L
C O 3 = 24 m E q/ L pH = 7.30, pCO2 =
50 mm Hg, HCO3 = 24 mEq/L

Which of the following arterial blood gas values represents respiratory alkalosis?*
1 point

pH = 7.30, pCO2 = 50 mm Hg, HCO3 = 24 mEq/L

pH = 7.20, pCO2 = 36 mm Hg, HCO3 = 18 mEq/L
pH = 7.80, pCO2 = 37 mm Hg , HCO3 = 32 mEq/L
pH = 7.60 , pCO2 = 38 mm Hg, HCO3 = 30 mEq/L

Which of the following is a sign or symptom of hypothyroidism?*

1 point
weight
gain
weight loss
diaphoresis
palpitations

Nocturia is best defined as:*

1 point

awakening at night to urinate.

painful and difficulty voiding.
total urine output of less than 30 cc/hr.
voiding more frequently than every 3 hours.

Which of the following foods are most likely to exacerbate acute cholecystitis?*
1 point

potatoes
bacon
beans
apples

The loop diuretics such as furosemide (Lasix) and bumetanide (Bumex) can be
ototoxic. This effect is enhanced when certain antibiotics are given concomitantly. An
example of an antibiotic that could potentiate ototoxicity is:*
1 point

a cephalosporin antibiotic such as cefoxitin (Mefoxin).

an aminoglycoside antibiotic such as gentamicin (Garamycin).
a beta-lactam antibiotic such as ampicillin (Omnipen,
Polycillin). a macrolide antibiotic such as azithromycin
(Zithromax).

What foods have the highest content of potassium and are included in a client’s care
plan when at risk for hypokalemia?*

1 point
canned soups and milk
carrots, squash, and okra
potatoes, apricots, broccoli
whole grain products,
apples

A patient has undergone “a classic cholecystectomy.” To promote comfort when

coughing, the nurse should teach the patient to:*
1 point

lean forward when coughing.

lie down on left side when coughing.
dangle feet on the side of the bed before
coughing. sit up and support abdomen with pillow.

Which of the following nursing diagnoses is most appropriate for the client who has
recently had surgery for repair of a mandibular fracture?*
1 point

impaired mobility
activity intolerance
imbalanced nutrition
bowel incontinence

Which of the following statements by a client going home after a below the knee
amputation indicates further need for teaching by the nurse?*
1 point

“I will only wear a residual limb sock on the

stump.” “I will perform range of motion daily.”
“I will change the residual limb sock weekly.”
“I will check my stump daily for signs of irritation.”

A patient is placed on a higher than usual dose of an opioid analgesic for pain
management of osteosarcoma. He asks the nurse if he is becoming a drug addict. An
appropriate response by the nurse is:*
1 point

“Opioids have never been shown to produce addiction in those who take them only for pain.”
“Addiction and tolerance are not the same. Your body needs more medicine now and it is
important not to undertreat your pain.”
“If you feel you are becoming addicted, switch your medicine to Tylenol.”
“Yes, the drugs you are taking are highly addictive, but you can be detoxed later.”

A client who is a Jehovah’s Witness needs a transfusion of packed red blood cells but
refuses the transfusion. What is the appropriate response of the nurse?*
1 point

Have the client sign a refusal form.

Lecture the client on the need for
blood. Give the transfusion anyhow.
Berate the client for such beliefs.

What is the maximum amount of time that packed red blood cells may be administered?
*
1 point

3 hours
5 hours
2 hours
4 hours

CJ, a patient with a serious GI illness has been receiving total parenteral nutrition
(TPN) for 2months. Today CJ reports right upper quadrant abdominal pain radiating to
the right shoulder. Nurse Rome would suspect:*
1 point

myocardial infarction (MI).

pneumonia.
infection
cholecystolithiasis.

Which of the following situations is considered to be sensory overload?*

1 point

a person who is blind and deaf

a prisoner in solitary confinement
a person with post-operative pain for three weeks
a client in ICU for 14 days

A patient who has suicidal intentions would be experiencing which class of crisis?*
1 point

developmental crisis
dispositional crisis
anticipated life transition crisis
psychiatric emergencies crisis
Jeremiah is diagnosed as having respiratory insufficiency due to longstanding restrictive
lung disease as a result of working in the coal mines for 35 years. Jeremiah should be
advised to prevent or control respiratory infections by:*
1 point

taking influenza injections and broad- spectrum antibiotics as prescribed.

having periodic blood studies to determine his PO2.
smoking low-tar cigarettes.
taking penicillin for the rest of his life as prophylaxis.

