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1. The nurse is caring for a client who has an upper respiratory infection and is receive prescribed ampicillin 500 mg IM every 6 hours. The vial reads to add 8 ml of normal saline for a FINAL concentration of 1gram/10ml. How many ml per dose will the nurse administer to the client?
2.The nurse is caring for a client who is two hours postoperative coronary artery bypass graft (CABG). The nurse notes that the client central venous pressure (CVP) monitoring is increased. Which action will the nurse take?
a. Auscultate lung sounds.
b. Check chest tube for kinks.
c. Administer prescribed dopamine.
d. Increased the prescribed IV fluids.
3. A nurse is assessing a client who is 30 minutes postoperative from an insertion of a permanent pacemaker. Which finding would require immediate follow-up by the nurse?
a. Serous drainage on the pressure dressing.
b. Bounding pulse
c. Report of hiccups
d. Reports of shortness of breath.
4. The nurse is reviewing the medical record of a client with hearing loss who communicates by reading lips and signs language. Which procedure does the nurse need to prepare the client for due to their hearing issue?
a. Nebulizer breathing treatment.
b. Insertion of a peripheral intravenous line
c. Thoracentesis
d. Magnetic resonance imaging
5. The nurse on a medical-surgical unit is caring for a client who reports pain in the jaw, back, and shortness of breath, and nausea. Which action should the nurse take?
a. Obtain an electrocardiogram (ECG).
b. Administer aspirin.
c. Maintain oxygen saturations greater than or equal to 92%
d. Administer nitroglycerin sublingual.
6. A postoperative patient has ineffective airway clearance. Which data would indicate to the nurse that intervention for this patient problem have been successful?
a. Patient’s temperature is less than 100 2 F orally.
b. Patient’s breath sounds are clear to auscultation.
c. Patient drinks 2 to 3 L of fluid in 24 hours.
d. Patient uses the spirometer 10 times every hour.
7. A nurse is caring for a client post-cardiac catheterization with femoral access. Which nursing intervention will the nurse include in the client plan of care? Select all that apply. One, some, or all responses may be correct.
a. Place the client in high-Fowler position
b. Measure the client vital signs every 30 minutes
c. Have the client remains in bed up to 6 hours.
d. Keep the client hip and leg extended.
e. Check peripheral pulses in the affected extremity.
8. The evening shift nurse is caring for a client scheduled for surgery. The client states, ”I once got a rash from wearing rubber gloves.” Which action should the nurse take?
a. Note in the medical records that the client has a latex allergy.
b. No intervention is needed since the client will not be wearing gloves.
c. Notify the OR staff about the allergy to sulfur-containing products.
d. Notify the surgeon so that the surgery can be canceled.
9. The nurse is planning care for a client who reports a change in central vision and distortion of objects. Which using the otoscope, the nurse inspection ocular fundus and notes the presence of drusen spots. Which intervention should the nurse include in the client plan of care?
a. Instruct the client to wear an eye patch.
b. Discuss the option of surgery for treatment.
c. Teach the client how to use the Ambler grid to measure the loss of vision over time.
d. Teach the client about the use of prescribed beta-blocker topical eye medication.
10. The nurse is caring for a client with hypertension (HTN) who receiving the first dose of prescribed lisinopril. The client reports dizziness with ambulation, And the nurse notes the client blood pressure (BP) to be 90/50mm/Hg. Which action should the nurse take?
a. Encourage the client to increase oral fluid intake.
b. Instruct the client to remain on strict bed rest throughout hospital stay.
c. Hold all prescribed anti-hypertensive medication until BP has improved.
d. Obtain a prescription for a bolus of 0.9% normal saline (NaCL).
11. The nurse is caring for a client who is one day post-operative. Which intervention should the nurse implement to prevent postoperative respiratory complication?
a. Administer prescribed pain medication every 4 hours intravenously.
b. Position the client in the supine position.
c. Provide oral care.
d. Restrict fluids for 24-hours post-operatively.
12. The nurse is teaching a client with glaucoma about the side effects of pilocarpine. Which statement will the nurse include in the teaching?
a. “Avoid ambulating in dimly lit areas.”
b. “You may experience a decrease in your heart rate.”
c. “Darkening of the iris will occur.”
d. “This medication can cause dryness of the eye.”
13. The nurse is assessing a client newly diagnosed with open-angle glaucoma. Which information is the priority for the nurse to assess?
a. Date of onset
b. Amount of blurred vision
c. Degree of lost version
d. Severity of headaches
14. The nurse is caring foe a client with conductive hearing loss. For which condition will the nurse assess the client? Select all that apply.
a. Otitis media
b. Otosclerosis
c. Exposure to noise
d. Impacted cerumen.
e. Presbycusis.
15. A nurse is reviewing the EKG strip of a client who has prolonged vomiting. Which finding on the client EKG should the nurse interpret as a sign of hypokalemia
a. Inverted T-waves
b. Elevated ST segment
c. Inverted P wave
d. Wide QRS
16.The nurse expects a cardiac tamponade for a client after cardiac surgery. Which assessment finding would the nurse expect to observe?
a. Flattened jugular veins.
b. Blood pressure 150/80
c. Widened pulse pressure.
d. muffed heart tones
17. The nurse is performing the Weber assessment test for a client reporting a unilateral hearing loss. Which finding would indicate to the nurse that the client is experiencing conductive hearing loss?
a. The client hears the sound equally in both ears.
b. The client hears the sound better in the affected ear.
The client hears the sound in the unaffected ear.
d. The sound is more audible with air conduction than with bone conduction.
18. The nurse is assessing a client with fluid overload. Which finding will the nurse expect? Select all that apply.
a. Increased blood pressure
b. Increased respiratory rate.
c. Increased temperature
d. Increased hematocrit
e. Increased heart rate.
19. The nurse is preparing to administer newly prescribed levobunolol eye drops to a client with glaucoma. Which is the priority assessment before administering the medication to the client?
a. Visual acuity
b. Pain level
c. Ocular redness
d. Lung sounds
20. A nurse is caring for a client with a ventricular pacemaker who is on ECG monitoring. The nurse understands that the pacemaker is functioning properly when which of the following appears on the monitor strip.
a. Pacemaker spikes after each QRS complex
b. Pacemaker spikes with each P wave
c. Pacemaker spikes with each T wave
d. Pacemaker spikes before each QRS complex.
21. the nurse is planning care for a client diagnosed with pernicious anemia. Which intervention should the nurse anticipate for this client?
A. dietary consult
B. vitamin B12 injection
C. oral iron supplement
D. transfusion of packed red blood cells
22. the nurse is conducting the health history interview for a client suspected of having cataracts, which manifestation reported by the client would indicate to the nurse that the client is experiencing the early stage of cataracts?
A. floating spots
B. blurry vision
C. Burning sensation
D. halos around light
23. the nurse is caring for a group of assigned nurses. Which client will the nurse see first?
A. the client who had an abdominal surgery 24 hours ago and reported swelling in the right calf.
B. the client who had a trabeculoplasty for glaucoma and has a decrease in the intraocular pressure.
C. The client with endocarditis who is febrile and receiving prescribed antibiotics.
D. the client who had a wound vac placed 48-hours ago and is requesting pain medication.
24. the nurse is assessing a newly admitted client diagnosed with right sided heart failure. Which finding should the nurse expect to observe?
A. dyspnea and orthopnea
B. a dry and hacking cough.
C. Jugular venous distention
D. frothy, pink, sputum
25. the client with a pressure ulcer has the following problem statement on their care plan. Altered skin integrity due to immobility. Which of the following is an expected outcome related to this problem statement?
A. the client pain will be controlled to less than 4/10 by relaxation techniques.
B. the client will show an increase in self-esteem by talking about their wound.
C. the client will demonstrate self-care techniques for caring for the wound.
D. the client will exhibit hearing of pressure ulcers in two weeks.
26. the nurse is caring for a client with peripheral neuropathy who is to receive prescribed gabapentin 300mg PO, three times per day using the label shown below, how many capsules will the client receive in a day? Answer:
27. the nurse has received a changed of shift report for four assigned clients. Which client should the nurse asses first?
A. 23 years old with a migraine headache who reported severe nausea.
B. 45 years old scheduled for heart catheterization in 30 minutes and needs preoperative teaching.
C. a 59years old with heart failure who report dyspnea with ambulation.
D. a 63years old with multiple myeloma with an oral temperature of 101.8 F (38.8 c) and report flank pain
28. the nurse is providing discharge teaching for a client after cataract surgery. Which statement made by the client would indicate to the nurse that further teaching is necessary?
A. I should wear sunglasses when exposed to bright light.
B. it is normal to experience post-operative pain in the affected eye.
C. I will avoid lying on the side of the affected eye the night after surgery.
D. I will avoid lifting or pulling on objects that are greater than 15 pounds.
29. the emergency room nurse is caring for a client who report palpitation. When the assessing the client telemetry strip, the nurse note a fast rhythm with a narrow QRS complex, as show in the figure below. Which action will the nurse take first?
A. Administer prescribed adenosine.
B. asses the client blood pressure and the pulse oximetry
C. have the client perform maneuvers.
D. prepare the client for synchronized cardioversion.
30. the nurse is assessing a client who experienced blunt chest trauma during a motor vehicle accident. Which assessment finding would indicate to the nurse the client has multiple rib fracture?
A. costovertebral angle tenderness
B. increased tactile fremitus.
C. Diminished breath sounds
D. unequal chest expiation
31. A nurse is prioritizing client care after receiving a change of shift report. Which client will the nurse plan to see first?
A. a client who is scheduled for an abdominal x-ray transport.
B. a client who has a prescription for discharge
C. a client who has a thoracic aneurysm and report sudden back pain
D. a client who received oral pain medication 30mint ago
32. the nurse is renewing the medical record for a client diagnosed with psoriasis who has a history of dysplastic nevi. The nurse should question which order by provider.
A. topical salicylic acid
B. oral a premilast
C. artificial phototherapy
D. corticosteroid injection.

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