| 1. | The nurse is caring for a client with systemic lupus erythematosus (SLE). The major complication associated with systemic lupus erythematosus is:
 | A. | Nephritis | | B. | Cardiomegaly | | C. | Desquamation | | D. | Meningitis |
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| 2. | A client with benign prostatic hypertrophy has been started on Proscar (finasteride). The nurse’s discharge teaching should include:
| A. | Telling the client’s wife not to touch the tablets | | B. | Explaining that the medication should be taken with meals | | C. | Telling the client that symptoms will improve in 1–2 weeks | | D. | Instructing the client to take the medication at bedtime, to prevent nocturia |
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| 3. | A five-year-old child is hospitalized for correction of congenital hip dysplasia. During the assessment of the child, the nurse can expect to find the presence of:
| A. | Scarf sign | | B. | Harlequin sign | | C. | Cullen’s sign | | D. | Trendelenburg sign |
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| 4. | Which diet is associated with an increased risk of colorectal cancer?
| A. | Low protein, complex carbohydrates | | B. | High protein, simple carbohydrates | | C. | High fat, refined carbohydrates | | D. | Low carbohydrates, complex proteins |
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| 5. | The nurse is caring for an infant following a cleft lip repair. While comforting the infant, the nurse should avoid:
| A. | Holding the infant | | B. | Offering a pacifier | | C. | Providing a mobile | | D. | Offering sterile water |
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| 6. | The physician has diagnosed a client with cirrhosis characterized by asterixis. If the nurse assesses the client with asterixis, he can expect to find:
| A. | Irregular movement of the wrist | | B. | Enlargement of the breasts | | C. | Dilated veins around the umbilicus | | D. | Redness of the palmar surfaces |
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| 7. | The physician has ordered Amoxil (amoxicillin) 500mg capsules for a client with esophageal varices. The nurse can best care for the client’s needs by:
| A. | Giving the medication as ordered | | B. | Providing extra water with the medication | | C. | Giving the medication with an antacid | | D. | Requesting an alternate form of the medication |
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| 8. | A client with an inguinal hernia asks the nurse why he should have surgery when he has had a hernia for years. The nurse understands that surgery is recommended to:
| A. | Prevent strangulation of the bowel | | B. | Prevent malabsorptive disorders | | C. | Decrease secretion of bile salts | | D. | Increase intestinal motility |
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| 9. | The nurse is providing dietary instructions for a client with iron-deficiency anemia. Which food is a poor source of iron?
| A. | Tomatoes | | B. | Legumes | | C. | Dried fruits | | D. | Nuts |
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| 10. | A client is admitted with suspected acute pancreatitis. Which lab finding confirms the diagnosis?
| A. | Blood glucose of 260mg/dL | | B. | White cell count of 21,000cu/mm | | C. | Platelet count of 250,000cu/mm | | D. | Serum amylase level of 600 units/dL |
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| 11. | The nurse is teaching a client with Parkinson’s disease ways to prevent curvatures of the spine associated with the disease. To prevent spinal flexion, the nurse should tell the client to:
| A. | Periodically lie prone without a neck pillow. | | B. | Sleep only in dorsal recumbent position. | | C. | Rest in supine position with his head elevated. | | D. | Sleep on either side, but keep his back straight. |
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| 12. | The physician has ordered Dilantin (phenytoin) 100mg intravenously for a client with generalized tonic clonic seizures. The nurse should administer the medication:
| A. | Rapidly with an IV push | | B. | With IV dextrose | | C. | Slowly over 2–3 minutes | | D. | Through a small vein |
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| 13. | The nurse is planning dietary changes for a client following an episode of acute pancreatitis. Which diet is suitable for the client?
| A. | Low calorie, low carbohydrate | | B. | High calorie, low fat | | C. | High protein, high fat | | D. | Low protein, high carbohydrate |
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| 14. | A client is admitted with a diagnosis of polycythemia vera. The nurse should closely monitor the client for:
| A. | Increased blood pressure | | B. | Decreased respirations | | C. | Increased urinary output | | D. | Decreased oxygen saturation |
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| 15. | A client with hypothyroidism frequently complains of feeling cold. The nurse should tell the client that she will be more comfortable if she:
| A. | Uses an electric blanket at night | | B. | Dresses in extra layers of clothing | | C. | Applies a heating pad to her feet | | D. | Takes a hot bath morning and evening |
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| 16. | The nurse caring for a client with a closed head injury obtains an intracranial pressure (ICP) reading of 17mmHg. The nurse recognizes that:
| A. | The ICP is elevated and the doctor should be notified. | | B. | The ICP is normal; therefore, no further action is needed. | | C. | The ICP is low and the client needs additional IV fluids. | | D. | The ICP reading is not as reliable as the Glascow coma scale. |
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| 17. | A client has been hospitalized with a diagnosis of laryngeal cancer. Which factor is most significant in the development of laryngeal cancer?