The nurse suspects that a patient with diabetes is experiencing ketoacidosis. What
manifestations is the nurse observing?*
1 point

tachycardia and pale, moist skin

bradycardia and dry, pale mucous membranes
hypertension and dry mucous membranes
hypotension and dry, hot, flushed skin

Client Mel, who is 64 years old, has chronic renal failure. Nurse Issa observes the
following measurements: BUN 64, hemoglobin 8.8, creatinine 2.4, and a urine output of
250 ml over the past 24 hours compared with a 10000-ml intake. An appropriate nursing
diagnosis for this set of data is:*
1 point

urinary retention related to intake greater than output.

fluid volume excess related to inability of the kidney to maintain body fluid balance.
anemia related to impaired renal function.
high risk for injury related to possible seizure activity.

Dr. Yap orders 250 milliliters of packed red blood cells (RBC) for a patient, you can

assume that this therapy is for treatment of:*

1 point

thrombocytopenia.
anemia.
hypoalbuminemia.
leukopenia.

Mr. Roxy Aquino requires a whole blood transfusion. In order for Transfusion Services
(the blood bank) to prepare the correct product, a sample of the patient’s blood must be
obtained for:*
1 point

a blood type and cross-match.

a complete blood count and
differential. a blood culture and
sensitivity.
a blood type and antibody screen.

Client Haina is undergoing a paracentesis, the client suddenly develops hypotension as

the peritoneal fluid is being drained. Which of the following is an appropriate action of
nurse Shaine?*
1 point

Monitor the blood pressure.

Document the blood pressure.
Slow the drainage rate.
Increase the drainage rate.

Which clients with the following diagnoses might warrant fecal occult blood testing?*
1 point

cerebral bleeding
gastrointestinal bleeding
vaginal bleeding
tracheal bleeding

Which of the following statements by a client who has undergone an outpatient

esophagogastroduodenoscopy indicates adequate understanding of post-test
instructions?*
1 point

“I will take Tylenol for a fever.”

“I will need someone to drive me home.”
“I can drive myself home after the test.”
“I can eat and drink right after the test.”

A patient has problems ambulating secondary to “foot drop.” A “foot drop” is what type
of contracture?*
1 point

foot in plantar extension

foot in plantar flexion
ankle with twisted flexion
hip with a fibrotic contracture

Venous stasis that occurs with decreased muscular contraction when a patient is on
bed rest (immobility) predisposes him/her to:*
1 point

orertshpoirsattaotricy haycpido
otesnis
s. ion.
deep vein thrombosis.
decreased cardiac
workload.

A nurse asks a client to describe the quality of pain currently experienced. Which is an
expected term for the client to use?*
1 point

intermittent
severe
stabbing
chronic

Pain in the elderly requires careful assessment because older people have which of the
following characteristics?*
1 point

decreased pain tolerance

increased pain tolerance
are likely to experience chronic pain
experience reduced sensory perception

Which vitamin is deficient in the diet of a client diagnosed with scurvy?*

1 point

vitamin
B
vitamin
A vitamin
C vitamin
D

What foods would most benefit a client with scurvy?*

1 point

oranges, broccoli, liver

csewreeatl,poeta
atnouetsb,
uctht ere, sfeis,hcantaloupe cheese,
grain cereal, milk

A patient with advanced cancer of the stomach is undergoing surgery to take out part
or debulk the tumor. This is known as surgery.*
1 point

palliative
tertiary
restorative
curative
Nurse Sheandrei is teaching a nutrition course at the local retirement center. Due to the
decreased peristalsis in older adults, many struggles with constipation. What
recommendation Nurse Sheandrei can make to help prevent this common problem?*
1 point

Increase fiber intake.

Take aspirin once a
day. Increase vitamin E.
Decrease water intake.

Ms. Milleny, aged 22 is admitted with seizure activity. Her electrolyte values are as
follows: Na, 115mEq/L; K, 3.0 mEq/L; Ca, 8.0 mg/dL; and Mg, 1/0 mEq/L. Which
imbalances must be controlled to reduce her seizure activity?*
1 point

Na and
Ca Na
and K K
and Ca
Mg and K

The most common sign of thrombocytopenia is:*

1 point

melena.
hemarthosis.
hemostasis.
petechiae.

