1. A nonstress test is performed on a client who is pregnant, and the results of the test indicate

1.) A nonstress test is performed on a client who is pregnant, and the results of the test indicate nonreactive findings. The health care provider prescribes a contraction stress test, and the results are documented as negative. How should the nurse document this finding?

• A normal test result
• An abnormal test result
• A high risk for fetal demise
• The need for a caesarean section

2.) The diagnosis of pregnancy is based on which positive signs of pregnancy? Select all that apply.

• Identification of fetal heartbeat
• Palpation of fetal outline
• Visualization of the fetus
• Verification of fetal movement
• Positive hCG test

3.) During pregnancy, many changes occur as a direct result presence of the fetus. Which of these adaptions meet this criterion? Select all that apply.

• Leukorrhea
• Development of the operculum
• Quickening
• Ballottement
• Lightening

4.) The multiple marker test is used to assess the fetus for which condition?

• Down syndrome
• Diaphragmatic hernia
• Congenital cardiac abnormality
• Anencephaly

5.) A client at 28 weeks’ gestation is admitted to the labor and birth unit. Which test would most likely be used to assess the client’s comprehensive fetal status?

• Amniocentesis.
• Biophysical profile (BPP).
• Nonstress test (NST).
• Ultrasound for physical structure.

6.) The nurse is reviewing four prenatal charts. Which client would be an appropriate candidate for a contraction stress test (CST)?

• A client with intrauterine growth retardation.
• A client with an incompetent cervix.
• A client with multiple gestation.
• A client with placenta previa.

7.) A prenatal client at 22 weeks’ gestation is scheduled for an amniocentesis. Which nursing actions would apply to any client undergoing this procedure? Select all that apply.

• Assess vital signs and fetal heart rate.
• Assess for bleeding.
• Administer Rh immune globulin to the client.

• Cleanse the skin with alcohol.

8.) A prenatal client at 30 weeks’ gestation is scheduled for a nonstress test (NST), and asks the nurse, “What is this test for?” The nurse correctly responds that the test is used to determine which of the following? Select all that apply.

• Accelerations of fetal heart rate.
• Fetal lung maturity.
• Adequate fetal oxygenation.
• Fetal well-being.

9.) Your patient has underwent testing of her blood type and Rh factor. She has A blood type. Which of the following statement is correct?

• At 36 weeks she will receive Rh immune globulin.
• At 28 weeks she should receive the Rh immune globulin.
• No further testing will be done because the patient is Rh negative, instead of Rh positive.
• The patient will be checked for clotting problems.

10.) The nurse recognizes that client identification in accordance with agency policy must occur immediately prior to which of the following actions? Select all that apply.

• Placement of the call light activation device within reach of the client
• Administration of oral acetaminophen
• Collection of a point of care blood glucose test
• Insertion of an indwelling urinary catheter
• Discontinuation of an intravenous normal saline infusion

11.) A client with a diagnosis of schizophrenia with catatonia has recently been admitted to the psychiatric unit. Which of the following is the priority nursing diagnosis?

• Impaired social interaction
• Impaired verbal communication
• Risk for deficient fluid volume
• Risk for impaired skin integrity

• A client recently diagnosed with schizophrenia is hospitalized. The client appears distraught and says

to the nurse, “The voices are bad today… they are so angry with me.” Which of the following is the best response by the nurse?

• “Do you need something to help you calm down?”
• “Don’t pay any attention to the voices. Let’s go into the dayroom.”
• “The voices are not real. Tell them to go away.”
• “What are the voices saying to you?”

13.) A client with schizophrenia says to the nurse, “The world turns as the world turns on a ball at the beach. But all the world’s a stagecoach and I took the bus home.” The nurse recognizes this statement as an example of the following?

• Concrete thinking
• Loose associations
• Tangentiality
• Word salad

14.) A client with schizophrenia is hospitalized. After 2 weeks of treatment, the frequency of the client’s hallucinations seems to be diminishing. When first hospitalized, the client refused to leave the room.Now the client spends time in the dayroom, sitting in a corner watching television, but does not initiate conversation or social interaction with other clients or staff. What is the most appropriate activity for the client?

• A board game with a staff member
• Participation in a group songfest
• Planning a unit picnic
• Playing Bingo with other clients

15.) A client is newly admitted to the mental health unit with a diagnosis of schizophrenia with persecutory delusions. Which nursing interventions should the nurse include in the client’s plan of care with regard to the delusional thinking? Select all that apply.