| A. | A family history of laryngeal cancer | | B. | Chronic inhalation of noxious fumes | | C. | Frequent straining of the vocal cords | | D. | A history of frequent alcohol and tobacco use |
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| 18. | The nurse is completing an assessment history of a client with pernicious anemia. Which complaint differentiates pernicious anemia from other types of anemia?
| A. | Difficulty in breathing after exertion | | B. | Numbness and tingling in the extremities | | C. | A faster than usual heart rate | | D. | Feelings of lightheadedness |
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| 19. | A client with rheumatoid arthritis is beginning to develop flexion contractures of the knees. The nurse should tell the client to:
| A. | Lie prone and let her feet hang over the mattress edge | | B. | Lie supine, with her feet rotated inward | | C. | Lie on her right side and point her toes downward | | D. | Lie on her left side and allow her feet to remain in a neutral position |
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| 20. | The chart of a client with schizophrenia states that the client has echolalia. The nurse can expect the client to:
| A. | Speak using words that rhyme | | B. | Repeat words or phrases used by others | | C. | Include irrelevant details in conversation | | D. | Make up new words with new meanings |
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| 21. | The mother of a one-year-old with sickle cell anemia wants to know why the condition didn’t show up in the nursery. The nurse’s response is based on the knowledge that:
| A. | There is no test to measure abnormal hemoglobin in newborns. | | B. | Infants do not have insensible fluid loss before a year of age. | | C. | Infants rarely have infections that would cause them to have a sickling crises. | | D. | The presence of fetal hemoglobin protects the infant. |
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| 22. | Which early morning activity helps to reduce the symptoms associated with rheumatoid arthritis?
| A. | Brushing the teeth | | B. | Drinking a glass of juice | | C. | Holding a cup of coffee | | D. | Brushing the hair |
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| 23. | A client with B negative blood requires a blood transfusion during surgery. If no B negative blood is available, the client should be transfused with:
| A. | A positive blood | | B. | B positive blood | | C. | O negative blood | | D. | AB negative blood |
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| 24. | The nurse notes that a post-operative client’s respirations have dropped from 14 to 6 breaths per minute. The nurse administers Narcan (naloxone) per standing order. Following administration of the medication, the nurse should assess the client for:
| A. | Pupillary changes | | B. | Projectile vomiting | | C. | Wheezing respirations | | D. | Sudden, intense pain |
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| 25. | A newborn weighed seven pounds at birth. At six months of age, the infant could be expected to weigh:
| A. | 14 pounds | | B. | 18 pounds | | C. | 25 pounds | | D. | 30 pounds |
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| 26. | A client with nontropical sprue has an exacerbation of symptoms. Which meal selection is responsible for the recurrence of the client’s symptoms?
| A. | Tossed salad with oil and vinegar dressing | | B. | Baked potato with sour cream and chives | | C. | Cream of tomato soup and crackers | | D. | Mixed fruit and yogurt |
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| 27. | A client with congestive heart failure has been receiving digoxin (Laxoxin). Which finding indicates that the medication is having a desired effect?
| A. | Increased urinary output | | B. | Stabilized weight | | C. | Improved appetite | | D. | Increased pedal edema |
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| 28. | Which play activity is best suited to the gross motor skills of the toddler?
