PREBOARD 11

1.) The nurse is caring for an older adult client who was admitted to the telemetry unit following a minor
surgical procedure. The client’s history includes insulin-dependent diabetes and a previous myocardial
infarction. The client’s telemetry monitor alarms and the rhythm shows asystole. Prioritize the actions
the nurse should take from highest priority (top to lowest priority (bottom).
1. Confirm ECG lead placement
2. Obtain a blood glucose level
3. Check level of consciousness
4. Assess respiration and pulse
5. Initiate emergency response system if indicated

2.) The nurse is preparing to administer a feeding through a percutaneous endoscopic gastrostomy tube.
What nursing action is needed before starting the feeding? Select all that apply.
1. Keep the feeding product refrigerated until ready to use
2. Verify the length and placement of the tube
3. Milk or massage the tube
4. Flush the tube with 30 mL of warm water
5. Elevate the head of the bed 30 to 45 degrees
6. Palpate the abdomen

3.) A client who previously had a stroke refuses to take the daily aspirin prescribed by their health care
provider. Which statements should the nurse include in her response to the client? Select all that
apply.
1. “Can you tell me what concerns you have about the aspirin?”
2. “Would you like to take aspirin at another time of day?”
3. “If you don’t take aspirin every day, you might die.”
4. “Do you take your other medications as prescribed by your provider?”
5. “Do you experience any nausea when you take the aspirin?”

4.) The nurse asks an unlicensed assistive person (UAP) to help with repositioning of a client in bed.
Which actions by the nursing staff support correct ergonomics and safe client handling? Select all that
apply.
1. Use a friction-reducing device/sheet underneath the client.
2. Instruct the client to hold their breath.
3. Coordinate lifting together by counting to three.
4. Ask a visiting family member to help.
5. Adjust the height of the bed to hip level.
6. Lower the head of the bed into a flat position.

5.) The nurse who cares for clients undergoing treatment for cancer might expect clients diagnosed with
cancer to make the following statements about their grief. Based on an understanding of the
Kubler/Ross stages of grief, place the statements in the correct order.
1. “If I eat a more balanced diet, I can live longer.”
2. “I think the tests got mixed up.”
3. “I don’t know where to go or what to do.”
4. “I will just go on with my life.”
5. “I am so mad at everyone for always reminding me that I have it.”
6.) The nurse working in a community clinic is administering an influenza vaccine. Which is the
appropriate IM injection site on an adult client? Use your cursor to select an area on the image below.

7.) Following a surgical procedure, pneumatic compression devices are applied to both lower extremities
of an adult client. The client reports that the device is hot and the client is sweating and itching.
Which steps should the nurse take? Select all that apply.
1. Inform the client that removing the device will likely result in the formation of DVT
2. Collaborate with the primary health care provider for anti-embolism stockings to be worm
under the sleeves of the device.
3. Explain that the primary health care provider ordered the device and it cannot be removed.
4. Confirm pressure setting of 45 mm Hg
5. Check for appropriate fit

8.) While being admitted for surgery, a client refuses to sign the surgical consent form. Which nursing
actions should the nurse take? Select all that apply.
1. Have a family member sign the consent form.
2. Inform the unit charge nurse.
3. Document the client’s refusal in the medical record.
4. Notify the health care provider.
5. Convince the client to sign the consent form.

9.) The nurse is evaluating the plan of care for a client who has been requesting a daily laxative to aid in
having a bowel movement. What additional interventions should the nurse include in the client’s plan
of care? Select all that apply.
1. Instruct the client to walk at least 30 minutes 3 to 5 times per week.
2. Encourage the client to drink more caffeinated beverages.
3. Have the client keep a bowel elimination record.
4. Request a prescription for psyllium.
5. Encourage the client to drink 2 to 3 liters of fluids a day.

10.) The parent of an 8-month-old infant asks the nurse if the child’s language development is
appropriate for this age. Which sounds should the nurse anticipate at this age? Select all that apply.
1. Babbles in a rhythm similar to spoken language
2. Squeals and yells to signal happiness or displeasure
3. Meaningful words single vowel sounds such as ah, eh and uh
4. Cooing, gurgling and laughing aloud
5. Vocalizes in response to voices
11.) The nurse is collecting data form an adolescent client. Which of the following issues should the nurse
address? Select all that apply.
1. “Have you decided what you are going to do after high school?”
2. “Have you gotten in any trouble lately?”
3. “Are you currently having conflicts with someone close to you?”
4. “Where are you currently living?”
5. “How many sexual partners have you had in the past six months?”
6. “How are things going at home?”