What is the best indication that a client is not getting adequate sleep? *
1 point

the patient reports not sleeping well

inability to concentrate
amount of time the client sleeps or doesn’t sleep
general appearance

The physiology of sleep is complex. Which of the following is the most appropriate
statement in regards to this process?*
1 point

The RAS is partially responsible for the level of consciousness of a person.

The Basal metabolic rate causes the REM sleep in most normal activities.
NREM refers to the cycle most patients experience when in a high stimulus environment.
Ultradian rhythm occurs in a cycle longer than 24 hours.

When a client is deprived of sleep, the nurse might assess such symptoms as: *
1 point
rapid respirations and inappropriateness.
confusion and mistrust.
decreased temperature and talkativeness.
elevated blood pressure and confusion.

During a routine health exam, the client Romar asks the nurse which foods he should
eat on a low cholesterol diet. Which of the following could Nurse Matthew use as
examples of foods consistent with a low cholesterol diet?*
1 point

eggs, potato chips, cottage cheese

steak, cheese, leafy vegetables
chicken, breads, fruits, beans
liver, yogurt, bread, rice

Carl, an elderly client expresses difficulty sleeping because his spirit is disturbed
because of sin in his life. Which intervention would have priority?*
1 point

Call the chaplain and schedule a visit.

Ascertain what religious practice is appropriate to the client.
Pray immediately with the client.
Administer sleep medications as ordered.

Client Dimple, who has type I diabetes mellitus, is experiencing nausea and vomiting.
Which action indicates that she understands the “sick day rules” for diabetes
management?*
1 point

drinking nondiatetic ginger ale

abandoning his normal meal timing in favor of getting an extended period of sleep
taking 2/3 of his normal insulin dose

monitoring his blood glucose every 6 hours

A client is to undergo bone marrow transplantation (BMT) for treatment of leukemia
and is receiving pre-procedure teaching with regard to nutrition. Which of the following
nutritional support options would most likely be utilized for this client?*
1 point

oral feedings as soon as possible following BMT to prevent gastroparesis

total parenteral nutrition (TPN) for a period of months to maintain nutritional balance
insertion of a PEG tube following the GMT to maintain nutritional balance
supplementation with enteral feedings to prevent catabolism
Junna, a client who is an intravenous drug abuser had an appendectomy. She
requests morphine sulfate for pain relief every hour, and it is only ordered every four
hours. What is the appropriate response of the nurse?*
1 point

Notify the physician of her request.

Let her know his addiction may get worse.
Instruct her on possible side effects.
Tell her it is only ordered every four hours.

Which statement made by a client following teaching about the importance of using only
unsaturated fats when cooking indicates that information about which fats are
unsaturated was understood?*
1 point

“I will use palm oil when cooking.”

“I will use lard when cooking.”
“I will use olive oil when cooking.”
“I will use butter when cooking.”

Client Carl James, comes to the clinic complaining of unexplained black and blues and
bloody appearing urine. Which type of medication is it most important to find out if the
client is taking?*
1 point

Antibiotic
Anticoagulant
Antipruritic
Antianemic

Nurse Shainna is monitoring the effects of bronchodilators, which of the following should

be included?*
1 point

Observe client for adverse effects and ensure that he uses metered-dose inhalers
correctly every hour.
Observe client for cyanosis, rapid respiratory rate, and monitor magnesium levels.
Monitor for cyanosis of lips, earlobes, nail beds and mucous membranes, and monitor
theophylline levels.
Be familiar with client’s VS, and monitor their bowel sounds and respiratory effort.

Client Denise complains of constipation. In assessing this complaint, which is the most
important question for nurse Marie to ask?*
1 point

How often do you normally move your bowels?

Do you strain when you move your bowels?
When did you move your bowels last?
What is the consistency of the stool?

Foods such as scallops, red wine, and gravies should be restricted in the diet of clients
with which disease?*

1 point
Muscular dystrophy
Gout
Rheumatoid arthritis
Systemic lupus erythematosus

Place the phases or stages of the inflammatory response in the correct sequential
order, do NOT include any phases that is NOT part of the inflammatory process. 1. The
vascular phase 2. The prodromal phase 3. The incubation phase 4. The initial injury 5.
The exudate phase 6. The convalescence phase*
1 point

