1. The nurse is caring for an infant with tetralogy of Fallot when the infant begins crying inconsolably and becomes cyanotic.
Which of the following actions should the nurse take first?
A. Administer intravenous morphine.
B. Notify the health care provider about the episode.
C. Comfort infant and place in the knees-to-chest position.
D. Start an intravenous 0.9% sodium chloride (normal saline) bolus.
2. The nurse is caring for a client who is diagnosed with intussusception and observes that the client is hypotensive, tachycardic, and has a rigid abdomen.
Which of the following actions should the nurse take?
A. Administer lv fluids.
B. Perform gastric lavage.
C. Prepare for an air enema.
D. Prepare for a pyloromyotomy.
3. The nurse reviews the initial arterial blood gas Laboratory Results for a client with chronic obstructive pulmonary disease (COPD) who is intubated and receiving mechanical ventilation.
Which of the following interventions does the nurse anticipate to follow up on this client’s acid-base imbalance?
A. Administer lv fluids.
B. Perform gastric lavage.
C. Prepare for an air enema.
D. Prepare for a pyloromyotomy.
4. The nurse is observing an unlicensed assistive personnel (UAP) assisting various clients with activities of daily living (ADLs).
Which of the following actions by the UAP would require the nurse to intervene?
A. Assists a client with diabetes mellitus to soak the feet in warm water
B. Transfers a client with one-sided weakness to the wheelchair using a gait belt
C. Provides a client taking apixaban with a soft-bristled toothbrush to brush the teeth
D. Instructs a client who is 3 days post-mastectomy to brush her hair using the affected arm
5. The nurse has taught a female client newly diagnosed with chlamydia about sexually transmitted infections (STIs).
Which of the following statements by the client would indicate a correct understanding of the teaching? Select all that apply.
A. “My partner needs to be treated.”
B. “l can’t get an STl from having oral sex.
C. “Not everyone with an STl will have symptoms.
D. “Birth control pills will protect me from another STl.”
E. ” will need to take an antibiotic to treat my chlamydia infection.”
F. “lf l don’t treat my chlamydia, l could have trouble getting pregnant later on.”
6. The nurse is screening clients for those at risk for hypokalemia.
At highest risk for hypokalemia is the client who
A. takes enalapril for hypertension
B. has severe vomiting and diarrhea
C. missed a hemodialysis session
D. has a diagnosis of acute adrenal insufficiency
7. The nurse in the pediatric unit is preparing to admit a client with pertussis.
The nurse should assign the client to a
A. private room with airborne precautions
B. shared room with a client with pertussis
C. private room with filtered positive pressure airflow
D. shared room with a client with respiratory syncytial virus
8. The charge nurse is observing the following client situations.
Which of the following actions by a staff member would require the charge nurse to intervene?
A. A nurse secures a soft wrist restraint to the raised side rail using a quick-release knot.
B. An assistive personnel elevates the head of the bed for a client in ankle restraints.
C. An assistive personnel temporarily removes mitten restraints to assist a client with toileting
D. A nurse places 2 fingers between the restraint and the client’s skin while applying soft wrist restraints.
9. The nurse and unlicensed assistive personnel (UAP) are caring for assigned clients.
Which of the following tasks would be appropriate for the nurse to assign to UAP?
A. Checking the dressing site of a client who underwent closed liver biopsy 3 days ago
B. Sitting at the bedside of an older adult client who is confused and at high risk for falls
C. Demonstrating incentive spirometer use for a client who is 1 day post cholecystectomy
D. Measuring a client’s vital signs 15 minutes after beginning a transfusion of red blood cells
10. The nurse is planning a staff education program about client confidentiality.
Which of the following scenarios should the nurse include as an example of a violation of client confidentiality?
A. Faxing a report sheet to an inpatient unit prior to transporting the client to the unit.
B. Contacting the local health department to report the client tested positive for chlamydia.
C. Sharing information regarding a mechanically ventilated client with their power of attorney.
D. Asking the client’s family member to translate treatment information to the client’s language.