Question 33
A nurse is teaching a client, who is newly diagnosed with type 1 diabetes mellitus, about insulin safety. Which of the following statements by the nurse is appropriate?
- “Insulin is stable at room temperature for one month but on unit kept in refrigerator.”
- “Clients with type 1 diabetes mellitus should keep backup medication and supplies in their car.”
- “Storing insulin in the freezer will prolong its stability.”
- “All insulins can be mixed in the same syringe.”
Question 34
A patient arrives in the emergency department with sudden right-sided weakness and slurred speech. A CT scan confirms an acute ischemic stroke, and the time of symptom onset was determined to be 2 hours ago. Which action should the nurse anticipate?
- D. Wait for 6 hours to ensure symptoms do not resolve spontaneously
- A. Prepare for administration of tissue plasminogen activator (tPA) as prescribed
- C. Administer aspirin immediately instead of tPA
- B. Hold tPA administration until 12 hours after symptom onset
Question 35
The nurse is preparing to collect a sputum specimen for culture from a patient with suspected pneumonia. Which instruction should the nurse give the patient to ensure proper collection?
- A. “Rinse your mouth with mouthwash before coughing up sputum.”
- “Provide the specimen at bedtime, after you have eaten and brushed your teeth.”
- C. “Spit saliva into the cup until it is half full.”
- B. “Cough deeply from the lungs and expectorate into the sterile container.”
Question 36
A nurse is obtaining a preoperative medical and surgical history from a client scheduled for a cataract extraction procedure. Which of the following client statements require further investigation by the nurse?
- “I had a cough and runny nose a couple days ago.”
- “I did not put my contact lenses in this morning.”
- “I stopped taking aspirin last week.”
- “I took my blood pressure meds with a sip of water.”
Question 37
A patient presents to the emergency department with sudden loss of consciousness and neurological deficits after vigorously exercising. What type of stroke should the healthcare provider suspect based on the presenting symptoms?
- Myocardial infarction (MI) leading to brain hypoxia
- Transient ischemic attack (TIA) manifesting as temporary neurological deficits
- Hemorrhagic stroke due to a ruptured artery or aneurysm
- Ischemic stroke caused by a blockage of circulation to the brain
Question 38
The nurse is teaching a client about chronic bronchitis. Which statement by the nurse correctly defines this disorder?
- A. “It is a persistent cough with sputum production lasting at least 3 months in 2 consecutive years.”
- D. “It is an acute bacterial infection of the bronchi requiring antibiotic therapy.”
- B. “It is sudden inflammation of the bronchioles that lasts less than 4 weeks.”
- C. “It is progressive destruction of alveoli leading to air trapping and hyperinflation.”
Question 40
A patient arrives in the emergency department with sudden right-sided weakness, facial droop, and slurred speech. What is the correct order of nursing actions based on priority?
- Maintain NPO status until swallow evaluation to prevent aspiration once immediate stabilization and diagnostics are underway.
- Assess ABCs first (airway, breathing, circulation) to ensure stability.
- Obtain a CT scan before initiating treatment to differentiate ischemic from hemorrhagic stroke.
- Determine time of symptom onset next, since eligibility for thrombolytic therapy (tPA) depends on being within the 3-4.5 hour window.
- 2, 4, 3, 1
- 2, 1, 3, 4
- 4, 3, 2, 1
- 1, 2, 3, 4
Question 43
The nurse is developing a care plan for a patient with pneumonia. Which intervention should the nurse include to promote airway clearance?
- A. Encourage the patient to increase fluid intake to 2-3 liters per day, if not contraindicated
- D. Place the patient in a flat supine position to improve lung expansion
- C. Administer antitussive medications around the clock to suppress coughing
- B. Instruct the patient to limit mobility and remain on bed rest
Question 44
A patient with a history of epilepsy is brought to the emergency department experiencing generalized tonic-clonic seizures lasting more than 10 minutes. Which action should the nurse take first?
