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Random Nursing Questions 2024/
1.The wife of a client with alcohol dependency tells the nurse, "I am tired of making excuses for him to his boss and coworkers when he cannot make it into work. I believe him every time he says he is going to quit." The nurse recognizes the wife's statement as indicating which behavior?: enabling 2.A client has been diagnosed with dementia related to chronic and heavy alcohol consumption. In a family meeting with the client, discharge plans are being discussed. Which points should the nurse share with the family and client? Select all that apply.: Safety alarms on the doors will keep the client from wandering off. As the need for supervision increases, it may be necessary for the client to be placed in an extended-care facility. 3.A client with a history of cocaine abuse is receiving intravenous therapy and exits the hospital "to visit a friend." The client returns to the nursing unit 1 hour later, agitated, aggressive, combative, and reporting "chest pain." Place the nurse's actions in priority order from first to last. All options must be used.: Contact the security department. Obtain an ECG. Obtain a urine sample. Initiate a referral to obtain drug rehabilitation counseling. 4.A client on the adolescent psychiatric unit was admitted with a diagnosis of body dysmorphic disorder. The client has not been able to attend school
2 / 29 or his/her part-time work over the past year as a result of certain body obsessions. Recently, the client shaved the hair all over his/her body, claiming, "It is all growing weird." What component of therapy would be most important for the nurse to apply to this client?: The client's body image is real to the client. 5.The nurse is caring for a client admitted to the emergency department after being found lying on the bathroom floor with several empty pill bottles around her. While waiting for a psychiatric consult, the nurse discovers that the client's boyfriend has recently broken up with her. Which response is most likely is to build and maintain a therapeutic relationship within the emergency department?: "What can I do to help while you are here?" 6.A client is being admitted to the substance abuse unit for alcohol detox- ification. As part of his intake interview, a nurse asks when he had his last alcoholic drink. He says that he had his last drink 6 hours before admission. Based on this response, the nurse should expect early withdrawal symptoms to peak:: in 1 to 2 days.
- A client was discharged from an alcohol rehabilitation program on clon- azepam 0.5 mg three times a day. Several months later he reports having insomnia, shakiness, sweating, and one seizure. The nurse should first ask the client if he:: has stopped taking the clonazepam suddenly. 8.While admitting a client to the alcohol treatment program, the nurse asks the client how long she has been drinking, how much she has been drinking, and when she had her last drink. The client replies that she has been drinking about a liter of vodka a day for the past week and her last
4 / 29 process, the husband tells the nurse that the wife will not receive any pain medica- tion during the process. The husband then waits in the waiting room. As the birthing process continues, the nurse asks the wife if she needs pain medication. She declines the offer and reminds the nurse by saying, "My husband told you I cannot have any pain medicine." What is the nurse's best response to the client?: "I want to advocate for you and assist with the pain during this process."
5 / 29 14.The client who experiences residual arm pain after a fall has been referred to an acupuncture treatment center. What is the nurse's best response to the client's question, "How is acupuncture supposed to help me?": "Pain is relieved by releasing endorphins, which balance the flow of energy." 15.A client admitted with acute pyelonephritis now reports having a severe migraine, but declines PRN analgesics. What should the nurse discuss with this client? (Select all that apply.): Ask the client which migraine treatments are helpful when at home. Alternative therapies such as relaxation or music can help. 16.A young woman is admitted for surgical treatment of genital lesions. What should the nurse identify as an important part of care for this client?: Provide a chaperone or assistant in her care whenever possible. 17.A hospital client has told the nurse that his religion involves the burning of incense and has asked permission to do so on the unit. The nurse is aware that this practice would violate the hospital's fire regulations. What is the nurse's best action?: Dialogue with the client about alternative rituals or the possibility of performing the ritual outdoors. 18.After unsuccessful CPR efforts, the nurse must prepare an Islamic client for the morgue. Which nursing action should the nurse take?: Asking the client's family if they want to perform the ritualistic washing 19.The family member of a client diagnosed with dissociative identity disorder (DID) asks a nurse if hypnotic therapy might help the client. How should the nurse respond?: "Yes, a client is often not consciously aware of alter personalities."