4,5,1
4,1,5
4,2,5
4,2,1

*
1 point

Option 1
Option 3
Option 2
Option 4

Nurse Thea caring for a post-operative client who is complaining of abdominal

distention and flatus. Which intervention would Nurse Thea most likely do for this
client?
*
1 point

cleansing enema
A laxative
A retention enema
A return-flow
enema

Nurse Marianne is planning discharge education for your client who has a new
colostomy. Which complication of a colostomy should Nurse Marianne educate this
client about?*
1 point
Nocturnal enuresis
GI stone formation
A prolapsed
stoma
A vitamin B12 deficiency

Nurse Camille is working as a wound care nurse. she measures the size of a client’s
wound and it is 3 cm deep, 2 cm long and 4 cm wide. Nurse Camille would document
the dimension of this wound as:*
1 point

12 cm
6 cm
24 cm
20 cm

Client Denden had a ruptured appendix and peritonitis. What type of healing would be
most likely for this client?*
1 point

Secondary prevention
healing Primary prevention
healing Secondary intention
healing Tertiary intention
healing

Which of the following theories of pain are you utilizing when you recognize the fact that
some of the factors that open this “gate” to pain are low endorphins and anxiety and
that some of the factors that close this “gate” to pain are decreased anxiety and fear? *
1 point

The Specificity Theory of Pain

Melzack and Wall’s theory of pain
The Intensive Theory of Pain

Moritz Schiff’s theory of pain

Christine is a 20-year-old female attending college is found unconscious in her dorm
room. She has a fever and a noticeable rash. She has just been admitted to the
hospital. Which of the following tests is most likely to be performed first?*
1 point

Blood cultures
Arterial blood gases
CT scan
Blood sugar check

Nurse Pauline routinely use the PQRST method to assess pain. The PQRST method
consists of:*
1 point

Precipitating factors, the quality of the pain, the region or area of the pain, the severity of the
pain, and the pain triggers
Precipitating factors, the quality of the pain, relief factors, the severity of the pain, and the pain
triggers
Pain level, the quality of the pain, the region or area of the pain, the severity of the pain, and
the
pain triggers
Pain level, the quantitative numerical pain score, the region or area of the pain, the severity of
the pain, and the pain triggers

The A, B, C, and Ds of a complete and comprehensive nutritional assessment

includes:*
1 point

Anthropometric data, biological data, chemical data and dietary data

Anthropometric data, biochemical data, clinical data and dietary data
Ancestral cultural data, biochemical data, clinical data and dietary data
Assessment data, biochemical data, clinical data and dietary data

Nurse Pauline will be administering packed red blood cells to your client. Which of the
following principles should Nurse Pauline apply to this blood administration?*
1 point

Nurse Pauline will need the help of another nurse prior to the administration of these packed
red blood cells.
Nurse Pauline must ensure that the client has a patent intravenous catheter that is at least 20
gauge.
The unit of packed red blood cells should start no more than 1 hour after it is picked
up. Nurse Pauline must remain with and monitor the client for at least 30 minutes
after the transfusion begins.

Melanie, a clinical instructor, in the operating room with a student nurse. The client has

received general anesthesia. The student nurse says, “Oh no, the general anesthesia is
not working. The client is shaking and moving.” How should you respond to this student
nurse?*
1 point

“This often happens during stage 2 of general anesthesia.”

"The client needs more general anesthesia.”
“The client is having a seizure.”
“The client is having anesthesia awareness which is not good.”

Intussusception occurs when:*

1 point

An ileostomy stoma retracts below the abdominal surface.

Lungs are infiltrated.
Part of the intestine slides into another part of the intestine.
The appendix ruptures.

You are having a nice dinner in a fancy restaurant. As you are eating, you hear the
gentleman eating at the next table start to bang the table, hold his throat and forceably
cough. What should you do?*
1 point

Encourage the person to continue coughing

Begin CPR and prepare for ACLS measures
Perform the Valsalva maneuver
Perform the Heimlich maneuver

Nurse Raquel is assigned to telephone triage. A client called who was stung by a
honeybee and is asking for help. The client reports pain and localized swelling but has
no respiratory distress or other symptoms of anaphylactic shock. What is the
appropriate initial action nurse Raquel should direct the client to perform?*
1 point

Taking an oral antihistamine

Removing the stinger by scraping it
Call Emergency and Disaster for transport and assistance.
Applying a cold compress

Nurse Leinus is conducting nutrition counseling for a patient with cholecystitis. Which of
the following information is important to communicate?*
1 point

The patient must maintain a high protein/low carbohydrate diet.