- B. Prepare the patient for endotracheal intubation
- C. Apply soft wrist restraints to prevent injury
- D. Monitor the patient’s consciousness
- A. Administer intravenous lorazepam as prescribed to help stop the seizure.
Question 45
A nurse is preparing to administer 10 units of regular insulin and 20 units of NPH insulin to a client. What is the sequence of events the nurse should follow? (Move the steps of mixing insulin on the left into the box on the right, placing them in the selected order of performance. All steps must be used.)
- Inspect vials for contaminants.
- Roll NPH vial between palms of hands.
- Inject air into NPH insulin vial.
- Inject air into regular insulin vial.
- Withdraw short-acting insulin into syringe.
- Add intermediate insulin to syringe.
Question 46
A nurse is providing teaching to a group of clients about the changes that occur when clients experience cataracts. Which of the following statements should the nurse include in the teaching?
- “Vision changes occur when blood vessels leak fluid or blood under a portion of the retina.”
- “Vision changes occur when retinal tissue pulls away from the blood vessels in the eye.”
- “Vision changes occur when pressure in the eye is increased due to a decrease of aqueous humor.”
- “Vision changes occur when the cloudy lens alters the passage of light through the eye.”
Question 50
The nurse is caring for a client who is post-operative following a thyroidectomy. Which of the following is the priority assessment for the nurse?
- Incision site for drainage
- Laryngeal nerve damage
- Serum calcium levels
- Upper airway obstruction
Question 55 of 83
A nurse is assessing a client who is experiencing thyroid storm. Which of the following findings should the nurse anticipate?
- Coma
- Hypothermia
- Tachycardia
- Fruity smelling breath
Question 56 of 83
A nurse is reviewing the medical records of clients on a hospital floor. Which client would the nurse expect is most at risk for hyperthyroidism?
- A 25-year-old female who has metabolic syndrome
- A 73-year-old male who has an iodine deficiency
- A 45-year-old female who has a family history of autoimmune disorders
- A 35-year-old male who has Graves’ disease
Question 57 of 83
A nurse is assessing a patient using the Glasgow Coma Scale (GCS). The patient opens their eyes to pain, speaks incomprehensible words, and withdraws from painful stimuli. What is the patient’s total GCS score?
- A. 6
- B. 7
- D. 9
- C. 8
Question 58 of 83
The nurse is using the Braden Scale to assess a patient’s risk for pressure injury. Which patient finding would result in the lowest Braden score, indicating highest risk?
- A. Patient is alert, ambulates with assistance, and eats more than half of meals
- B. Patient is confused, bedfast, incontinent of urine, and has very limited mobility
- D. Patient walks independently, has dry skin, and consumes a balanced diet
- C. Patient requires minimal assistance to turn in bed and occasionally refuses meals
Question 59 of 83
A patient with diabetes reports feeling shaky, confused, and sweating profusely. The nurse assesses the patient’s blood glucose level as 50 mg/dL. Which action should the nurse take first based on the 3 P’s of diabetes?
- Assess for signs of diabetic ketoacidosis (DKA)
- Offer the patient a high-protein snack
- Check the patient’s insulin pump for malfunction
- Administer 15 grams of fast-acting carbohydrates
Question 60 of 83
A nurse is caring for a client who is newly diagnosed with hyperthyroidism and reports dry eyes and sensitivity to light. The nurse notes that the client’s eyes have a bulging appearance. Which of the following should the nurse include in the client’s plan of care?
- “Eye drops and dim lighting can improve your symptoms.”
- “Exposure to sunlight will help to strengthen your eyes.”
- “These are unusual symptoms. I will ask the provider for an ophthalmology referral.”
- “Surgery will be necessary to correct the damage to your eyes.”
Question 61 of 83
A nurse is caring for a patient diagnosed with positional vertigo. The patient reports experiencing sudden vertigo with position changes. Which action by the nurse is most appropriate to help manage the vertigo?
- Instruct the patient to avoid sudden head movements
- Advise the patient to perform quick head movements
- Encourage the patient to increase caffeine intake
- Recommend bed rest for prolonged periods
Question 62 of 83
A patient with Addison’s disease is starting lifelong hormone replacement therapy. Which of the following actions should the nurse prioritize to ensure safe and effective management of the therapy?