| A. | Coloring book and crayons | | B. | Ball | | C. | Building cubes | | D. | Swing set |
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| 29. | A client in labor admits to using alcohol throughout the pregnancy. The most recent use was the day before. Based on the client’s history, the nurse should give priority to assessing the newborn for:
| A. | Respiratory depression | | B. | Wide-set eyes | | C. | Jitteriness | | D. | Low-set ears |
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| 30. | The physician has ordered Basaljel (aluminum carbonate gel) for a client with recurrent indigestion. The nurse should teach the client common side effects of the medication, which include:
| A. | Constipation | | B. | Urinary retention | | C. | Diarrhea | | D. | Confusion |
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| 31. | A client is admitted with suspected abdominal aortic aneurysm (AAA). A common complaint of the client with an abdominal aortic aneurysm is:
| A. | Loss of sensation in the lower extremities | | B. | Back pain that lessens when standing | | C. | Decreased urinary output | | D. | Pulsations in the periumbilical area |
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| 32. | The nurse is caring for a client hospitalized with nephrotic syndrome. Based on the client’s treatment, the nurse should:
| A. | Limit the number of visitors. | | B. | Provide a low-protein diet. | | C. | Discuss the possibility of dialysis. | | D. | Offer the client additional fluids. |
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| 33. | A client is admitted with acute adrenal crisis. During the intake assessment, the nurse can expect to find that the client has:
| A. | Low blood pressure | | B. | A slow, regular pulse | | C. | Warm, flushed skin | | D. | Increased urination |
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| 34. | A five-month-old infant is admitted to the ER with a temperature of 103.6°F and irritability. The mother states that the child has been listless for the past several hours and that he had a seizure on the way to the hospital. A lumbar puncture confirms a diagnosis of bacterial meningitis. The nurse should assess the infant for:
| A. | Periorbital edema | | B. | Tenseness of the anterior fontanel | | C. | Positive Babinski reflex | | D. | Negative scarf sign |
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| 35. | A client with pneumocystis jiroveci pneumonia is receiving intravenous Pentam (pentamidine). While administering the medication, the nurse should give priority to checking the client’s:
| A. | Deep tendon reflexes | | B. | Blood pressure | | C. | Urine output | | D. | Tissue turgor |
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| 36. | The doctor has ordered Ampicillin 100mg every six hours IV push for an infant weighing 7kg. The suggested dose for infants is 25–50mg/kg/day in equally divided doses. The nurse should:
| A. | Give the medication as ordered. | | B. | Give half the amount ordered. | | C. | Give the ordered amount q 12 hrs. | | D. | Check the order with the doctor. |
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| 37. | An elderly client is hospitalized for a transurethral prostatectomy. Which finding should be reported to the doctor immediately?
| A. | Hourly urinary output of 40–50mL | | B. | Bright red urine with many clots | | C. | Dark red urine with few clots | | D. | Requests for pain med every four hrs. |
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| 38. | Which statement by the parent of a child with sickle cell anemia indicates an understanding of the disease?
| A. | “The pain he has is due to the presence of too many red blood cells.” | | B. | “He will be able to go snow-skiing with his friends as long as he stays warm.” | | C. | “He will need extra fluids in summer to prevent dehydration.” | | D. | “There is very little chance that his brother will have sickle cell.” |
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| 39. | A toddler with otitis media has just completed antibiotic therapy. A recheck appointment should be made to:
| A. | Determine whether the ear infection has affected her hearing. | | B. | Make sure that she has taken all the antibiotic. | | C. | Document that the infection has completely cleared. | | D. | Obtain a new prescription, in case the infection recurs. |
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| 40. | A nine-year-old is admitted with suspected rheumatic fever. Which finding is suggestive of Sydenham’s chorea?
| A. | Irregular movements of the extremities and facial grimacing | | B. | Painless swellings over the extensor surfaces of the joints | | C. | Faint areas of red demarcation over the back and abdomen | | D. | Swelling, inflammation, and effusion of the joints |
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| 41. | A child with croup is placed in a cool, high-humidity tent connected to room air. The primary purpose of the high-humidity tent is to:
| A. | Prevent insensible water loss | | B. | Provide a moist environment with oxygen at 30% | | C. | Prevent dehydration and reduce fever | | D. | Liquefy secretions and relieve laryngeal spasm |
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| 42. | The nurse is suctioning the tracheostomy of an adult client. The recommended pressure setting for performing tracheostomy suctioning on the adult client is:
| A. | 40–60mmHg | | B. | 60–80mmHg | | C. | 80–120mmHg | | D. | 120–140mmHg |
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| 43. | A client is admitted with a diagnosis of myxedema. An initial assessment of the client would reveal the symptoms of:
| A. | Slow pulse rate, weight loss, diarrhea, and cardiac failure | | B. | Weight gain, lethargy, slowed speech, and decreased respiratory rate | | C. | Rapid pulse, constipation, and bulging eyes | | D. | Decreased body temperature, weight loss, and increased respirations |
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| 44. | Which statement describes the contagious stage of varicella?
