PREBOARD 30 Set A

1.) The nurse assesses the heart tones of a 77-year-old client with chronic heart failure. Which
heart tone should the nurse document? Listen to the audio clip.
a. Pericardial friction rub
b. S1, S2, no adventitious tones
c. S3 extra heart tone
d. Systolic murmur

2.) The nurse is caring for a client with 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?
a. Facial and upper body edema
b. Generalized edema and hyponatremia
c. Hyperkalemia and hyperuricemia
d. Hypotension and elevated lactic acid

3.) The nurse is caring for a client diagnosed with acute pericarditis. Which clinical finding would
cause the nurse to immediately contact the health care provider?
a. Chest pain that worsens when in a supine position
b. Muffled heart sounds and narrow pulse pressure
c. Pericardial friction rub heard on auscultation
d. ST-segment elevation in almost all ECG leads

4.) The nurse has provided teaching to the parents of a 6-month-old child who is being discharged
with a new prescription for a liquid iron supplement. Which statements by a parent indicate a
need for additional instruction? Select all that apply.
a. "Our child might become constipated while taking this medication."
b. "Our child's stools might become black and tarry."
c. "We can give the dose with milk to prevent stomach irritation."
d. "We will administer the dose into the back of our child's cheek."
e. "We will administer the dose with meals to increase absorption."

5.) The nurse working in a gastrointestinal clinic is reviewing the list of clients. Which client should
the nurse see first?
a. Client reporting constipation since having a barium enema 3 days ago
b. Client reporting moderate flatulence after a resolved bowel obstruction
c. Client with irritable bowel syndrome reporting 3-4 loose stools per day for the past 3 days
d. Client with ulcerative colitis reporting 2-3 loose, bloody stools per day for the past 2 days
6.) A nurse in the intensive care unit is responding to a low-pressure limit mechanical ventilator
alarm. The nurse will assess for which conditions that can trigger a low-pressure alarm? Select
all that apply.
a. Client has pulled out endotracheal tube
b. Client is coughing or gagging
c. Endotracheal tube cuff is leaking
d. Secretions are built up in endotracheal tube
e. Ventilator tubing is disconnected

7.) The charge nurse is rounding on clients in restraints. Which situation would require immediate
intervention by the nurse?
a. Client in a belt restraint in the semi-Fowler position
b. Client in an enclosure bed in the high-Fowler position
c. Client in mitten restraints in the side-lying position
d. Client in soft wrist restraints in the supine position

8.) 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?
a. Flaccid right hand and arm
b. Impaired gag reflex when suctioning
c. Presence of urinary incontinence
d. Rigid flexion of arms at the elbows

9.) The infection control nurse observes a new graduate nurse in the intensive care unit. Which
action by the graduate nurse requires intervention by the infection control nurse?
a. Removes gloves prior to removing mask when leaving client's room
b. Scrubs underneath artificial nails while performing hand hygiene
c. Uses alcohol-based hand sanitizer when entering client's room
d. Washes hands with soap and water for 20 seconds

10.) The nurse is reviewing telemetry strips of clients. Which rhythm requires further assessment by
the nurse?
11.) The nurse is caring for a client in labor at 37 weeks gestation and notes a baseline fetal heart
rate of 180 beats per minute. Which interventions should the nurse perform? Select all that
apply.
a. Measure maternal blood pressure
b. Reassess fetal heart rate in an hour
c. Reduce IV fluid rate
d. Review medication administration record
e. Take maternal temperature

12.) The nurse is preparing to discharge a client 4 days after colostomy placement. Which of the
following findings are concerning and require further investigation? Select all that apply.
a. Areas of excoriation are noted on the skin surrounding the stoma
b. No bowel sounds are present and the client reports nausea
c. The client states, "I'll call home health to come empty the pouch."
d. The client states, "There is a little gas in the colostomy bag."
e. The stoma is red, edematous, and smaller than the previous day

13.) The nurse is reinforcing education about good sleep hygiene to a client with chronic insomnia.
Which of the following instructions should the nurse include? Select all that apply.
a. "Avoid caffeinated beverages for at least 4 hours before bedtime."
b. "Drink a glass of red wine about 1 hour before going to bed every night."
c. "If still awake 20 minutes after lying down, get out of bed and read a book."
d. "Prepare the bedroom environment by making it dark, quiet, and cool."
e. "Watch television in bed until you feel tired enough to fall asleep.”