- Encourage a diet low in salt to prevent hypertension.
- Instruct the patient to take medications only when symptoms appear.
- Advise the patient to avoid all physical activity to prevent fatigue.
- Monitor blood pressure and adjust medication dosage as needed.
Question 63 of 83
What is the initial treatment option for conductive hearing loss due to impaction of cerumen?
- Refer for surgical intervention
- Manual removal of the impaction
- Prescribe antibiotics
- Perform a cleansing irrigation of the auditory canal
Question 64 of 83
A patient with type 2 diabetes is prescribed a sliding scale insulin regimen. The blood glucose before lunch is 248 mg/dL. According to the sliding scale, the nurse should administer 6 units of regular insulin subcutaneously. Which action by the nurse is most appropriate?
- C. Give the insulin after the meal to avoid hypoglycemia
- A. Hold the insulin dose until after the patient has eaten at least half of the meal
- B. Administer 6 units of regular insulin subcutaneously immediately before the patient eats
- D. Mix the insulin dose with the patient’s scheduled long-acting insulin
Question 65 of 83
A nurse in a provider’s office is caring for a client who has a new diagnosis of type 2 diabetes mellitus. Which of the following findings is the nurse’s priority?
- The client reports having difficulty checking their blood glucose.
- The client is experiencing shakiness.
- The client has a small foot wound.
- The client reports burning and tingling in their feet.
Question 66 of 83
A nurse is caring for a client with acute inflammation. Which clinical manifestation should the nurse expect?
- D. Bradycardia
- A. Pallor at the site
- C. Decreased capillary permeability
- B. Localized warmth
Question 67 of 83
A nurse is caring for two patients admitted with acute stroke: one with an ischemic stroke and the other with a hemorrhagic stroke. Which intervention is appropriate only for the patient with an ischemic stroke?
- C. Monitoring for signs of increased intracranial pressure (ICP)
- Maintaining systolic blood pressure below 140 mm Hg
- D. Keeping the patient NPO until a swallow evaluation is completed
- B. Preparing the patient for administration of tissue plasminogen activator (tPA)
Question 68 of 83
A nurse is preparing to teach a client who has hearing loss. Which of the following actions should the nurse plan to take?
- Speak quickly during the educational session.
- Face the client during the educational session.
- Use a loud tone of voice during the educational session.
- Turn on the television in the client’s room during the educational session.
Question: 68 of 83
A nurse is preparing to teach a client who has hearing loss. Which of the following actions should the nurse plan to take?
- Speak quickly during the educational session.
- Face the client during the educational session.
- Use a loud tone of voice during the educational session.
- Turn on the television in the client’s room during the educational session.
Question: 69 of 83
A nurse is planning care for a client who has type 1 diabetes mellitus and is scheduled for joint replacement surgery. Which of the following considerations should the nurse include in the plan of care?
- The client will be less able to handle temperature changes.
- The client is at higher risk for developing loss of bone density.
- The client may need more time to feel the effects of pain medication.
- The client’s blood glucose levels may fluctuate more severely.
Question: 70 of 83
A patient who has undergone a total thyroidectomy presents with fever, increased restlessness, and palpitations. The nurse should prioritize which action?
- Assess the surgical incision for redness.
- Assess for airway involvement- have airway at bedside.
- Dim the lights in the room to reduce stimulation.
- Encourage the patient to perform deep breathing exercises.
Question: 71 of 83
A nurse is reviewing a client’s laboratory results and sees that their hemoglobin A1C is 9%. Which of the following statements from the nurse is appropriate?
- “Your average blood sugar is high.”
- “Your blood sugar is very unstable.”
- “Your blood sugar is too high after meals.”
- “You have many dangerously low blood sugar levels.”
Question: 72 of 83
A patient with a suppressed immune system has difficulty performing the cell functions needed for wound healing. Which medication would further contribute to poor wound healing in this patient?
- Antibiotics
- Antihistamines
- Corticosteroids
- Aspirin
Question: 73 of 83
A nurse is assessing a client with open-angle glaucoma. Which of the following findings would the nurse most likely expect?
- C. Clouding of the lens
- D. Red, inflamed sclera with discharge
- A. Sudden severe eye pain and nausea
- B. Gradual loss of peripheral vision
Question: 74 of 83
A nurse is caring for a patient admitted with community-acquired pneumonia. Which assessment finding requires the most immediate intervention?
- A. Productive cough with thick, yellow sputum
- B. Fever of 99.8°F (37.6°C)
- C. Respiratory rate of 32 breaths per minute with use of accessory muscles
- D. Crackles heard in the right lower lung lobe
Question: 75 of 83
A nurse is caring for a client that is immobile. The nurse recognizes that the appearance of non-blanchable erythema on the heels most likely indicates which of the following stages of pressure injuries?
- Stage IV pressure injury
- Stage II pressure injury
- Stage I pressure injury
- Stage III pressure injury
Question: 76 of 83
A client with a left-sided ischemic stroke may demonstrate which clinical manifestation?
- C. Aphasia
- D. Left-sided neglect
- B. Poor judgment
- A. Impulsive behavior
Question: 77 of 83
The nurse is teaching a group of nursing students about wound healing. Which example best demonstrates secondary intention healing?
- A. A surgical incision closed with staples that heals without complications
- D. A laceration that is sutured immediately after injury
- B. A pressure ulcer left open and allowed to fill with granulation tissue
- C. A contaminated abdominal wound that is initially left open, then later surgically closed
Question: 78 of 83
A nurse is caring for a patient diagnosed with influenza. Which of the following nursing interventions is the highest priority?
- C. Provide the influenza vaccine to family members
- A. Encourage increased fluid intake
- D. Place the patient on droplet precautions
- B. Administer antipyretics for fever as prescribed
Question: 79 of 83
Click to highlight the information in the client’s medical record that requires intervention by the nurse. To deselect a finding, click on the finding again.
- Client is repositioned every 2 hr.
- Passive range of motion exercises to affected extremities performed once each day.
- Feet warm, pedal pulses 2+ bilaterally.
- Joint contracture noted to right wrist.
- Right heal with 1.3 cm x 1.3 cm (0.5 in x 0.5 in) area of nonblanchable redness, skin intact.
Question: 80 of 83
A nurse witnesses a hospitalized client suddenly lose consciousness and begin having rhythmic, full-body muscle contractions. The episode lasts approximately 2 minutes. Which of the following actions should the nurse take during the seizure?
- Turn the client onto their side.
- Insert an oral airway to prevent tongue biting.
- Move nearby furniture away from the client.
- Restrain the client’s arms and legs to prevent injury.
- Loosen restrictive clothing around the neck.
- C. 2, 4, 5
- D. 2, 3, 5
- A. 1, 2, 3
- B. 1, 3, 5
Question: 81 of 83
A patient with syndrome of inappropriate antidiuretic hormone (SIADH) is at risk for which electrolyte imbalance?
- Hypernatremia
- Hypocalcemia
- Hypokalemia
- Hyponatremia
Question: 82 of 83
A patient with a large surgical wound is receiving discharge teaching. Which statement by the patient indicates a correct understanding of nutritional needs to promote wound healing?
- C. “I should avoid foods high in vitamin C until my wound closes.”
- A. “I should increase my protein intake to help repair tissue.”
- B. “I will limit my fluid intake so my wound doesn’t get too much drainage.”
- D. “I will cut back on calories to prevent weight gain while I am less active.”
Question: 83 of 83
The nurse is caring for a patient who just returned from a bronchoscopy with biopsy. Which assessment finding requires immediate intervention?
- D. The patient is stridorous (high pitched) with severe difficulty breathing
- B. The patient is drowsy from the sedation
- C. The patient has blood-tinged sputum
- A. The patient reports a sore throat and hoarseness