| A. | The contagious stage is one day before the onset of the rash until the appearance of vesicles. | | B. | The contagious stage lasts during the vesicular and crusting stages of the lesions. | | C. | The contagious stage is from the onset of the rash until the rash disappears. | | D. | The contagious stage is one day before the onset of the rash until all the lesions are crusted. |
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| 45. | The nurse is reviewing the results of a sweat test taken from a child with cystic fibrosis. Which finding supports the client’s diagnosis?
| A. | A sweat potassium concentration less than 40mEq/L | | B. | A sweat chloride concentration greater than 60mEq/L | | C. | A sweat potassium concentration greater than 40mEq/L | | D. | A sweat chloride concentration less than 40mEq/L |
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| 46. | A client in labor has an order for Demerol (meperidine) 75 mg. IM to be administered 10 minutes before delivery. The nurse should:
| A. | Wait until the client is placed on the delivery table and administer the medication. | | B. | Question the order. | | C. | Give the medication IM during the delivery to prevent pain from the episiotomy. | | D. | Give the medication as ordered. |
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| 47. | Which of the following statements describes Piaget’s stage of concrete operations?
| A. | Reflex activity proceeds to imitative behavior. | | B. | The ability to see another’s point of view increases. | | C. | Thought processes become more logical and coherent. | | D. | The ability to think abstractly leads to logical conclusion. |
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| 48. | A client admitted to the psychiatric unit claims to be the Pope and insists that he will not be kept away from his subjects. The most likely explanation for the client’s delusion is:
| A. | A reaction formation | | B. | A stressful event | | C. | Low self-esteem | | D. | Overwhelming anxiety |
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| 49. | Which of the following statements reflects Kohlberg’s theory of the moral development of the preschool-age child?
| A. | Obeying adults is seen as correct behavior. | | B. | Showing respect for parents is seen as important. | | C. | Pleasing others is viewed as good behavior. | | D. | Behavior is determined by consequences. |
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| 50. | The nurse is caring for an eight-year-old following a routine tonsillectomy. Which finding should be reported immediately?
| A. | Reluctance to swallow | | B. | Drooling of blood-tinged saliva | | C. | An axillary temperature of 99°F | | D. | Respiratory stridor |
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| 51. | The nurse is admitting a client with a suspected duodenal ulcer. The client will most likely report that his abdominal discomfort decreases when he:
| A. | Avoids eating | | B. | Rests in a recumbent position | | C. | Eats a meal or snack | | D. | Sits upright after eating |
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| 52. | The nurse is assessing a newborn in the well-baby nursery. Which finding should alert the nurse to the possibility of a cardiac anomaly?
| A. | Diminished femoral pulses | | B. | Harlequin’s sign | | C. | Circumoral pallor | | D. | Acrocyanosis |
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| 53. | A two-year-old is hospitalized with a diagnosis of Kawasaki’s disease. A severe complication of Kawasaki’s disease is:
| A. | The development of Brushfield spots | | B. | The eruption of Hutchinson’s teeth | | C. | The development of coxa plana | | D. | The creation of a giant aneurysm |
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| 54. | The charge nurse is formulating a discharge teaching plan for a client with mild preeclampsia. The nurse should give priority to:
| A. | Teaching the client to report a nosebleed | | B. | Instructing the client to maintain strict bed rest | | C. | Telling the client to notify the doctor of pedal edema | | D. | Advising the client to avoid sodium sources in the diet |
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| 55. | The nurse is preparing to discharge a client who is taking an MAOI. The nurse should instruct the client to:
| A. | Wear protective clothing and sunglasses when outside. | | B. | Avoid over-the-counter cold and hay fever preparations. | | C. | Drink at least eight glasses of water a day. | | D. | Increase his intake of high-quality protein. |
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| 56. | Which of the following meal selections is appropriate for the client with celiac disease?
| A. | Toast, jam, and apple juice | | B. | Peanut butter cookies and milk | | C. | Rice Krispies bar and milk | | D. | Cheese pizza and Kool-Aid |
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| 57. | A client with hyperthyroidism is taking lithium carbonate to inhibit thyroid hormone release. Which complaint by the client should alert the nurse to a problem with the client’s medication?
