1. A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following

laboratory findings should the nurse expect?

a. Negative urine ketones

b. BUN 32 mg/dL

c. pH 7.43

d. HCO3 23 mEq/L

DKA results in osmotic diuresis and subsequent dehydration. The nurse should expect

a client who has DKA to have elevated BUN, creatinine, and specific gravity levels

resulting from the excess glucose present in the urine

2. A nurse and an assistive personnel (AP) are caring for a client who has bacterial meningitis.

The nurse should give the AP which of the following instructions?

a. Wear a mask

b. Wear a gown

c. Keep the client’s room well-lit

d. Maintain the head of the bed at a 45 degree elevation

Bacterial meningitis requires droplet precautions; therefore, the AP and the nurse

should wear a mask when coming within 0.9 m (3 ft) of the client until 24 hr after the

client has begun receiving antibiotic therapy.

3. A nurse is providing instructions to a client who has type 2 diabetes mellitus and a new

prescription for metformin. Which of the following statements by the client indicates an

understanding of the teaching?

a. "I will monitor my blood sugar carefully because the medication increases the secretion

of insulin."

b. "I should take this medication with a meal."

c. "I can expect to gain weight while taking this medication."

d. “While taking this medication, I will experience flushing of my skin."

The client should take metformin with or immediately following meals to improve

absorption and to minimize gastrointestinal distress.

4. A nurse in a provider’s office is assessing a client who has hypertension and takes propranolol.

Which of the following findings should indicate to the nurse that the client is experiencing an

adverse reaction to this medication?

a. Report of a night cough

b. Report of tinnitus

c. Report of excessive tearing

d. Report of increased salivation

The nurse should recognize that a night cough is an early indication of heart failure and

report this adverse reaction to the provider.

5. A nurse is caring for a client who has a leg cast and is returning demonstration on the proper

use of crutches while climbing stairs. Identify the sequence the client should follow when

demonstrating crutch use.

a. The client should first place their body weight on the crutches. Next, they should

advance the unaffected leg onto the stair. Third, they should shift their weight from the

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crutches to the unaffected leg. Last, they should bring the crutches and the affected leg

up to the stair.

6. A nurse in an emergency department is caring for a client who is experiencing a thyroid storm.

Which of the following manifestations should the nurse expect? (Select all that apply.)

a. Fever

b. Non-Pitting edema

c. Hypertension

d. Tachycardia

e. Hypoglycemia

Non-Pitting edema and hypoglycemia are manifestations of myxedema coma, a

complication of hypothyroidism.

7. A nurse is caring for a client who has anorexia, low-grade fever, night sweats, and a productive

cough. Which of the following actions should the nurse take first?

a. Obtain a sputum sample

b. Administer antipyretics

c. Provide hand hygiene education

d. Initiate airborne precautions

This client is exhibiting manifestations of tuberculosis. The greatest risk in this client

situation is for other people in the facility to acquire an airborne disease from this client.

Therefore, the first action the nurse should take is to initiate airborne precautions.

8. A nurse is caring for a client who has a closed head injury and has an intraventricular catheter

placed. Which of the following findings indicates that the client is experiencing increased

intracranial pressure (ICP)? (Select all that apply.)

a. Flat jugular veins

b. A Glasgow Coma Scale score of 15

c. Sleepiness exhibited by the client

d. Widening pulse pressure

e. Decerebrate posturing

With increased ICP, the jugular veins are typically distended. A Glasgow Coma Scale

score of 15 indicates neurological functioning within the expected reference range for

eye opening, motor, and verbal response.

9. A nurse is caring for a client who is having a seizure. Which of the following interventions is the

nurse’s priority?

a. Loosen the clothing around the client's neck.

b. Check the client's pupillary response.

c. Turn the client to the side.

d. Move furniture away from the client.

The greatest risk to this client is hypoxia from an impaired airway. Therefore, the priority

intervention the nurse should take is to place the client in a side-lying position to prevent

aspiration.

10.A nurse is providing discharge instructions to a client who has a partial-thickness burn on the

hand. Which of the following instructions should the nurse include?

a. Change the dressing every 72 hr.

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b. Immobilize the hand with a pressure dressing.

c. Take pain medication 30 min after changing the dressing.

d. Wrap fingers with individual dressings.

The nurse should instruct the client to wrap the fingers individually to allow for functional

use of the hand while healing occurs. The nurse should also instruct the client to

perform range-of-motion exercises to each finger every hour while awake to promote

the function of the injured hand.

11.A home health nurse is assigned to a client who was recently discharged from a rehabilitation

center after experiencing a right-hemispheric stroke. Which of the following neurologic deficits

should the nurse expect to find when assessing the client? (Select all that apply.)

a. Expressive aphasia

b. Visual spatial deficits

c. Left hemianopsia

d. Right hemiplegia

e. One-sided neglect

Expressive aphasia, or an inability to express what one wants to convey, occurs

secondary to a left-hemispheric stroke. Right hemiplegia occurs secondary to a

left-hemispheric stroke.

12.An older adult client is brought to an emergency department by a family member. Which of the

following assessment findings should cause the nurse to suspect that the client has hypertonic

dehydration?

a. Serum sodium level 145 mEq/L

b. Forearm skin tents when pinched

c. Respiratory rate decreased

d. Urine specific gravity 1.045

A urine specific gravity greater than 1.030 indicates a decrease in urine volume and an

increase in osmolarity, which is a manifestation of hypertonic dehydration.

13.A nurse is assessing a client who has had a suspected stroke. The nurse should place the

priority on which of the following findings?

a. Dysphagia

b. Aphasia

c. Ataxia

d. Hemianopsia

Dysphagia indicates that this client is at greatest risk for aspiration due to impaired

sensation and function within the oral cavity. Therefore, the nurse should place priority

on this finding. Aphasia indicates that the client is at risk for communication impairment.

Ataxia indicates that the client is at risk for injury from falling. Hemianopsia indicates the

client is at risk for injury when ambulating.

14.A nurse is providing teaching to a client who has a gastric ulcer and a new prescription for

omeprazole. The nurse should instruct the client that the medication provides relief by which of

the following actions?

a. Neutralizing gastric acid

b. Reducing the growth of ulcer-causing bacteria

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