The patient should limit fatty foods.
The patient must maintain a low-calorie diet.
The patient should limit sweets and sugary drinks.

Client Laarni arrives at the emergency department who suffered multiple injuries from a
head-on car collision. Which of the following assessment should take the highest
priority to take?*
1 point

Unequal pupils
A deviated trachea
Ecchymosis in the flank
area Irregular pulse

A group of people arrived at the emergency unit by a private car with complaints of

periorbital swelling, cough, and tightness in the throat. There is a strong odor emanating
from their clothes. They report exposure to a “gas bomb” that was set off in the house.
What is the priority action?*
1 point

Direct the clients to the decontamination area

Direct the clients to the cold or clean zone for immediate treatment

Imnsmtruecdtiaptelrysorenmneolvteo

odtohnerpcelriesonntsalapnrdotveiscitiovres efrqoumipmthenat rea

Client Marcelo arrives in the emergency unit and reports that a concentrated household
cleaner was splashed in both eyes. Which of the following nursing actions is a priority? *
1 point

Examine the client's visual acuity

Flush the eye repeatedly using sterile normal
saline Use Restasis (Allergan) drops in the eye
Patch the eye

Client Chretienne was brought to the emergency department after suffering a closed

head injury and lacerations around the face due to a hit-run accident. Client Chretienne
is unconscious and has a minimal response to noxious stimuli. Which of the following
assessment findings if observed after few hours, should be reported to the physician
immediately?*
1 point

Withdrawal of the client in response to painful stimuli

Bruises and minimal edema of the eyelids
Drainage of a clear fluid from the client's nose
Bleeding around the lacerations

Client Queen, 23-year-old male client who has had a full-thickness burn is being

discharged from the hospital. Which information is most important for the nurse to
provide prior to discharge?*
1 point

How to maintain home smoke detectors

Joining a community reintegration program
Learning to perform dressing changes
Options available for scar removal

Client Dany has a large burned area on the right arm. The burned area appears pink,
has blisters, and is very painful. How will the nurse categorize this injury?*
1 point

Full-thickness
Partial-thickness deep
Full-thickness deep
Partial-thickness superficial

A 22-year-old female named Michaela who ingested 15 tablets of maximum strength

acetaminophen 45 minutes ago is rushed to the emergency department. Which of these

orders should the nurse do first?*

1 point

Have the patient drink activated charcoal mixed with water

Administer acetylcysteine (Mucomyst) orally
Start an IV Dextrose 5% with 0.33% normal saline to keep the vein open
Gastric lavage

The hospital has sounded the call for a disaster drill on the evening shift. Which of these
clients would the nurse Mercado put first on the list to be discharged in order to make a
room available for a new admission?*
1 point

An elderly client with a history of hypertension, hypercholesterolemia, and lupus, and was
admitted with Stevens-Johnson syndrome that morning.
An adolescent with a positive HIV test and admitted for acute cellulitis of the lower leg 48 hours
ago.
A middle-aged client with a history of being ventilator dependent for over seven (7) years and
admitted with bacterial pneumonia five days ago.
A young adult with diabetes mellitus Type 2 for over ten (10) years and admitted with antibiotic-
induced diarrhea 24 hours ago.

In children suspected to have a diagnosis of diabetes, which one of the following

complaints would be most likely to prompt parents to take their school-age child for
evaluation?*
1 point

Weight loss
Bedwetting
Polyphagia
Dehydration

Which of the following should the nurse implement to prepare a client for a KUB
(Kidney, Ureter, Bladder) radiography test?*
1 point

Enema to be administered prior to the examination

No special orders are necessary for this examination
Medicate client with furosemide 20 mg IV 30 minutes prior to the
examination Client must be NPO before the examination
Jerald, triage nurse has these four (4) clients arrive in the emergency department within
15 minutes. Which client should the triage nurse send back to be seen first? *
1 point

Lianne, an elderly client with complaints of frequent liquid brown colored stools
Kelvin, a 2-month-old infant with a history of rolling off the bed and has bulging fontanelle with

c r y in
G e o r g e , a middle-aged client with intermittent pain behind the right
scapula Joshua, a teenager who got a singed beard while camping

Client Sheena is scheduled for a magnetic resonance imaging (MRI) scan. Which of the
following is a contraindication to the study for this patient?*
1 point

The patient is allergic to shellfish.

The patient suffers from claustrophobia.
The patient takes antipsychotic medication.
The patient has a pacemaker.

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