| A. | The client complains of blurred vision. | | B. | The client complains of increased thirst and increased urination. | | C. | The client complains of increased weight gain over the past year. | | D. | The client complains of rhinorrhea. |
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| 58. | The physician has ordered intravenous fluid with potassium for a client admitted with gastroenteritis and dehydration. Before adding potassium to the intravenous fluid, the nurse should:
| A. | Assess the urinary output. | | B. | Obtain arterial blood gases. | | C. | Perform a dextrostick. | | D. | Obtain a stool culture. |
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| 59. | A two-month-old infant has just received her first Tetramune injection. The nurse should tell the mother that the immunization:
| A. | Will need to be repeated when the child is four years of age. | | B. | Is given to determine whether the child is susceptible to pertussis. | | C. | Is one of a series of injections that protects against diphtheria, pertussis, tetanus and H.influenzae b. | | D. | Is a one-time injection that protects against measles, mumps, rubella and varicella. |
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| 60. | A client with Addison’s disease has been receiving glucocorticoid therapy. Which finding indicates a need for dosage adjustment?
| A. | Dryness of the skin and mucus membranes | | B. | Dizziness when rising to a standing position | | C. | A weight gain of six pounds in the past week | | D. | Difficulty in remaining asleep |
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| 61. | The nurse is caring for an obstetrical client in early labor. After the rupture of membranes, the nurse should give priority to:
| A. | Applying an internal monitor | | B. | Assessing fetal heart tones | | C. | Assisting with epidural anesthesia | | D. | Inserting a Foley catheter |
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| 62. | The physician has prescribed Synthroid (levothyroxine) for a client with myxedema. Which statement indicates that the client understands the nurse’s teaching regarding the medication?
| A. | “I will take the medication each morning after breakfast.” | | B. | “I will check my heart rate before taking the medication.” | | C. | “I will report visual disturbances to my doctor.” | | D. | “I will stop the medication if I develop gastric upset.” |
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| 63. | The nurse is caring for a client with a radium implant for the treatment of cervical cancer. While caring for the client with a radioactive implant, the nurse should:
| A. | Provide emotional support by spending additional time with the client. | | B. | Stand at the foot of the bed when talking to the client. | | C. | Avoid handling items used by the client. | | D. | Wear a badge to monitor the amount of time spent in the client’s room. |
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| 64. | The nurse is caring for a client hospitalized with bipolar disorder, manic phase, who is taking lithium. Which of the following snacks would be best for the client with mania?
| A. | Potato chips | | B. | Diet cola | | C. | Apple | | D. | Milkshake |
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| 65. | The physician has prescribed imipramine (Tofranil) for a client with depression. The nurse should continue to monitor the client’s affect because the maximal effects of tricyclic antidepressant medication do not occur for:
| A. | 48–72 hours | | B. | 5–7 days | | C. | 2–4 weeks | | D. | 3–6 months |
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| 66. | An elderly client with glaucoma has been prescribed Timoptic (timolol maleate) eyedrops. Timoptic should be used with caution in clients with a history of:
| A. | Diabetes | | B. | Gastric ulcers | | C. | Emphysema | | D. | Pancreatitis |
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| 67. | A two-year-old is hospitalized with suspected intussusception. Which finding is associated with intussusception?
| A. | “Currant jelly” stools | | B. | Projectile vomiting | | C. | “Ribbonlike” stools | | D. | Palpable mass over the flank |
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| 68. | Which of the following findings would be expected in the infant with biliary atresia?