12.) The nurse is counselling a postpartum client who has a history of a substance-abuse problem. Which
question is a priority when interviewing the client?
1. When was the last time you used illegal substances?
2. Do you feel that you have bonded with your infant?
3. How have you managed the stress of being a new mother?
4. Have you attended any support groups related to substance abuse?

13.) The home health nurse is developing a plan of care for a 3-year-old client diagnosed with cerebral
palsy (CP). Which goals are the priority for this client? Select all that apply.
1. Promote locomotion
2. Prevent seizures
3. Arrange for genetic counseling
4. Select appropriate school environment
5. Treat muscle spasms

14.) The client is admitted in stable condition from the emergency department. Based on the ECG strip,
the nurse anticipates which of the following types of medications will be ordered? Select all that
apply.

1. Vasodilator
2. An anticoagulant
3. Calcium channel blocker
4. Cardiac glycoside
5. Beta blocker
6. Diuretic

15.) A client is transported to the emergency department following a boating accident and submersion in
cold water. The client is conscious, shivering and confused. What interventions should the nurse
implement? Select all that apply.
1. Massage extremities
2. Monitor vital signs
3. Administer warmed IV fluids as ordered
4. Give the client warm tea
5. Monitor level of consciousness
6. Provide warmed blankets
7. Remove wet clothing
16.) The nurse is caring for a newly admitted 6 month-old infant diagnosed with nonorganic failure-to-
thrive (NOFTT). What findings would the nurse expect to observe during the initial assessment?
1. Irritable and “colicky,” making no attempts to turn or sit up
2. Pale skin, thin arms and legs and uninterested in surroundings
3. Alert, laughing, playing with a rattle and sitting with support
4. Dusky in color with poor skin turgor over abdomen

17.) The nurse is caring for a client receiving mechanical ventilation when the device signals a high-
pressure alarm. The nurse should include what assessments in addressing this alarm? Select all that
apply.
1. Assess client for partial or total extubation
2. Assess client for signs of bronchospasm
3. Assess tubing to ensure it is not kinked
4. Assess for obstructing secretions
5. Assess the client’s behaviour (coughing, biting, gagging, etc.)

18.) The nurse on the mental health unit is assigned to a client diagnosed with post-traumatic stress
disorder (PTSD). What priority interventions shall the nurse include in the client’s plan of care? Select
all that apply.
1. Medicate the client with a sedative while they experience flashbacks.
2. Place the client in a secluded area away from others.
3. Discuss the coping strategies the client is using in response to the trauma.
4. Stay with the client during periods of flashbacks and nightmares.
5. Encourage the client to talk about the trauma at their own pace.
6. Assign the same staff to the client as often as possible.

19.) The nurse is caring for a client who is receiving isoniazid for tuberculosis (TB). Which assessment
finding would indicate the client is having a possible adverse response to this medication?
1. Headache and nausea
2. Tinnitus and decreased hearing
3. Tingling in extremities
4. Yellowing of the sclera

20.) The nurse is caring for a client who has end-stage renal disease and is scheduled for hemodialysis
later today. The client has an arteriovenous fistula. Which interventions should the nurse implement
to help prepare the client for dialysis? Select all that apply.
1. Ensure the client eats a high fiber, high protein breakfast
2. Weigh the client
3. Hold all oral medications
4. Assess the patency of the fistula
5. Administer Vitamin D, as prescribed
6. Administer the phosphate binder, as prescribed
21.) The nurse is caring for a client who underwent a laparoscopic procedure to diagnose and excise
endometriosis. Where would the nurse expect to find the incision? Use your cursor to select an area
on the image below.