14.) Four clients enter the emergency department at the same time. Which client should the nurse
alert the health care provider to see first?
a. 8-year-old who is crying and reports a headache after sustaining a head injury
b. 17-year-old who cannot raise an arm above the head after a football-related injury
c. 40-year-old with deep, partial-thickness burns and singed facial hair from a campfire
d. 70-year-old experiencing severe diarrhea and a poor appetite for the past 24 hours

15.) The clinic nurse is discussing injury prevention with the parent of a 6-month-old infant. Which
of the following statements by the parent indicate that teaching has been effective? Select all
that apply.
a. "I can switch to a front-facing car seat as my baby is in the 99th percentile for height."
b. "I do not need a childproof gate by the stairs as my baby cannot walk yet."
c. "I should place safety locks on the 3. "I should cabinets under the bathroom and kitchen sinks."
d. "I use the restraining belt on the changing table if I leave the room to get more supplies."
e. "I will need to move sharp or breakable objects onto high shelves, out of reach."

16.) The clinic nurse receives telephone messages from several clients who are in the third trimester
of pregnancy. Which of the following reports by a client require immediate follow-up? Select all
that apply.
a. Copious amounts of watery, clear vaginal discharge
b. Dysuria and right flank pain
c. Ear fullness and nasal stuffiness
d. Headache and blurred vision
e. Yellowish discharge from both nipples

17.) The nurse is caring for a client who has a blistering rash newly diagnosed as disseminated
herpes zoster. What personal protective equipment should the nurse wear while assisting the
client with a shower and linen change?
a. Eye shield, gloves, gown, and N95 respirator mask
b. Eye shield, gloves, gown, and surgical mask
c. Gloves, gown, N95 respirator mask, and surgical cap
d. Gloves, gown, surgical cap, and surgical mask

18.) A 16-year-old client is brought to the emergency department due to an asthma exacerbation.
The client's parent is visibly upset and confronts the client about the smell of cigarette smoke on
the clothes. What is the nurse's best action?
a. Allow the client and parent to finish the conversation privately
b. Ask the parent to leave the room until calm can be maintained
c. Redirect the parent to focus on the client's breathing technique
d. Reinforce education about the importance of smoking cessation

19.) The nurse is assisting the health care provider (HCP) with insertion of a central venous access
device for a client scheduled to receive chemotherapy. Which of the following nursing actions
are appropriate? Select all that apply.
a. Applying a sterile, occlusive dressing to the site once insertion is completed
b. Asking family members to refrain from entering the room during the procedure
c. Infusing only 0.9% sodium chloride until catheter placement is confirmed by x-ray
d. Putting on a face mask and providing one to the HCP before the procedure
e. Verifying that the client has signed informed consent before the procedure begins

20.) Which of the following methods would the nurse use to collect a urine sample for culture and
sensitivity testing in a 16-month-old client?
a. Apply a urine collection bag to the perineum
b. Aspirate a specimen from an indwelling catheter collection bag
c. Insert a sterile intermittent urinary catheter
d. Place cotton balls inside the diaper

21.) The nurse receives report on a client with chronic atrial fibrillation who had an episode of
torsade de pointes during the night. The client spontaneously converted back to the baseline
rhythm of atrial fibrillation and is now stable. Which information should the nurse immediately
report to the health care provider?
a. Client is scheduled to receive a dose of sotalol this morning
b. Client is scheduled to receive a dose of warfarin this afternoon
c. Client's magnesium level is 2.1 mEq/L (1.05 mmol/L)
d. Client's potassium level is 4.5 mEq/L (4.5 mmol/L)