7 / 29 that being present with the person is important. 25.The nurse facilitating the medication management group consistently no- tices that a particular client positions himself on the perimeter of the group. In order to be culturally mindful about the origin of this behavior, what question would the nurse ask the client?: "Where will you be comfortable sitting and still remain a part of the group?" 26.A Muslim client is scheduled to be discharged in 2 days, but insists on fasting until after dark. The nurse anticipates which explanation from the client?: "My religion requires me to fast all day until sunset." 27.A client on vacation experiences severe allergy symptoms, headache, and sinusitis (without respiratory distress). This client adamantly declines any supportive medications when offered. The nurse questions the client and learns the client receives weekly acupuncture treatments for these symptoms. The nurse's best response is:: "Let us try this until you can have acupuncture." 28.The nurse is attending a family meeting where a recent immigrant's treat- ment plan is being discussed. The client is a retired English teacher and defers to the oldest son when the care team asks the client questions. How should the nurse best interpret the client's action?: The client's action may reflect cultural and familial norms. 29.The nurse is caring for a group of clients in an acute medicine setting. What statement by a client would most warrant a referral to spiritual care, with the client's permission?: "It feels like one round of bad news after another for me, like I am being punished." 30.A client in home hospice care verbalizes to her caregiver that she wants
8 / 29 to meet with her minister. The caregiver, who does not want the minister to visit or to interact with the minister because of her different values and beliefs, asks the home health nurse how to handle this situation. To prevent further disagreement between the client and caregiver, what is the best recommen- dation for the nurse to implement?: Arrange for an alternative caregiver to be available for the client when the minister visits.
10 / 29 term care facility 38.While performing a cervical examination on a client in labor, a nurse's fingertips feel pulsating tissue. What is the most appropriate nursing inter- vention?: Leave the fingers in place and press the nurse call light 39.A nurse is performing an assessment of a postpartum client two hours after birth, and notes heavy bleeding with large clots. What should be the nurse's initial action?: Massaging the fundus firmly 40.A mother calls the health clinic and tells the nurse that she found her toddler with an open and empty bottle of acetaminophen. The mother asks the nurse what she should do. What is the nurse's priority intervention?: Give the mother instructions on how to call poison control 41.The nurse is assessing a laboring client. The client suddenly screams and exclaims, "My baby is coming." What is the priority action by the nurse?: As- sess for crowning
- The nurse is assigned to care for four clients. Which client should the nurse assess first?: A client admitted one hour ago with new-onset atrial fibrillation who is receiving IV diltiazem 43.A nurse is caring for a client exhibiting mild contractions and a cervical dilation of 4 cm. Using an external fetal monitor, the nurse observes variable decelerations. Which action should the nurse take first?: Place the client on her left side 44.A nurse suspects an infant may have a tracheoesophageal fistula or esophageal atresia. What is the most important intervention by the nurse?- : Report the suspicion to the health care provider
11 / 29 45.A nurse administers incorrect medication to a client. After assessing the client, and completing an incident report, which is the priority action by the nurse?: Report the incident to risk management 46.The mother of a two-year-old with epiglottitis states that she needs to pick up her older child from school. The two-year-old child begins to cry and appears more stridorous. What is the nurse's priority action?: Ask the mother if there's anyone else who can meet the older child
- A client is admitted to the labor and delivery unit in labor with blood flowing down her legs. What would be the priority nursing intervention?: Monitor fetal heart tones 48.Which nursing assessment data would be given priority for a child with clinical findings related to tubercular meningitis?: Signs of increased intracra- nial pressure (ICP) 49.What is the most important intervention for the nurse to implement while caring for a neonate with an omphalocele?: Carefully position and handle the omphalocele 50.What is the nurse's priority action in caring for a client who has just had a liver biopsy?: Monitor vital signs 51.A charge nurse is developing the client care assignments for the shift. Which client is most appropriately assigned to a licensed practical nurse (LPN)?: A client who experienced a cerebral vascular accident and has a do-not-re- suscitate (DNR) 52.A 40-year-old client with schizophrenia lives in a rooming house. At the weekly nursing clinic he reports creatures eating at his skin while scratching vigorously. Which intervention should be done first?: Assess the
13 / 29 safety in the sleeping environment 60.A client was admitted to the hospital 2 weeks ago following an ischemic stroke. Following the early introduction of stroke rehabilitation, he has seen significant improvements in both his medical status and activities of daily living (ADLs). This morning, however, his nurse notes that the client has been coughing since eating a minced and pureed breakfast. Auscultation of the chest reveals coarse crackles. Which of the following practitioners should the nurse liaise with to obtain a swallowing assessment?: Speech therapist. 61.A nurse and an LPN are working in the labor and birth unit. Of the activities that must be done immediately, which should the nurse assign to the LPN?: - Perform a straight catheterization for protein analysis.