22.) The nurse admits a client to the mental health unit with suspected bulimia nervosa. Which lab result
is most likely to confirm the nurse’s diagnosis?
1. A Ph value of 7.50
2. A serum calcium of 11 mg/dL
3. A serum sodium of 140 mEq/L
4. A serum glucose of 76 mg/dL

23.) The nurse is working in a health care setting that utilizes an electronic medical record (EMR) for
documentation. Which actions will reduce the risk for inappropriate access to confidential client
information? Select all that apply.
1. The nurse reviews only the medical records of assigned clients during their shift.
2. The nurse utilizes the automatic sign-off to close the medical record after a period of
inactivity.
3. The system administration department monitors all medical records accessed by staff
members.
4. The nurse changes their personal password for the EMR more frequently than required.
5. The nurse writes down their current password on a list that’s kept in the manager’s office.

24.) Where should the nurse administer the annual purified protein derivative (PPD) to the client with a
left arm arteriovenous (AV) fistula? Use your cursor to select an area on the image below.

25.) The nurse is assigned to a client who is receiving treatment for a traumatic head injury. The client’s
blood pressure on admission was 140/70 mmHg. Four hours later, the blood pressure increased to
179/68 mmHg. The nurse is trying to determine if the client has widening pulse pressure as a result of
increased intracranial pressure (ICP). What is the difference in pulse pressures? Record your answer
as a whole number.
1
26.) The nurse is developing a plan of care for a client who underwent total hip arthroplasty 24 hours ago.
Which interventions should the nurse include? Select all that apply.
1. Encourage the use of an abduction pillow or splint between the legs
2. Encourage the client to perform leg exercises while in bed
3. Encourage the client to use the incentive spirometer every 2 hours
4. Remind the client to not bend the knee of the affected leg while seated
5. Assist the client with a clear liquid diet
6. Provide a seat riser for the toilet or commode

27.) A client with late-stage lung cancer was started on chemotherapy two days ago and might be
experiencing tumor lysis syndrome. Which findings support this diagnosis? Select all that apply.
1. A serum phosphorus level of 1.8 mg/dL
2. A serum creatinine level of 2.4 mg/dL
3. A serum potassium level of 3.0 mg/dL
4. Weakness and muscle cramps
5. A serum calcium level of 13.8 mg/dL
6. A serum uric acid level of 22 mg/dL

28.) The nurse is using the image below to explain and clarify teaching for a client with a new colostomy.
Based on this image, which of the following statements about the consistency of the drainage is
correct?

1. The feces are semiformed to formed

29.) A nurse is caring for a client after a spinal fusion to treat scoliosis. Which nursing intervention is
appropriate in the immediate postoperative period? Select all that apply.
1. Perform neurovascular check every 8 hours
2. Position the client flat in bed and logroll every 2 to 4 hours
3. Encourage use of patient-controlled analgesia
4. Encourage passive leg and ankle exercises
5. Assist the client to stand and walk to the bathroom as needed
6. Maintain bedrest with the head of the bed elevated at least 30 degrees
30.) The nurse is performing a pulmonary assessment on a client. Indicate the correct sequence of a
pulmonary assessment by dragging and dropping the steps below into the correct order.
1. Inspection
2. Percussion
3. Palpation
4. Auscultation

31.) The health care provider writes a new order for a fentanyl patch to manage chronic pain experienced
by a client in hospice care. The nurse is teaching the client and family members about the fentanyl
patch and knows that teaching was effective when the client makes which of the following
statements? Select all that apply.
1. “I can soak in a hot tub to help decrease my pain.”
2. “If my pain is too great while I am on the patch, I can take a supplemental pain medication.”
3. “I should cut up the patch before I throw it away so no one else can use it.”
4. “It may take up to a half day or longer for the patch to start working, the first time I use it.”
5. “I will take the old patch off before I apply the new patch on.”

32.) The nurse is assessing a client with a history of a murmur due to aortic regurgitation. Select the area
on the image below where the nurse should place the stethoscope to best hear the murmur.
Use your cursor to select an area on the image below.

