Question 1
Readiness Benchmark Exam-Nursing. The nurse cares for a 4-year-old child in the emergency department.
Nursing Notes (1125): 4-year-old client present to ED. Parents report a 2-day history of fevers, irritability, and malaise. Yesterday the client told parents, “It hurts to pee.” Client is arousable but lethargic and moaning. Skin turgor dry and tenting. 22G IV in right antecubital. Health care provider at bedside; awaiting orders.
Vital Signs (1115): * Blood Pressure: 66/42
- Heart Rate: 140
- Respiratory Rate: 24
- Temperature: 102°F (39°C)
Laboratory Results (Urinalysis):
- Specific Gravity: 1.030 (Reference: 1.016–1.022)
- White Blood Cells: +2 (Reference: <1)
Which assessment cue is most concerning to the nurse?
- Objective assessment findings
- Vital signs
- Laboratory results
- Subjective symptom reports
Question 2
A client with seizures is to have phenytoin oral suspension 125 mg three times daily. The medication dispensing system delivers a phenytoin solution with concentration of phenytoin 50 mg/mL.
How many milliliters (mL) should the nurse administer? Round to the nearest tenth.
- Answer: 2.5 mL
Question 3
A 78-year-old client presents to the primary care provider’s office accompanied by the client’s adult child. Pneumonia is confirmed with chest x-ray. Ciprofloxacin 500 mg PO every 12 hours for 10 days is prescribed. On 6/24, the daughter states, “I give the medication at 8 AM and 8 PM with a glass of milk”. Readiness Benchmark Exam-Nursing
Complete the following sentences by choosing from the lists of options. The nurse should respond to the client’s daughter by stating, “This medication cannot be taken alone with foods rich in calcium. If you give your mother calcium at the same time, the medication will be more less effective.”
Question 4
An infant had a bilateral cleft lip repair two days ago.
Which nursing intervention should the nurse include in the client’s plan of care?
- Remove the restraints periodically to cuddle the infant.
- Leave the infant in crib at all times to prevent suture strain.
- Alternate infant’s position from prone to side-lying to supine.
- Keep infant heavily sedated to prevent stress on the suture line.
Question 5
The nurse cares for a preschool child with an arm cast applied recently for a fractured humerus.
Which assessment findings would warrant an immediate call to the health care provider due to a potential serious complication? Select all that apply.
- Inability to move extremity.
- Severe pain not relieved by analgesics.
- Lack of sensation in the extremity.
- Tingling of extremity.
- Palpable distal pulse.
- Capillary refill to extremity of <3 seconds.
Question 6
The nurse cares for a client in the emergency department.
- Weight: 75 kg
- Order: Morphine sulfate 0.2 mg/kg IVP every 4 hours PRN pain
- Administered (1005): Morphine sulfate 33 mg IVP
- Status (1025): Client confused and sedated. Oxygen saturation 91% on 2L/NC. Heart rate 60.
Complete the diagram to specify the condition, actions, and parameters.
- Condition: Wrong dose
- Actions to Take: * Call code team for a rapid response
- Administer naloxone
- Parameters to Monitor:
- Respiratory rate
- Blood pressure
Question 7
The nurse cares for a client undergoing conscious sedation for a colonoscopy.
During the procedure, which client data is the most important parameter for the nurse to monitor?
- Temperature.
- Oxygen saturation.
- Blood pressure.
- Heart rate.
Question 8
The nurse prepares for the client’s first home visit, which will include a full assessment, catheter site dressing change, and education as needed. For each potential assessment cue, click to specify if the cue is expected or would require further evaluation by the nurse.
- Muscle cramping at night: Requires Evaluation
- Access site dressing saturated with blood: Requires Evaluation
- Reports of general malaise: Requires Evaluation
- Abdominal discomfort on dialysate inflow: Expected
- 5-pound (2.27 kg) weight gain in 24 hours: Requires Evaluation
- Afebrile status: Expected
Question 9
The home health nurse prepares to care for client’s catheter site. Which supplies should the nurse gather to perform the indicated action? Select all that apply.
- Prescribed cleansing solution
- Sterile gloves
- Suture removal scissors
- Clean gloves
- Surgical pressure dressing
- Gauze pads
- Tap water
- Cotton swabs
- Alcohol wipes
- Face masks
Question 89
A client who is deaf and mute is admitted to the acute care unit. The nurse assigned to the client is able to communicate using sign language and plans to use it while admitting the client using the computer on wheels.
What is most important for the nurse to consider in this plan?
- Position the computer on wheels so it is not between the client and nurse.
- Stand directly in front of the client when communicating.
- Speak in a clear tone of voice and do not yell.
- The client may not understand sign language.
Question 90
A 19-year-old client presents to a primary care clinic reporting a severe headache, nuchal rigidity, temperature 102 °F (38.9 °C), and scattered petechiae on the torso.
What is the nurse’s most appropriate initial action?
- Inquire about recent travel outside of the country.
- Place client in a private room on droplet precautions.
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- Obtain a prescription for intravenous morphine.
- Infuse ceftriaxone intravenously as prescribed.
Question 91
A confused client pulled out their nasogastric tube and indwelling urinary catheter. Both are reinserted and the client is placed in wrist restraints to prevent pulling them out again.
What is most important for the nurse to include in the client’s plan of care?
- Ensure client safety by checking circulation and range of motion every shift and toileting the client.
- Release the restraints from both wrists one at a time and offer the client food, fluid, and hygiene care.
- Remove restraints as soon as possible and ask the health care provider for a PRN restraint prescription.
- When the client is up in a chair, tie the restraints tightly around the wrists so they cannot reach the urinary catheter.
Question 92
A hospital plans to apply for Magnet® designation and has started to take the necessary steps to reach that goal. Shared governance councils were established on the nursing units.
With the establishment of these shared governance councils, what changes among nurses on the units should hospital leaders anticipate? Select all that apply.
- Improved decision-making regarding practice on the units.
- More ownership for practice policies and procedures.
- Lack of support for disciplinary policies.
- Increase in autonomy and confidence.
- Less interaction with each other on the units.
Question 93
The charge nurse has delegated care of five clients to the night shift nurse who starts the shift at 1900. Which client should the nurse see first?
- Client returned from abdominal surgery at 1830 and is experiencing nausea and vomiting.
- Confused client with an intestinal obstruction who just pulled out the nasogastric tube.
- Older adult client admitted this morning with pneumonia and oxygen applied at 3 L/minute.
- Client sitting up in a chair whose pressure injury dressing is saturated and leaking on the floor.
- Client admitted today, medicated for alcohol withdrawal symptoms at 1700 and is sleeping.
Question 94
A client with human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) is placed on reverse isolation for neutropenia.
Which comment made by the client requires further discussion with the nurse? Readiness Benchmark Exam-Nursing
- “Everyone is wearing a mask to keep from spreading my germs to others.”
- “My family needs to wear a mask and wash hands when they visit.”
- “The health care provider prescribed these special precautions.”
- “Reverse isolation protects me from outside infections.”
Question 95
A client with a history of sickle cell anemia is admitted to the hospital with a vaso-occlusive crisis. The client reports severe pain in the lower back, chest, joints, hands, and feet. A fever of 101°F is present. The nurse is assessing the need for referrals and obtaining the necessary orders. Which referral should the nurse prioritize?
- Physical therapist
- Cardiologist
- Pain management specialist
- Rheumatologist
Question 96
A client scheduled to have surgery will be using patient-controlled analgesia to control pain postoperatively. Which statement by the client requires additional discussion by the nurse?
- “I need to be careful how many times I push the button on the machine because I could overdose myself.”
- “I will have a button to push so that when I have pain, I can give myself a dose of medicine.”
- “I will be getting some pain medication all the time and then, when I push the button, I will get a little extra.”
- “With this machine and the button, I will be able to get pain medication much sooner than having to call the nurse.”
Question 97
A school-age child is to be discharged home on a month of intravenous antibiotic therapy to treat osteomyelitis. Which component should the nurse ensure is part of the discharge plan and instructions for this client?
- Ensuring the child maintains the routine of the hospital while at home.
- Arrangements for tutoring and schoolwork while at home.
- Instructions for a low-calorie, moderate fat, low-protein diet.
- Instructions for the parent to return the child to team sports immediately.
Question 98
Based on the information in the chart, what lapse in nursing care occurred?
- Supplemental oxygen was not administered.
- Respiratory isolation was not instituted.
- No medication was given for increased temperature.
- Nurse did not administer medication for the cough.
Question 99
The nurse on the postpartum unit receives change-of-shift report for her assigned clients. Which client will the nurse see first?
- Client who delivered vaginally 10 hours ago requiring an episiotomy; UAP reports heart rate of 50, blood pressure of 98/64, temperature of 100.3 F (37.9 C).
- Client who delivered twins via cesarean 24 hours ago and has not been out of bed yet; needs dose of enoxaparin.
- Client who successfully delivered 9 lb 4 oz baby 4 hours ago vaginally; UAP reports blood pressure of 86/60, heart rate 114.
- Client who delivered 6 lb 4 oz baby vaginally 8 hours ago; recent lab shows white blood cell count of 13,600 mm3 and hemoglobin of 10.8 g/dL.
Question 100
A client with bipolar disorder calls the 24-hour nurse phone line and states, “I take lithium, and I just don’t feel well. For the past 2 days I have been having stomach problems, frequent diarrhea, vomiting, and I am sweating a lot.” What is the most appropriate response by the nurse?
- “Take an extra dose of your lithium today and restrict your fluid intake.”
- “Don’t take your lithium and go see your health care provider today.”
- “Call 911 now as you are experiencing lithium toxicity, which can be fatal.”
- “You may have eaten some bad food. Just let the diarrhea run its course.”
