1.     A school nurse is assessing a child who has been stung by a bee. The child’s hand is swelling and the nurse notes that the child is allergic to insect stings. Which of the following findings should the nurse expect if the child develops anaphylaxis? (Select All That Apply)

B) Nausea D) Urticaria

E) Stridor

Explanation: Anaphylaxis often involves nausea, hives (urticaria), and stridor, which is a sign of airway obstruction. Bradycardia and hypertension are not typical symptoms of anaphylaxis.

2. A nurse is caring for a client who is unconscious. Which of the following actions should the nurse take when providing oral care for the client?

A) Test for the presence of the client’s gag reflex

Explanation: It is essential to test for the gag reflex in unconscious clients to avoid aspiration during oral care.

3. A nurse is planning care for a client who has acute myelogenous leukemia and a platelet count of 48,000/mm³. Which of the following interventions should the nurse include?

A) Avoid IM injections

Explanation: Avoiding intramuscular (IM) injections is important because a low platelet count increases the risk of bleeding.

4. A nurse is preparing to assess the function of the client’s trigeminal nerve (cranial nerve V). Which of the following items should the nurse gather for the test?

C) Cotton wisps

Explanation: Cotton wisps are used to test sensory functions of the trigeminal nerve.

5. A nurse is caring for a client with alcohol use disorder who has undergone detoxification. Which of the following medications should the nurse expect the provider to prescribe to assist the client with maintaining sobriety?

D) Disulfiram

Explanation: Disulfiram is a medication that helps maintain sobriety by causing unpleasant effects when alcohol is consumed.

6. A newly admitted client who has major depressive disorder states to the nurse, “I’m a failure, I can’t even cope with the little things anymore." Which of the following responses should the nurse provide?

C) Do you feel like you don’t deserve to feel good about yourself?"

Explanation: This response allows the client to explore their feelings of self-worth.

7. A nurse is caring for a middle-aged adult client. The nurse should identify which of the following statements as an indication that the client has completed Erikson’s developmental task for her age group?

B) “I think I have done a good job with my children since they are all independent now."

Explanation: This reflects Erikson’s stage of generativity vs. stagnation, where individuals feel accomplished by contributing to society and helping the next generation.

8. A nurse is conducting an admission interview with a client. Which of the following pieces of assessment information should the nurse collect during the introductory phase of the interview?

A) Client’s level of comfort and ability to participate in the interview

Explanation: Establishing the client’s comfort and readiness for the interview is part of the introductory phase of assessment.

9. A nurse is planning to assess the abdomen of a client who reports feeling bloated for several weeks. Which of the following methods of assessment should the nurse use first?

A) Inspection

Explanation: Inspection is the first step in abdominal assessment to observe for any visible abnormalities.

10. A nurse is performing a comprehensive physical assessment of a client. The nurse should use inspection to assess which of the following?

D) Gait Explanation: Inspection involves visually observing the client’s movement, including gait.

11. A nurse is caring for a client who is immobile. The nurse should recognize that immobility places the client at risk of which of the following health alterations?

C) Decreased cardiac output

Explanation: Immobility can lead to decreased cardiac output due to reduced venous return and muscle inactivity.

12. A nurse is preparing to perform mouth care for an unresponsive client. Which of the following actions should the nurse plan to take?

C) Raise the level of the bed

Explanation: Raising the bed allows the nurse to maintain proper body mechanics and reduces the risk of aspiration for the client.

13. A nurse is preparing to administer an afternoon dose of ampicillin to a client. The client appears upset and refuses to take the medication before throwing the pill on the floor. Which of the following entries should the nurse enter into the client’s medical record?

D) “The client threw the medication on the floor."

Explanation: Documentation should be objective and describe the client’s actions.

14. A nurse in a rehabilitation facility is observing an assistive personnel (AP) help a client transfer from a bed to a wheelchair. Which of the following actions indicates to the nurse that the AP understands how to perform this task?

A) Locking the brakes on the bed and the wheelchair before moving the client

Explanation: Locking the brakes ensures safety during the transfer process.

15. A nurse is caring for a client who has cancer and refuses visitors because of his debilitated physical appearance. Which of the following comments should the nurse make?

D) “Would you like to talk about how you feel?“Explanation: This response provides emotional support and invites the client to express feelings.

16. A nurse is assessing the pH of a client’s gastric fluid to confirm the placement of an NG tube in the stomach. Which of the following pH values should the nurse expect?

B) 2

Explanation: Gastric fluid typically has a pH of 1-4, indicating the correct placement of the NG tube.

17. A nurse is caring for a client who is scheduled to receive transcutaneous electrical nerve stimulation (TENS) for pain management. The client asks how a TENS unit helps to relieve pain. Which of the following responses should the nurse make?

B)“It modulates the transmission of the pain impulse.”

Explanation: TENS works by interfering with pain signal transmission to the brain.

18. A nurse is performing a physical assessment of a client. The nurse should recognize that which of the following places the client at risk of impaired skin integrity?

B) Faint pedal pulses

Explanation: Faint pedal pulses indicate poor circulation, which increases the risk of skin breakdown.

19. A nurse is assessing a client. Which of the following findings should the nurse identify as an indication of protein-calorie malnourishment? (Select All That Apply)

B) Dry, brittle hair

D) Spoon-shaped nails

E) Poor wound healing

Explanation: These are all signs of protein-calorie malnutrition, as it affects hair quality, nails, and the body’s ability to heal wounds.

20. A nurse is caring for a client who has bilateral casts on her hands. Which of the following actions should the nurse take when assisting the client with feeding?

A) Sit at the bedside while feeding the client

Explanation: Sitting at the bedside ensures that the nurse is actively assisting and can monitor the client for any difficulties.

21. A nurse is changing the dressing for a client recovering from an appendectomy following a ruptured appendix. The client’s surgical wound is healing by secondary intention. Which of the following observations should the nurse report to the provider?

D) Halo of erythema on the surrounding skin

Explanation: Erythema (redness) around the wound site can indicate infection, requiring prompt reporting.

22. A nurse is teaching a client who is postoperative following a knee arthroplasty about the muscles he will need to strengthen in physical therapy. Which of the following muscle groups is responsible for movement at the knee joint?

B) Antagonistic

Explanation: Antagonistic muscles are those that work in opposition to each other to create movement, such as those around the knee joint.

23. A nurse is caring for a client who has a terminal illness. The family wants to care for the client at home. Which of the following statements indicates that the nurse understands family-centered care?

C) “Let’s set up a meeting time with the doctor to discuss your options for home care."

Explanation: Involving the family in decision-making and planning care options demonstrates family-centered care.

24. A nursehas received a prescription for dextran to administer to a client. The nurse should recognize that dextran belongs to which of the following functional classifications?

D) Plasma volume expanders

Explanation: Dextran is used to increase plasma volume in cases of hypovolemia or shock.

25. A nurse is providing teaching to a client regarding protein intake. Which of the following foods should the nurse include as an example of an incomplete protein?

C) Lentils

Explanation: Lentils contain incomplete proteins, which means they lack one or more essential amino acids.