| A. | Rapid weight gain and hepatomegaly | | B. | Dark stools and poor weight gain | | C. | Abdominal distention and poor weight gain | | D. | Abdominal distention and rapid weight gain |
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| 69. | A client is being treated for cancer with linear acceleration radiation. The physician has marked the radiation site with a blue marking pen. The nurse should:
| A. | Remove the unsightly markings with acetone or alcohol. | | B. | Cover the radiation site with loose gauze dressing. | | C. | Sprinkle baby powder over the radiated area. | | D. | Refrain from using soap or lotion on the marked area. |
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| 70. | The blood alcohol concentration of a client admitted following a motor vehicle accident is 460mg/dL. The nurse should give priority to monitoring the client for:
| A. | Loss of coordination | | B. | Respiratory depression | | C. | Visual hallucinations | | D. | Tachycardia |
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| 71. | The nurse is caring for a client with acromegaly. Following a transphenoidal hypophysectomy, the nurse should:
| A. | Monitor the client’s blood sugar. | | B. | Suction the mouth and pharynx every hour. | | C. | Place the client in low Trendelenburg position. | | D. | Encourage the client to cough. |
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| 72. | A client newly diagnosed with diabetes is started on Precose (acarbose). The nurse should tell the client that the medication should be taken:
| A. | one hour before meals | | B. | 30 minutes after meals | | C. | With the first bite of a meal | | D. | Daily at bedtime |
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| 73. | A client with a deep decubitus ulcer is receiving therapy in the hyperbaric oxygen chamber. Before therapy, the nurse should:
| A. | Apply a lanolin-based lotion to the skin. | | B. | Wash the skin with water and pat dry. | | C. | Cover the area with a petroleum gauze. | | D. | Apply an occlusive dressing to the site. |
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| 74. | The physician has ordered DDAVP (desmopressin acetate) for a client with diabetes insipidus. Which finding indicates that the medication is having its intended effect?
| A. | The client’s appetite has improved. | | B. | The client’s morning blood sugar was 120mg/dL. | | C. | The client’s urinary output has decreased. | | D. | The client’s activity level has increased. |
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| 75. | A client with pregnancy-induced hypertension is scheduled for a C-section. Before surgery, the nurse should keep the client:
| A. | On her right side | | B. | Supine with a small pillow | | C. | On her left side | | D. | In knee chest position |
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| 76. | The physician has prescribed Coumadin (sodium warfarin) for a client having transient ischemic attacks. Which laboratory test measures the therapeutic level of Coumadin?
| A. | Prothrombin time | | B. | Clot retraction time | | C. | Partial thromboplastin time | | D. | Bleeding time |
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| 77. | An adolescent client with cystic acne has a prescription for Accutane (isotretinoin). Which lab work is needed before beginning the medication?
| A. | Complete blood count | | B. | Clean-catch urinalysis | | C. | Liver profile | | D. | Thyroid function test |
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| 78. | Twenty-four hours after an uncomplicated labor and delivery, a client’s WBC is 12,000cu/mm. The elevation in the client’s WBC is most likely an indication of:
| A. | A normal response to the birth process | | B. | An acute bacterial infection | | C. | A sexually transmitted virus | | D. | Dehydration from being NPO during labor |
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| 79. | The home health nurse is visiting a client who plans to deliver her baby at home. Which statement by the client indicates an understanding regarding screening for phenylketonuria (PKU)?
| A. | “I will need to take the baby to the clinic within 24 hours of delivery to have blood drawn.” | | B. | “I will need to schedule a home visit for PKU screening when the baby is three-days old.” | | C. | “I will remind the midwife to save a specimen of cord blood for the PKU test.” | | D. | “I will have the PKU test done when I take her for her first immunizations.” |
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| 80. | The physician has ordered intubation and mechanical ventilation for a client with periods of apnea following a closed head injury. Arterial blood gases reveal a pH of 7.47, PCO2 of 28, and HCO3 of 23. These findings indicate that the client has:
| A. | Respiratory acidosis | | B. | Respiratory alkalosis | | C. | Metabolic acidosis | | D. | Metabolic alkalosis |
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| 81. | A client is diagnosed with emphysema and cor pulmonale. Which findings are characteristic of cor pulmonale?