22.) The nurse is caring for a client who began receiving continuous tube feeding 1 week ago. Which
of the following assessment findings suggest that the client is experiencing a tube feeding
complication? Select all that apply.
a. 2 episodes of emesis
b. 3 episodes of brown, liquid stool today
c. 7-lb (3.2-kg) weight gain in 1 week
d. Low gastric residual volume
e. Serum glucose of 104 mg/dL (5.8 mmol/L)

23.) During a follow-up visit to the primary care clinic, the nurse evaluates a client's understanding
about prevention of complications from varicose veins. Which client statements indicate a
correct understanding? Select all that apply.
a. "I have been dieting and have lost 10 pounds (4.5 kg)."
b. "I have started wearing elastic compression hose."
c. "I quit my retail job and now sit at a desk instead."
d. "I try to elevate my legs as often as possible."
e. "I try to walk at least 1 mile (1.6 km) every day.”

24.) When performing a head-to-toe assessment, the nurse has difficulty hearing the client's heart
sounds. What should the nurse do to better auscultate the S1 and S2 heart sounds?
a. Ask the client to lean forward in a sitting position
b. Have the client inhale deeply and hold the breath
c. Instruct the client to raise the left arm over the head
d. Use the bell of the stethoscope instead of the diaphragm
25.) The nurse is caring for a client with chronic kidney disease who has a scheduled dose of epoetin
alfa. Which of the following laboratory results would cause the nurse to hold the medication and
contact the health care provider?
a. Blood urea nitrogen: 26 mg/dL (9.3 μmol/L)
b. Creatinine: 2.5 mg/dL (221 µmol/L)
c. Hemoglobin: 13 g/dL (130 g/L)
d. Platelets: 120,000/mm 3 (120 x 109/L)

26.) A client's family member reports to the charge nurse that the nurses on the unit are not
responding appropriately to the client's report of pain. What is the charge nurse's priority
action?
a. Ask the client to rate current pain on a scale of 0-10
b. Discuss the concerns with the nurse assigned to the client
c. Evaluate the client's medication administration record
d. Review the narcotic count and look for discrepancies

27.) The nurse provides teaching for a client newly diagnosed with Addison disease. Which of the
following client statements indicate that teaching has been effective? Select all that apply.
a. "I may need more medication during times of extreme emotional stress."
b. "I should avoid being around people who are sick with colds or flu."
c. "I will begin decreasing the amount of sodium that I consume."
d. "I will have to take the prescribed medications for about a year."
e. "I will wear a medical alert bracelet to advise others of my diagnosis."

28.) A medical-surgical nurse with no critical care experience has been assigned to float to the
intensive care unit for the shift. Which of the following clients would be appropriate for the
charge nurse to assign to this nurse? Select all that apply.
a. Client 3 days postoperative from a femoral-popliteal bypass graft
b. Client in restraints to prevent self-extubation of an endotracheal tube
c. Client receiving a continuous IV norepinephrine infusion for septic shock
d. Client with acute stroke receiving tissue plasminogen activator
e. Client with diabetic ketoacidosis receiving insulin before meals

29.) The nurse is preparing to reposition several clients. For which of the following clients should the
nurse elevate the affected extremity? Select all that apply.
a. Client 2 days after above-the-knee amputation
b. Client scheduled for a right hip fracture repair
c. Client who just returned from femoral- approach percutaneous coronary intervention
d. Client with edema and a history of deep venous thrombosis in the left calf
e. Client with weeping cellulitis of the right foot
30.) A nurse is called in from home to help care for an influx of clients being admitted after a bus
accident. While assisting a coworker to prepare for incoming clients, the nurse becomes
concerned that the coworker may be under the influence of an impairing substance. Which
action by the nurse is best?
a. Ask another coworker to observe the individual to confirm the suspicion
b. Confront the coworker about the concern and offer emotional support
c. Speak with the nursing supervisor in private about the concern
d. Telephone the appropriate regulatory agency and make a report