Priority

1. The nurse must know that the most accurate oxygen delivery system available is
A) the Venturi mask
B) nasal cannula
C) partial non-rebreather mask
D) simple face mask

2. A client arrives in the emergency department after a radiologic accident at a local factory. The first action of the
nurse would be to
A) begin decontamination procedures for the client
B) ensure physiologic stability of the client
C) wrap the client in blankets to minimize staff contamination
D) double bag the client’s contaminated clothing

3. The nurse is caring for a client on complete bed rest. Which action by the nurse is most important in preventing the
formation of deep vein thrombosis?
A) Elevate the foot of the bed
B) Apply knee high support stockings
C) Encourage passive exercises
D) Prevent pressure at back of knees

4. If a very active two year-old client pulls his tunneled central venous catheter out, what initial nursing action is
appropriate?
A) Obtain emergency equipment
B) Assess heart rate, rhythm and all pulses
C) Apply pressure to the vessel insertion site
D) Use cold packs at the exit incision site

5. The nurse assesses several post partum women in the clinic. Which of the following women is at highest risk for
puerperal infection?
A) 12 hours post partum, temperature of 100.4 degrees Fahrenheit since delivery
B) 2 days post partum, temperature of 101.2 degrees Fahrenheit this morning
C) 3 days post partum, temperature of 100.8 degrees Fahrenheit the past 2 days
D) 4 days post partum, temperature of 100 degrees Fahrenheit since delivery

6. The nurse is caring for a client with a chest tube. On the second postoperative day, the chest tube accidentally
disconnects from the drainage tube. The first action the nurse should take is
A) reconnect the tube
B) raise the collection chamber above the client's chest
C) call the health care provider
D) clamp the chest tube

7. A client is placed on sulfamethoxazole-trimethoprim (Bactrim) for a recurrent urinary tract infection. Which of the
following is appropriate reinforcement of information by the nurse?
A) "Drink at least 8 glasses of water a day."
B) "Be sure to take the medication with food."
C) "It is safe to take with oral contraceptives."
D) "Stop the medication after 5 days."

8. A client calls the evening health clinic to state “I know I have a severely low sugar since the Lantus insulin was given 3 hours ago
and it peaks in 2 hours.” What should be the nurse’s initial response to the client?
A) What else do you know about this type of insulin?
B) What are you feeling at this moment?
C) Have you eaten anything today?
D) Are you taking any other insulin or medication?

9. The nurse is caring for a client who is receiving total parenteral nutrition (TPN) (hyperalimentation and lipids). What
is the priority nursing action on every 8 hour shift?
A) Monitor blood pressure, temperature and weight
B) Change the tubing under sterile conditions
C) Check urine glucose, acetone and specific gravity
D) Adjust the infusion rate to provide for total volume

10. The nurse reviews an order to administer Rh (D) immune globulin to an Rh negative woman following the birth of
an Rh positive baby. Which assessment is a priority before the nurse gives the injection?
A) Newborn's blood type
B) Coombs' test results
C) Previous RhoGAM history
D) Gravida and parity
11. A client has been on antibiotics for 72 hours for cystitis. Which report from the client requires priority attention by
the nurse?
A) foul smelling urine
B) burning on urination
C) elevated temperature
D) nausea and anorexia

12. The nurse is caring for a school-aged child with a diagnosis of secondary hyperparathyroidism following treatment
for chronic renal disease. Which of the following lab data should receive priority attention?
A) Calcium and phosphorus levels
B) Blood sugar
C) Urine specific gravity
D) Blood urea nitrogen

13. When caring for a client with urinary incontinence, which content should be reinforced by the nurse?
A) hold the urine to increase bladder capacity
B) avoid eating foods high in sodium
C) restrict fluid to prevent elimination accidents
D) avoid taking antihistamines

14. A client returns from the operating room after a right orchiectomy. For the immediate post-operative period the
nursing priority would be to
A) maintain fluid and electrolyte balance
B) manage post-operative pain
C) ambulate the client within 1 hour of surgery
D) control bladder spasms

15. A client with a fracture of the radius had a plaster cast applied 2 days ago. The client complains of constant pain
and swelling of the fingers. The first action of the nurse should be
A) elevate the arm no higher than heart level
B) remove the cast
C) assess capillary refill of the exposed hand and fingers
D) apply a warm soak to the hand

16. A client is 2 days post operative. The vital signs are: BP - 120/70, HR -- 110 BPM, RR - 26, and Temperature -
100.4 degrees Fahrenheit (38 degrees Celsius). The client suddenly becomes profoundly short of breath, skin color is
gray. Which assessment would have alerted the nurse first to the client's change in condition?
A) Heart rate
B) Respiratory rate
C) Blood pressure
D) Temperature

17. A client is waiting to have an intravenous pyelogram (IVP). The most important information to be obtained by the
nurse prior to the procedure is
A) time of the client's last meal
B) client's allergy history
C) assessment of the peripheral pulses
D) results of the blood coagulation studies

18. What must the nurse emphasize when teaching a client with depression about a new prescription for nortriptyline
(Pamelor)?
A) Symptom relief occurs in a few days
B) Alcohol use is to be avoided
C) Medication must be stored in the refrigerator
D) Episodes of diarrhea can be expected

19. Before administering a feeding through a gastrostomy tube, what is the priority nursing assessment?
A) Measure the vital signs
B) Palpate the abdomen
C) Assess for breath sounds
D) Verify tube patency

20. The nurse is caring for a client with a vascular access for hemodialysis. Which of these findings necessitates
immediate action by the nurse?
A) pruritic rash
B) dry, hacking cough
C) chronic fatigue
D) elevated temperature
21. The nurse is caring for a client several days following a cerebral vascular accident. Coumadin (warfarin) has been
prescribed. Today's prothrombin level is 40 seconds (normal range 10-14 seconds). Which of the following findings
requires priority follow-up?
A) Gum bleeding
B) Lung sounds
C) Homan's sign
D) Generalized weakness

22. The registered nurse (RN) is making decisions regarding client room assignments on a pediatric unit. Which
possible roommate would be most appropriate for a 3 year-old child with minimal change nephrotic syndrome?
A) 2 year-old with respiratory infection
B) 3 year-old fracture whose sibling has chickenpox
C) 4 year-old with bilateral inguinal hernia repair
D) 6 year-old with a sickle cell anemia crisis

23. The nurse is caring for a pregnant woman with pregnancy induced hypertension (PIH) receiving magnesium
sulfate
intravenously. In assessing the client, it is noted that respirations are 12, pulse and blood pressure have dropped
significantly, and 8 hour output is 200 ml. What should the nurse do first?
A) Administer calcium gluconate
B) Call the provider immediately
C) Discontinue the magnesium sulfate
D) Perform additional assessments

24. A client has a serum glucose of 385 mg/dl. Which of these orders would the nurse question first?
A) Repeat glycohemoglobin in 24 hours
B) Document Accu-checks, intake and output every 4 hours
C) Humulin N 20 units IV push
D) IV fluids of 0.9% normal saline at 125 ml per hour

25. The nurse performs an assessment during a fluid exchange for the client who is 48 hours post-insertion of an
abdominal Tenckhoff catheter for peritoneal dialysis. The nurse knows that the appearance of which of the following
needs to be reported to the provider immediately?
A) slight pink-tinged drainage
B) abdominal discomfort
C) muscle weakness
D) cloudy drainage