• Explore the meaning behind the client’s delusions
• Focus on reality and verbally reinforce it
• Focus on the client’s feelings secondary to the delusions
• Gently confront the client about the false beliefs
• Present logical explanations to discredit the delusions

16.) The new nurse is providing teaching to a client scheduled for electroconvulsive therapy (ECT). What information given by the new nurse would cause the charge nurse to intervene?

• “Be sure to take your valproic acid prior to the procedure.”
• “Do not drive during the course of ECT treatment.”
• “Temporary confusion is common immediately after treatment.”
• “You should avoid eating 8 hours prior to the procedure.”

17.) The nurse in the emergency department is admitting a client for pneumonia and sepsis. The health care provider (HCP) has given the nurse orders. Prioritize the order of implementation from highest (1) to lowest (5) priority.

• Apply oxygen at 2 L/min via nasal cannula.
• Start an IV infusion of 0.9% NaCI at 100 mL/hr.
• Obtain a set of blood cultures.
• Give ceftriaxone 1 gram every 12 hours IVPB.
• Teach the patient how to use incentive spirometry.

18.) The nurse is giving change-of-shift/hand-off report to the nurse from the next shift. Which statements are appropriate to include in the report? Select all that apply.

• “The client has been irritable and rude to staff members.”
• “The client has a history of hyperlipidemia.”
• “The client‘s heart rate has been ranging from 60 to 80 bpm.”
• “The client was admitted for a myocardial infarction.”
• “The client has declined a cardiac catheterization procedure.”

19.) The nurse in a preoperative surgery unit is reviewing the chart of a client who is scheduled to have a laparoscopic cholecystectomy today. The nurse notices the client has not signed the surgical consent.Which action would be most appropriate for the nurse to take?

• Initiate the Universal Protocol procedure and begin the surgical “time-out” process.
• Ask the client first if they understand the surgical procedure listed on the consent form.

• Ask the client to sign the consent form and then thee nurse can sign as the witness.
• Contact the surgeon and tell them that the client has not signed the consent form yet.

20.) The nurse on an inpatient hospital unit notices an unfamiliar person viewing a client’s medical record. The person has no visible identification badge. The nurse asks the person who they are, and they state they are from a local assisted living facility. Which action by the nurse is most appropriate?

• Allow the person to continue reviewing the client’s record.
• Call the security office to report the person and their actions.
• Request to see identification and an explanation for reviewing the client’s record.
• Ask the person to fill out and sign the facility’s Notice of Privacy Practices form.

21.) The charge nurse observes a new nurse inserting an indwelling urinary catheter on a female client who is experiencing urinary retention. After the nurse inserts the catheter, no urine outflow appears.Which action should the charge nurse take?

• Ask the nurse to withdraw and redirect the catheter anteriorly toward the pubic bone.
• Leave the catheter in place and check for urine output in 15 minutes.
• Remove and re-lubricate the catheter and assist the nurse with re-insertion.
• Remove the catheter and have the nurse get a new catheter and insertion kit.

22.) At a monthly staff meeting, the nurse manager is discussing quality improvement initiatives on the hospital nursing unit. Which is an example of a quality improvement outcome indicator?

• The frequency of postoperative wound infections on the unit
• The amount of time it takes for nurses to administer medications
• The percentages of clients who have Medicare insurance
• The number of clients who receive smoking cessation information

23.) The nurse receives their client care assignment for the upcoming shift. The nurse has been assigned a client with a nephrostomy tube. The nurse has never cared for a client with a nephrostomy tube before. Which is the most appropriate action by the nurse?

• Ask the charge nurse to provide an in-service about nephrostomy tube care.
• Plan to check-in with the charge nurse and the client often during the upcoming shift.
• Conduct a literature review about proper nephrostomy tube care.
• Ask the charge nurse to change the assignment to a different nurse.

24.) The nurse is providing care for a client who was recently diagnosed with end-stage heart failure. The client does not have advance directives in place. Which of the following statements by the nurse would be appropriate? Select all that apply.

• “What does your family know about your condition and prognosis?”
• “Have you thought about your options for a heart transplant?”
• “Have you thought about what you want done as your disease progresses?”
• “Have you discussed your wishes regarding resuscitation with your health care provider?”
• “Someone in your family needs to learn how to do cardiopulmonary resuscitation (CPR).”

25.) The nurse receives an illegible hand-written medication order from the primary health care provider (HCP). Which is the most appropriate statement made by the nurse to the HCP?

• “Please write your orders more legibly in the future.”
• “I need you to clarify what you have written so I am sure I am reading it correctly.”
• “I have spent a lot of time trying to read this order and I can’t figure it out.”