33.) The nurse is assessing a client who sustained multiple fractures, contusions, and lacerations in a
motor vehicle accident three days ago. The client suddenly becomes confused. Which findings would
support the nurse’s concern that the client has developed a fat embolism? Select all that apply.
1. Low oxygen saturation
2. Dyspnea
3. Petechiae on the upper anterior chest
4. Elevated temperature
5. Hypertension

34.) A client with a history of asthma and kidney stones is admitted with a diagnosis of recurrent renal
calculi. The client experiences shortness of breath following a lithotripsy. The nurse auscultates the
client’s lungs and finds decreased air movement with no wheezing. The arterial blood gas (ABG)
 results are pH 7.31, PaO2 53 mm Hg, PaCO2 50 mm Hg, and O2 sat 82%. Which of the following
actions are appropriate for the nurse to take? Select all that apply.
1. Increase IV fluids
2. Administer a short-acting bronchodilator via nebulizer
3. Start high flow oxygen via face mask
4. Call respiratory therapy
5. Contact the health care provider
6. Prepare for possible intubation

35.) The nurse is evaluating a client’s ability to perform basic activities of daily living (ADLs). Which tasks
should the nurse observe the client performing? Select all that apply.
1. Getting fully dressed
2. Eating a meal independently
3. Making a bank account withdrawal
4. Using the bathroom
5. Using the telephone
6. Driving safely around town

36.) The nurse is preparing to hang a new bag of total parenteral nutrition (TPN) through a central venous
access device (CVAD). Indicate the correct order in which the following nursing actions should be
performed by dragging and dropping the options below.
1. Clean the infusion hub of the CVAD with an antiseptic swab for at least 10 seconds.
2. Perform hand washing.
3. Connect and prime the supplied tubing and filter.
4. Program the infusion pump at the prescribed rate.
5. Thread the intravenous tubing through the infusion pump.
6. Check the solution for cloudiness or sediment.
7. Start the infusion.
8. Connect the tubing to the central venous access device.

37.) A client is admitted to the psychiatric unit after a suicide attempt. Which of the following
interventions is important for the nurse to implement initially? Select all that apply.
1. Ask the client directly if they have suicidal thoughts or plan to commit suicide
2. Assign a staff member to stay with the client at all times
3. Help the client identify the stressors that precipitated their current crisis
4. Ask why the client attempted suicide
5. Identify resources that the client may use after discharge
6. Establish a trusting, therapeutic relationship

38.) The charge nurse is making assignments on the day shift for a registered nurse (RN), a licensed
practical nurse (LPN) and a certified nursing assistant (CNA). Which assignments are appropriate for a
client who fell during the night, has a skin tear on the arm, a hematoma on the hip, and is scheduled
for an X-ray of the hip? Select all that apply.
1. Assign the LPN to report confusion or headache
2. Assign complete care to the LPN
3. Assign the CNA to assist with personal hygiene tasks
4. Assign wound care to the RN
5. Assign medication administration to the LPN
39.) The nurse is caring for a client who is being treated for complications of a chronic disease on a
medical-surgical unit. The nurse understands that which people can have access to the client’s
medical record? Select all that apply.
1. The certified nursing assistant documenting vital signs
2. The client’s spouse or other close family member
3. The facility researcher collecting data for a study to which the client consented
4. The nursing instructor planning clinical assignments
5. The person who has health care power of attorney
6. The emergency department nurse who originally admitted the client and now wants to know
the client’s current status

40.) The nurse is caring for a client who is being treated for heart failure. After completing the medication
reconciliation process, the nurse notes that the prescriber has added lisinopril 5mg orally bid. Which
medication from the list below should the nurse question due to possible drug-to-drug interaction
with lisinopril?

1. Metoprolol
2. Enoxaparin
3. Naproxen
4. Glipizide

41.) The nurse is evaluating the plan of care for an 11-year-old client with glomerulonephritis. Which
assessment findings would indicate that the client is recovering? Select all that apply.
1. Protein-free urine
2. Fine bibasilar crackles
3. Weight gain
4. Acute infection absent
5. Edema absent or minimal
6. Nutrition maintained

42.) The nurse is caring for a client with chronic renal failure who is undergoing peritoneal dialysis. The
nurse notes that the dialysate solution is instilling very slowly. Which of the following actions would
be appropriate for the nurse to implement? Select all that apply.
1. Reposition the client
2. Assess for bruit or vibration
3. Check tubing and catheter for kinks
4. Assess for headache and hypertension
43.) The nurse is reviewing the medical record of a client who is receiving hemodialysis for end-stage
renal disease (ESRD). Which lab values are important to monitor for this client? Select all that apply.
1. Serum calcium
2. Troponin level
3. Serum potassium
4. Serum creatinine
5. Hemoglobin level

