Q: A nurse is reviewing the medical record of a client to identify risk factors for colorectal
cancer. The nurse should identify which of the following findings as increasing the client’s risk?
a. History of Crohn’s disease
b. BMI of 24
c. Diet high in fiber
d. Age 46 years
Answer:
a. History of Crohn’s disease
Q: A nurse is caring for a client who is scheduled for a mastectomy. The client tells the nurse,
“I’m not sure I want to have a mastectomy.” Which of the following statements should the nurse
make?
a. “I can give you a list of other people who had the same procedure”
b. “You will be cancer-free if you have the procedure”
c. “I can give you additional information about the procedure”
d. “You should should get a second opinion regarding the procedure”
Answer:
c. “I can give you additional information about the procedure”
Q: A nurse is preparing to administer a unit of packed RBCs to a client who is anemic. Identify
the sequence of steps the nurse should follow.
e. Remain with the client for the first 15 to 30 min of the infusion
a. Obtain venous access using 19-gauge needle
c. Verify blood compatibility with another nurse
d. Initiate transfusion of the unit of packed RBCs
b. Obtain the unit of packed RBCs from blood bank
Answer:
a. Obtain venous access using 19-gauge needle
b. Obtain the unit of packed RBCs from blood bank
c. Verify blood compatibility with another nurse
d. Initiate transfusion of the unit of packed RBCs
e. Remain with the client for the first 15 to 30 min of the infusion
Q: A nurse is preparing a teaching plan for a client who has mucositis related to chemotherapy
treatment. Which of the following instructions should the nurse include?
a. “rinse your mouth with hydrogen peroxide”
b. “brush your teeth for 60 seconds twice daily”
c. “wear your dentures only during meals”
d. “floss your teeth following each meals”
Answer:
d. “floss your teeth following each meals”
Q: A critical care nurse is assessing a client who has severe head injury. In response to painful
stimuli, the client does not open her eyes, displays decerebrate posturing, and makes
incomprehensible sounds. Which of the following Glasgow Coma Scale scores should the nurse
assign the client?
a. 5
b. 2
c. 13
d. 10
Answer:
a. 5
Q: A nurse is providing discharge teaching to a client who has heart failure and instructs him to
limit sodium intake to 2 g per day. Which of the following statements by the client indicates an
understanding of the teaching?
a. “I can season my foods with garlic and onion salts”
b. “I can have mayonnaise on my sandwiches”
c. “I can have a frozen fruit juice bar for dessert”
d. “I can drink vegetable juice with a meal”
Answer:
c. “I can have a frozen fruit juice bar for dessert”
Q: A nurse is preparing to perform ocular irrigation for a client following chemical splash to the
eye. Which of the following actions should the nurse plan to take first?
a. Instill 0.9% sodium chloride solution into the affected eye
b. Administer proparacaine eyedrops into the affected eye
c. Collect information about the irritant that caused the injury
Answer:
c. Collect information about the irritant that caused the injury
Q: A nurse is assessing a client following extubation from a ventilator. For which of the
following findings should the nurse intervene immediately?
a. Rhonchi
b. SaO2 92%
c. Sore throat
d. Stridor
Answer:
d. Stridor
Q: A nurse is reviewing the laboratory reports of a client who has acute pancreatitis. Which of
the following findings should the nurse expect?
a. Elevated serum calcium
b. Elevated blood glucose
c. Decreased serum amylase
d. Decreased erythrocyte sedimentation rate
Answer:
b. Elevated blood glucose
Q: A nurse is reviewing the medical record of a client who has diabetes insipidus. Which of the
following findings should the nurse expect?<\/p>\n\n\n\n
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