| A. | Hypoxia, shortness of breath, and exertional fatigue | | B. | Weight loss, increased RBC, and fever | | C. | Rales, edema, and enlarged spleen | | D. | Edema of the lower extremities and distended neck veins |
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| 82. | A client with a laryngectomy returns from surgery with a nasogastric tube in place. The primary reason for placement of the nasogastric tube is to:
| A. | Prevent swelling and dysphagia | | B. | Decompress the stomach | | C. | Prevent contamination of the suture line | | D. | Promote healing of the oral mucosa |
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| 83. | The physician orders the removal of an in-dwelling catheter the second post-operative day for a client with a prostatectomy. The client complains of pain and dribbling of urine the first time he voids. The nurse should tell the client that:
| A. | Using warm compresses over the bladder will lessen the discomfort. | | B. | Perineal exercises will be started in a few days to help relieve his symptoms. | | C. | If the symptoms don’t improve, the catheter will have to be reinserted. | | D. | His complaints are common and will improve over the next few days. |
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| 84. | A client with a right lobectomy is being transported from the intensive care unit to a medical unit. The nurse understands that the client’s chest drainage system:
| A. | Can be disconnected from suction if the chest tube is clamped | | B. | Can be disconnected from suction, but the chest tube should remain unclamped | | C. | Must remain connected by means of a portable suction | | D. | Must be kept even with the client’s shoulders during the transport |
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| 85. | A nurse is caring for a client with a myocardial infarction. The nurse recognizes that the most common complication in the client following a myocardial infarction is:
| A. | Right ventricular hypertrophy | | B. | Cardiac dysrhythmia | | C. | Left ventricular hypertrophy | | D. | Hyperkalemia |
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| 86. | A client develops a temperature of 102°F following coronary artery bypass surgery. The nurse should notify the physician immediately because elevations in temperature:
| A. | Increase cardiac output | | B. | Indicate cardiac tamponade | | C. | Decrease cardiac output | | D. | Indicate graft rejection |
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| 87. | The chart indicates that a client has expressive aphasia following a stroke. The nurse understands that the client will have difficulty with:
| A. | Speaking and writing | | B. | Comprehending spoken words | | C. | Carrying out purposeful motor activity | | D. | Recognizing and using an object correctly |
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| 88. | A client receiving Parnate (tranylcypromine) is admitted in a hypertensive crisis. Which food is most likely to produce a hypertensive crisis when taken with the medication?
| A. | Processed cheese | | B. | Cottage cheese | | C. | Cream cheese | | D. | Cheddar cheese |
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| 89. | To prevent deformities of the knee joints in a client with an exacerbation of rheumatoid arthritis, the nurse should:
| A. | Tell the client to remain on bed rest until swelling subsides. | | B. | Discourage passive range of motion because it will cause further swelling. | | C. | Encourage motion of the joint within the limits of pain. | | D. | Tell the client she will need joint immobilization for 2–3 weeks. |
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| 90. | The nurse is assessing a trauma client in the emergency room when she notes a penetrating abdominal wound with exposed viscera. The nurse should:
| A. | Apply a clean dressing to protect the wound. | | B. | Cover the exposed viscera with a sterile saline gauze. | | C. | Gently replace the abdominal contents. | | D. | Cover the area with a petroleum gauze. |
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| 91. | A client is admitted to the emergency room with multiple injuries. What is the proper sequence for managing the client?
| A. | Assess for head injuries, control hemorrhage, establish an airway, prevent hypovolemic shock | | B. | Control hemorrhage, prevent hypovolemic shock, establish an airway, assess for head injuries | | C. | Establish an airway, control hemorrhage, prevent hypovolemic shock, assess for head injuries | | D. | Prevent hypovolemic shock, assess for head injuries, establish an airway, control hemorrhage |
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| 92. | The nurse is teaching the mother of a child with attention deficit disorder regarding the use of Ritalin (methylphenidate). The nurse recognizes that the mother understands her teaching when she states the importance of:
| A. | Offering high-calorie snacks | | B. | Watching for signs of infection | | C. | Observing for signs of oversedation | | D. | Using a sunscreen with an SPF of 30 |
|
| 93. | A home health nurse has several elderly clients in her case load. Which of the following clients is most likely to be a victim of elder abuse?
| A. | A 76-year-old female with Alzheimer’s dementia | | B. | A 70-year-old male with diabetes mellitus | | C. | A 64-year-old female with a hip replacement | | D. | A 72-year-old male with Parkinson’s disease |
|
| 94. | A camp nurse is applying sunscreen to a group of children enrolled in swim classes. Chemical sunscreens are most effective when applied:
| A. | Just before sun exposure | | B. | five minutes before sun exposure | | C. | 15 minutes before sun exposure | | D. | 30 minutes before sun exposure |
|
| 95. | The physician has made a diagnosis of “shaken child” syndrome for a 13-month-old who was brought to the emergency room after a reported fall from his highchair. Which finding supports the diagnosis of “shaken child” syndrome?
| A. | Fracture of the clavicle | | B. | Periorbital bruising | | C. | Retinal hemorrhages | | D. | Fracture of the humerus |
|
| 96. | A post-operative client has an order for Demerol (meperidine) 75mg and Phenergan (promethazine) 25mg IM every 3–4 hours as needed for pain. The combination of the two medications produces a/an:
| A. | Agonist effect | | B. | Synergistic effect | | C. | Antagonist effect | | D. | Excitatory effect |
|
| 97. | Which obstetrical client is most likely to have an infant with respiratory distress syndrome?