44.) The nurse is developing a plan of care for a client undergoing chemotherapy. The client tells the
nurse that they would like to try complimentary and alternative approaches to help with the
chemotherapy-induced nausea and vomiting. Which alternative approaches would be appropriate to
include? Select all that apply.
1. Meditation
2. Music therapy
3. Oxygen therapy
4. Massage
5. Acupuncture
6. Scopolamine patch

45.) The nurse is teaching the parents of an adolescent who recently attempted suicide about suicide
prevention. The nurse should include which warning signs? Select all that apply.
1. Exhibits dramatic changes in mood
2. Keeps away from family and friends
3. Introduces new partner to family and friends
4. Starts giving away prized possessions and collectibles
5. States feeling trapped with no way out
6. Enrolls in a community art class

46.) The nurse is preparing to start a peripheral venous access device on an alert and oriented adult
client. Which supplies should the nurse select? Select all that apply.
1. Transparent dressing
2. Soft wrist restraint
3. An arm board
4. An appropriate size IV catheter
5. Adhesive tape

47.) The nurse works with clients in an outpatient substance abuse treatment program. Which
intervention is indicated to prevent relapse and promote a successful recovery? Select all that apply.
1. Medication-assisted treatment
2. Counseling about alternative coping skills
3. Participate in group psychotherapy
4. Refer clients for mental health assessments

48.) The nurse is preparing to teach a client with type 2 diabetes mellitus about their newly prescribed
exenatide (Byetta) pen. Which instructions should the nurse include? Select all that apply.
1. Take the exenatide immediately after meals.
2. Take any oral medications 1 hour before the exenatide.
3. Inject yourself in the abdominal or thigh area.
4. You may experience some weight loss.
5. After use, store the injector pen in the refrigerator.
49.) The caregiver of a client with Alzheimer’s disease asks the nurse for information about different
treatment options that can help with memory or behaviour problems. Which of the following
responses by the nurse are correct? Select all that apply.
1. “Donepezil (Aricept) may help slow cognitive decline.”
2. “Music therapy has been found to help some clients.”
3. “Garlic may help with this disease.”
4. “Ginkgo biloba may help with memory.”
5. “Acupuncture may be very relaxing.”

50.) A client is diagnosed with rheumatoid arthritis (RA). Which types of drugs might the nurse expect to
be ordered as a combination drug therapy regimen? Select all that apply.
1. Biological-response modifiers
2. Antimicrobial agents
3. Glucocorticoids
4. Anti-inflammatory drugs
5. Diuretics

51.) The nurse is caring for a client who requires an orthotic due to a musculoskeletal disorder. Which of
the following tasks can the nurse delegate to an unlicensed assistive person (UAP)? Select all that
apply.
1. Help the client with putting on the orthotic.
2. Evaluate the client’s response to ambulatory activity.
3. Assist the client with transferring from the bed to a chair.
4. Encourage the client’s independence in self-care.
5. Report any redness or signs of skin breakdown.

52.) The school nurse is performing an assessment on a 15-year-old client who sustained a mild traumatic
brain injury without loss of consciousness during a football game, one week earlier. The nurse
suspects post-concussion syndrome. Which findings would support this diagnosis? Select all that
apply.
1. Short-term memory loss
2. Nausea and vomiting
3. Learning difficulties
4. Positive Romberg sign
5. Delayed pupillary response
6. Insomnia

53.) The nurse is assessing a client with suspected aspirin overdose. Which assessment findings would
support this diagnosis? Select all that apply.
1. Jaundice
2. Headache
3. Tinnitus
4. Respiratory rate of 28
5. Serum pH 7.31
6. Hypoglycemia
54.) The nurse is caring for a post-surgical client who is using patient controlled analgesia (PCA) with
morphine for pain is severe and does not get better, even after “pushing the PCA button”. Indicate
the sequence of actions the nurse should take by dragging and dropping the options in the correct
order.
1. Offer non-pharmacological interventions
2. Consult with the health care provider
3. Verify that the client is using the PCA equipment correctly
4. Confirm that the pump is working and the tubing is patent
5. Check the MAR for adjuvant medications prescribed

55.) Sputum culture results for a client admitted with a cough and fever indicate a methicillin-resistant
staphylococcus aureus (MRSA) infection in the nares. What nursing intervention must now be taken?
Select all that apply.
1. Move the client to a private room.
2. Dedicate the use of personal and noncritical medical equipment to the client.
3. Place the client in a room with another client colonized with MRSA.
4. Place a mask on the client if the client needs to leave the room.
5. Staff will wear N-99 or N-100 particulate respirators when in the client’s room.

56.) A client has been taking rosuvastatin for six weeks as part of a treatment plan to reduce
hyperlipidemia. The clinic nurse is reviewing and reinforcing information about the medication with
the client. Which statements by the client indicates an understanding about the medication? Select
all that apply.
1. “I will need to come back to have my liver and kidney labs checked.”
2. “I need to be careful when I get up because this medication can make my blood pressure
drop.”
3. “I add some nuts and fresh fruit to my oatmeal in the morning and I can’t remember when I
last ate a steak.”
4. “This medication has to be taken first thing in the morning, before I eat breakfast.”
5. “I will need to call my doctor if I have any muscle weakness or pain, especially in my legs.”

57.) A 32-year-old female with human epidermal growth factor receptor 2-positive (HER2-positive)
metastatic breast cancer is scheduled to begin therapy with pertuzumab. What information is
important for the nurse to reinforce and discuss with the client? Select all that apply.
1. Use contraception during and for 6 months following the use of this drug.
2. Other therapies for cancer treatment are no longer needed.
3. Report chills, fatigue, or headache during treatment
4. Report shortness of breath, lightheadedness, dizziness, cough or swelling of the feet.
5. Take the medication at the same time every day on an empty stomach.

58.) The nurse is evaluating an adult client who is receiving continuous enteral nutrition (EN) through a
nasogastric tube. Which findings indicate that the client may be experiencing a complication from the
EN? Select all that apply.
1. New onset adventitious lung sounds
2. A weight loss of 2 kg in 24 hours
3. Gastric residual volume of 100 mL
4. 200 mL dark yellow urine voided in the last eight hours
5. Pale and dry oral mucous membranes
6. Aspirated gastric fluid has a pH of 4
59.) The nurse is using the SBAR technique to communicate with the health care provider. Which phrase
would be associated with “b-Background”?
1. “Vital signs are…”
2. “The client’s treatments are…”
3. “I’m not sure what the problem is, but the client’s condition is deteriorating.”
4. “I would like you to…”

60.) A healthy 18-year-old who is entering college in the fall presents to the clinic for immunizations.
Which immunization(s) does the nurse anticipate the health care provider recommending prior to
college? Select all that apply.
1. Tetanus, Diphtheria, Pertussis vaccine (Tdap)
2. Human papillomavirus (HPV) vaccine
3. Meningococcal conjugate vaccine (MCV4)
4. Shingles vaccine
5. Pneumococcal polysaccharide vaccine (PPSV23)
6. Seasonal influenza vaccine

61.) A client is being prepared for an above-the-knee amputation. Which actions by the nurse would
represent appropriate care of this client? Select all that apply.
1. Verify the surgical leg is marked with indelible marker over, or as close as possible to, the
surgical incision site
2. Explain the procedure, including any risks, before the client signs the surgical consent form
3. Verify that the informed consent form is signed
4. Verify any allergies
5. Have the client confirm his or her identity, the surgical site and the procedure before
administration of any medications

62.) The nurse is preparing to suction a client’s tracheostomy. Which interventions should the nurse
implement? Select all that apply.
1. Auscultate lung sounds before and after
2. Instill a small amount of saline prior to inserting the catheter
3. Explain the procedure
4. Administer a mild sedative prior to suctioning
5. Hyperoxygenate the client prior to suctioning
6. Use a sterile suction catheter

63.) The nurse is developing a plan of care for a client who has developed blisters and sores in the mouth
after receiving chemotherapy. Which interventions should the nurse include? Select all that apply.
1. Examine your mouth frequently.
2. Drink 2 or more liters of water per day.
3. Suck on ice chips during chemotherapy.
4. Avoid spicy or acidic foods.
5. Use strong mouthwashes to kill bacteria.
6. Visit a dental hygienist weekly.
64.) The nurse in a primary care clinic is reviewing the medical record of a client with chronic
gastroesophageal reflux disease (GERD). Which findings are risk factors for developing GERD? Select
all that apply.
1. Smoking
2. Diabetes mellitus type 2
3. Taking a calcium channel blocker
4. Helicobacter pylori infection
5. Essential hypertension
6. Being overweight or obese

65.) The nurse in a urology office is developing a plan of care for a client newly diagnosed with urge
urinary incontinence due to an overactive bladder. Which interventions should the nurse include?
Select all that apply.
1. Administration of anticholinergic drugs
2. Surgical sphincteromy
3. Avoidance of caffeinated beverages
4. Pelvic floor muscle exercises
5. Protection of skin integrity

66.) A newly admitted client reports taking phenytoin for several months. Which assessment should the
nurse include in the admission report? Select all that apply.
1. Report of any seizure activity
2. Serum phenytoin levels
3. Report of anorexia, numbness and tingling of the extremities
4. Report of unsteady gait, rash and diplopia.

67.) The nurse is preparing to administer medications through gastrostomy tube. The nurse should contact
the health care provider before giving which drugs through the gastrostomy tube? Select all that
apply.
1. Aspirin EC
2. Diltazem SR
3. Calcium carbonate
4. Metoprolol XL
5. Terazosin IR
6. Acetaminophen

68.) The nurse is reviewing the nutrition needs for a child diagnosed with cystic fibrosis. The nurse
anticipates that the client is at risks for which vitamin deficiencies?
1. A, C and D
2. B12,, D and K
3. A, B1, and C
4. A, D and K

69.) The school nurse is preparing information to present to parents about mandated health assessments
for all students. Based on the image below, which statement should be included in the presentation?
Select all that apply.
 1. This is an image of lordosis
2. More cases occur in girls than boys
3. Treatment for this condition always involves surgery
4. Screening for this condition is typically mandated for student in 6th grade
5. This is an image of scoliosis

70.) The nurse receives an order to infuse 1 liter of 0.45% sodium chloride over 12 hours to a client
admitted with cellulitis. At how many mL per hour should the nurse program the infusion pump?
Record your answer as a whole number.
1 mL/hour

71.) The nurse on medical-surgical unit is working with a team that consists of several other nurses and
one unlicensed assistive person (UAP). Which tasks can the nurse delegate to the UAP? Select all that
apply.
1. Assist a client in skeletal traction with meals and snacks
2. Provide information about a low-sodium diet prior to discharge
3. Obtain a daily weight on a client before breakfast
4. Give a client on bed rest due to severe anemia a bed bath
5. Ambulate a client in the hallway twice a shift

72.) The home care nurse is reviewing the medical record of a new client with a history of crhronic
obstructive pulmonary disease, atrial fibrillation and gout. After reviewing the client’s medications
should the nurse arrange to monitor blood levels? Select all that apply.
1. Theophylline
2. Beclomethasone
3. Montelukast
4. Allopurinal
5. Digoxin

73.) The nurse is assessing a client who was admitted with suspected Guillain-Barre syndrome. Which
assessment findings should the nurse expect? Select all that apply.
1. Weakness
2. Hypotonia
3. Diarrhea
4. Hyporeflexia
5. Paresthesia
6. Seizures
74.) A client who has returned from surgery reports feeling nauseated and later has an emesis. The nurse
administers promethazine per standing orders. In addition to relief from nausea, what other effects of
this medication does the nurse expect? Select all that apply.
1. Dry mouth
2. Heart palpitations
3. Pinpoint pupils
4. Sedation
5. Rhinorrhea

75.) A client has been prescribed alendronate for osteoporosis. Which statements indicate that the client
understands how to safely take this medication? Select all that apply,
1. “I will notify my doctor if experience worsening heartburn.’’
2. “I will always eat breakfast before taking the pill.”
3. “I will take the pill with an antacid to prevent stomach upset.”
4. “I will stand or sit quietly for 30 minutes after taking the pill.”
5. “I will swallow the pill with a full glass of water.”