- A client with chronic back pain is admitted to the medical-surgical floor and is receiving multiple pain medications and an antidepressant for pain control. The physician's orders include a physical therapy consult for ambulation and back strengthening, magnetic resonance imaging (MRI) of the lumbar spine, and a computed tomography (CT) scan of the abdomen. How should the nurse schedule therapy and diagnostic tests?: Schedule the MRI of the lumbar spine first, then the physical therapy consult, and then the CT scan. 63.A nurse and an unlicensed assistive personnel (UAP) are caring for four clients together on the telemetry unit. Which of the following nursing actions can safely be delegated to the UAP?: Applying electrodes in the correct position for ECG monitoring. 64.The nurse is caring for a client with esophageal varices. The nurse
14 / 29 should discuss which laboratory report finding with the health care provider (HCP)?- : elevated PT/INR 65.A client receiving chemotherapy for cancer has an elevated serum creati- nine level. The nurse should next:: notify the HCP. 66.A nurse is working with an unlicensed assistive personnel (UAP). Which clients should the nurse assign to the UAP? Select all that apply.: Older adult client who had hip replacement surgery and needs to walk in the hall with a walker. Adult client who had a hysterectomy 3 days ago and requires vital sign checks every 4 hours. 67.A charge nurse is making assignments for a team that includes two regis- tered nurses (RNs) and one unlicensed assistive personnel (UAP). One client requires a nurse to perform several complex procedures. The charge nurse should:: assign fewer clients to the RN managing this client's care. 68.A client with heart failure has been receiving an I.V. infusion at 125 ml/hour. Now the client is short of breath and the nurse notes bilateral crackles, jugular vein distention, and tachycardia. What should the nurse do first?: Slow the I.V. infusion. 69.A 4-month-old infant has been carried into the emergency department after falling off his parents' bed and hitting his head on the floor. What should the nurse do next?: Move the family to an area where an assessment can be completed and call for a physician.
16 / 29 IV, given over one hour. At the end of the alteplase infusion, the nurse notes that the client's tongue was swollen. What is the nurse's priority action?: Administer antihistamines, intravenous corticosteroids, and or epinephrine 75.An alert and oriented client comes to the emergency department after hitting his head in a motor vehicle accident. What should the nurse do first?- : Immobilize the client's head and neck 76.What is a priority for the nurse developing a plan with a client admitted to the hospital with an acute exacerbation of rheumatoid arthritis?: Continuing to work on a positive self image because joint deformities are common in this disease 77.A client receiving intravenous heparin has developed hematuria and pe- techiae. What is the nurse's best action?: Administer protamine sulfate 78.A nurse who works in a community-based clinic is implementing primary prevention with the clients who use the clinic. What should the nurse include in primary prevention activities?: Obtaining a rubella titer on a woman who is planning to start a family 79.After administering the prescribed medications, which of the following clients requires immediate intervention?: A client taking digoxin who has a morning potassium level of 3.0 mEq/L. 80.The nurse is preparing to administer the last dose of ceftriaxone before discharge to a 1-year-old but finds the the IV has occluded. The nurse should:-
17 / 29 : contact the prescriber to request a prescription change. 81.A client has a tracheostomy. Which nursing action would prevent compli- cations of suctioning?: Sterility of suction catheter 82.A nurse calls the unit manager to report that her purse has been stolen from the locked break room. The nurse says she thinks she knows which of the staff stole the purse. Which actions by the nurse manager would be appro- priate? Select all that apply.: Call hospital security to initiate an investigation. Ask the nurse to document all the facts related to the missing purse. Alert nursing administration that a staff's purse has been stolen. Ask other staff to report any suspicious activity they may have observed. 83.A nurse from a surgical unit is asked to work on the pediatric unit during a staffing shortage. The surgical nurse has not worked in pediatrics for 10 years and is not familiar with the unit. The surgical nurse approaches the nurse manager and claims not to be competent to work on the pediatric unit. What
19 / 29 treatment for anxiety and insomnia. The practitioner has prescribed lorazepam 1 mg/po/tid. The nurse determines that teaching has been effective when the client states:: "I'll avoid coffee." 90.Which physical assessment data would alert the nurse to a possible mild toxic reaction in a client receiving lithium?: Vomiting and diarrhea 91.Liquid oral iron supplements have been prescribed for a child. What is the most important information for the nurse to provide to this child's parents?: - Give the medicine via a dropper or through a straw 92.A laboring client in the latent stage of labor begins reporting pain in the epigastric area, blurred vision, and a headache. Which medication would the nurse anticipate for these symptoms?: Magnesium sulfate 93.Which recommendation would be most helpful to suggest to a primigravid client at 37 weeks' gestation who has leg cramps?: Straighten the knee and flex the toes toward the chin. 94.The nurse is caring for a client with gestational trophoblastic disease (GTD). Which of the following interventions will the nurse include in the client's plan of care? Select all that apply.: Measure fundal height. Administer ondansetron IV. 95.A 34-year-old multiparous client at 16 weeks' gestation who received regu- lar prenatal care for all of her previous pregnancies tells the nurse that she has already felt the baby move. How does the nurse interpret this finding?: normal because multiparous clients can experience quickening between 14 and 20 weeks' gestation 96.A primigravid client visits the clinic for a routine examination at 35 weeks' gestation. The client's blood pressure is near the baseline of 120/
20 / 29 mm Hg with no proteinuria or evidence of facial edema. The client asks the nurse, "What should I take if I get an occasional headache after looking at my com- puter at work all day?" The nurse instructs the client that she can occasionally take which over-the-counter medication?: acetaminophen 97.After explaining to a multigravid client at 36 weeks' gestation who is diagnosed with severe hydramnios about the possible complications of this condition, which client statement indicates the need for further instruction?: "I can continue to work at my job at the automobile factory until labor starts." 98.A cerclage procedure is performed on a client at 20 weeks' gestation who is diagnosed with cervical incompetence. When preparing the discharge teaching plan, the nurse should expect to instruct the client to monitor herself for which problem?: symptoms of infection
- After teaching a primigravid client at 24 weeks' gestation, who has received permission from the primary care provider to make a 6-hour automobile trip to visit her parents, about precautions to take during the trip, which client statement indicates the need for further teaching?: "I will sleep for 1 hour at the halfway point of the trip."
- A client at 24 weeks gestation comes to the clinic for a prenatal check-up and informs the nurse that she has been "seeing double." The nurse checks the urine and determines that there is 3+ proteinuria. What does the nurse determine is the potential priority problem?: Gestation hypertension
- A client with preeclampsia is prescribed magnesium sulfate to prevent seizure activity. The nurse is reviewing the results of the client's