| A. | A 28-year-old with a history of alcohol use during the pregnancy | | B. | A 24-year-old with a history of diabetes mellitus | | C. | A 30-year-old with a history of smoking during the pregnancy | | D. | A 32-year-old with a history of pregnancy-induced hypertension |
|
| 98. | A client with a C4 spinal cord injury has been placed in traction with cervical tongs. Nursing care should include:
| A. | Releasing the traction for five minutes each shift | | B. | Loosening the pins if the client complains of headache | | C. | Elevating the head of the bed 90° | | D. | Performing sterile pin care as ordered |
|
| 99. | The nurse is assessing a client following a coronary artery bypass graft (CABG). The nurse should give priority to reporting:
| A. | Chest drainage of 150mL in the past hour | | B. | Confusion and restlessness | | C. | Pallor and coolness of skin | | D. | Urinary output of 40mL per hour |
|
| 100. | Before administering a client’s morning dose of Lanoxin (digoxin), the nurse checks the apical pulse rate and finds a rate of 54. The appropriate nursing intervention is to:
| A. | Record the pulse rate and administer the medication | | B. | Administer the medication and monitor the heart rate | | C. | Withhold the medication and notify the doctor | | D. | Withhold the medication until the heart rate increases |
|
| 101. | What information should the nurse give a new mother regarding the introduction of solid foods for her infant?
| A. | Solid foods should not be given until the extrusion reflex disappears at 8–10 months of age. | | B. | Solid foods should be introduced one at a time, with 4- to 7-day intervals. | | C. | Solid foods can be mixed in a bottle or infant feeder, to make feeding easier. | | D. | Solid foods should begin with fruits and vegetables. |
|
| 102. | When performing Leopold maneuvers on a client at 32 weeks gestation, the nurse would expect to find:
| A. | No fetal movement | | B. | Minimal fetal movement | | C. | Moderate fetal movement | | D. | Active fetal movement |
|
| 103. | A client with a history of phenylketonuria (PKU) is seen in the local family planning clinic. While completing the intake history, the nurse provides information for a healthy pregnancy. Which statement indicates that the client needs further teaching?
| A. | “I can use artificial sweeteners to keep me from gaining too much weight when I get pregnant.” | | B. | “I need to go back on a low-phenylalanine diet before I get pregnant.” | | C. | “Fresh fruits and raw vegetables will make good between-meal snacks for me.” | | D. | “My baby could be mentally retarded if I don’t stick to a diet eliminating phenylalanine.” |
|
| 104. | The nurse is teaching the mother of an infant with galactosemia. Which information should be included in the nurse’s teaching?
| A. | Check food and drug labels for the presence of lactose. | | B. | Foods containing galactose can be gradually added. | | C. | Future children will not be affected. | | D. | Sources of galactose are essential for growth. |
|
| 105. | Which finding is associated with Tay Sachs disease?
| A. | Pallor of the conjunctiva | | B. | Cherry-red spots on the macula | | C. | Blue-tinged sclera | | D. | White flecks in the iris |
|
| 106. | A client with schizophrenia is started on Zyprexa (olanzapine). Three weeks later, the client develops severe muscle rigidity and elevated temperature. The nurse should give priority to:
| A. | Withholding all morning medications | | B. | Ordering a CBC and CPK | | C. | Administering prescribed anti-Parkinsonian medication | | D. | Transferring the client to a medical unit |
|
| 107. | A client with human immunodeficiency syndrome has gastrointestinal symptoms, including diarrhea. The nurse should teach the client to avoid:
| A. | Calcium-rich foods | | B. | Canned or frozen vegetables | | C. | Processed meat | | D. | Raw fruits and vegetables |
|
| 108. | A four-year-old is admitted with acute leukemia. It will be most important to monitor the child for:
| A. | Abdominal pain and anorexia | | B. | Fatigue and bruising | | C. | Bleeding and pallor | | D. | Petechiae and mucosal ulcers |
|
| 109. | A five-month-old is diagnosed with atopic dermatitis. Nursing interventions will focus on:
| A. | Preventing infection | | B. | Administering antipyretics | | C. | Keeping the skin free of moisture | | D. | Limiting oral fluid intake |
|
| 110. | A client on a mechanical ventilator begins to fight the ventilator. