a. A specialized team reviews each case for eligibility. I will contact them to review

51.) After a traumatic head injury, a 36-year-old client on a mechanical ventilator is declared brain dead. The client’s spouse states, “Maybe this happened for a reason. Do you think organ donation is possible?” Which response by the nurse is appropriate?

• “A specialized team reviews each case for eligibility. I will contact them to review

your spouse’s history.”

• “It depends on whether your spouse gave consent to be an organ donor before the

injury.”

• “Organ donation often provides comfort to family members who are grieving the

loss of a loved one.”

• “You seem to be thinking the worst. Your spouse was young and healthy, and we are

doing everything we can.”

52.) The nurse cares for a client with end-stage liver disease who is not a candidate for a liver transplant. The client is considering participation in a research study investigating an experimental therapy. In discussing possible enrollment in the study with the client, which of the following statements by the nurse are appropriate? Select all that apply.

• “Ask the research team about the risks, consequences, and benefits before signing

consent.”

• “Before signing consent, make sure you understand the study’s duration and your

obligations.”

• “In your own words, can you tell me what you have been told about the study and what

you will be required to do?”

• “Remember that if you participate, you are not obligated to stay in the study. You may

withdraw at any time.”

• “To maintain the integrity of the study, certain information may be withheld, such as

potential for harm or discomfort.”

53.) The nurse conducts telephone screenings with several clients who are scheduled for CT scan of the abdomen with oral contrast. The nurse should notify the health care provider about which client before the CT scan is performed?

• Client in remission from breast cancer who has abdominal pain
• Client who had a total hip arthroplasty with a titanium implant
• Client with a history of heart disease and an implanted pacemaker
• Client with a history of stroke who has dysphagia and is drooling

54.) The nurse completes a follow-up assessment on a client with sickle cell crisis who has just received a blood transfusion. The nurse notifies the health care provider and receives the following new prescriptions. Which prescription is the priority for the nurse to administer?Click on the exhibit button for additional information.

• Diphenhydramine 25 mg IV every 8 hours, PRN for itching
• Furosemide 20 mg IV once, now
• Lorazepam 1 mg IV once, now
• Morphine 2-4 mg IV every 4 hours, PRN for pain

55.) Four clients enter the emergency department at the same time. Which client should the nurse alert the health care provider to see first?

• 8-year-old who is crying and reports a headache after sustaining a head injury
• 17-year-old who cannot raise an arm above the head after a football-related injury
• 40-year-old with deep, partial-thickness burns and singed facial hair from a campfire
• 70-year-old experiencing severe diarrhea and a poor appetite for the past 24 hours

56.) The nurse reviews self-care strategies for a client with overflow urinary incontinence. Which client statement indicates a need for further teaching?

• “I should increase the amount of fiber in my diet so that I do not become constipated.”
• “I should leave my desk every 2 hours to walk around a bit and to use the bathroom.”
• “I will decrease my fluid intake to 6 glasses each day and avoiding drinking fluids after 7

PM.”

• “I will use my hand to apply pressure over my lower abdomen when I urinate.”

57.) The nurse is caring for a client win non-Hodgkin Lymphoma who is starting chemotherapy.What assessment findings alert the nurse that the client is developing the potential complication of tumor lysis syndrome?

• Facial and upper body edema
• Generalized edema and hyponatremia
• Hyperkalemia and hyperuricemia
• Hypotension and elevated lactic acid

58.) The nurse on a medical-surgical unit prepares scheduled daily medications for a client and places them in a pill cup. After receiving the pill cup, the client states, “I take a whole tablet of metoprolol at home. Why did you cut this one in half?” What is the best response by the nurse?

• “Do you know how many milligrams of metoprolol you normally take at home every

day?”

• “Show me which pill you’re talking about so I can verify your prescriptions again.”
• “This is the same dose you received the past 3 days in the hospital, so we know it’s safe

to take.”

• “Your health care provider has prescribed a half-dose of metoprolol while you’re in the

hospital.”

59.) The nurse assesses a client who is intubated and mechanically ventilated after a cerebrovascular accident. Which assessment finding is most important for the nurse to report to the health care provider?

• Flaccid right hand and arm
• Impaired gag reflex when suctioning
• Presence of urinary incontinence
• Rigid flexion of arms at the elbows

60.) The emergency department nurse is caring for a client with diabetic ketoacidosis. Which new prescription should the nurse implement first? Click on the exhibit button for more information.

• Administer 50 mEq sodium bicarbonate IVP
• Give 1 L bolus of 0.9% sodium chloride IV
• Initiate a continuous infusion of regular insulin
• Insert and maintain an indwelling urinary catheter

61.) The nurse provides discharge teaching for family members of a client going home following a suicide attempt. Which of the following instructions are appropriate for the nurse to include? Select all that apply.

• “Avoid initiating discussion about suicide as this may increase risk for additional

attempts.”

• “If the client hints at self-harm, redirect the conversation to positive subject.”
• “Maintain a list of community resources and a suicide hotline for quick reference.”
• “Remove excess and unused medications, firearms, and knives from the home.”
• “Sudden positive outlook or calmness may indicate an impending suicide attempt.”

62.) The nurse is admitting a client with a seizure disorder and delegates preparation of the client’s room to the student nurse. Which of the following actions by the student nurse indicate a correct understanding of seizure precautions? Select all that apply.

• Ensures that suction equipment is present and operable
• Ensures that supplemental oxygen and a bag valve mask are present
• Places an oral airway at the head of the bed
• Places padding on the side rails of the bed
• Tapes a padded tongue blade at the head of the bed

63.) Dozens of clients arrive in the emergency department with chemical burns and inhalation injuries from exposure to anhydrous ammonia gas released from a tanker truck on a highway. What is the priority action by the nurse?

• Administer 100% oxygen to all clients with evidence of inhalation injuries
• Assist clients to remove contaminated clothing and shower with copious amounts of

water

• Estimate the extent of the clients’ burn injuries using the rule of nines
• Rapidly assess the clients’ vital signs, respiratory effort, and neurological status

64.) The nurse is reviewing telemetry strips of clients. Which rhythm requires further assessment by the nurse?

a.b.c.d.

65.) The clinic nurse teaches a female client how to collect a clean-catch urine specimen for culture and sensitivity. Which of the following client statements indicate that instruction has been effective? Select all that apply.

• “I will be very careful not to touch the inside or rim of the container.”
• “I will begin to urinate before passing the container into the stream for collection.”
• “I will cap the container and restart later if I cannot collect enough urine.”
• “I will cleanse the vulva with single-use antiseptic wipes prior to urinating.”
• “I will have to collect the specimen when I first urinate tomorrow morning.”

66.) The nurse is performing a 12-lead ECG on a client suspected of having a myocardial infarction. The nurse notes significant interference on lead V2. Which electrode will the nurse troubleshoot? Left-clicking the mouse will put an X to show the answer before submitting the question.Please use the button shown below to view the image and make your selection(s)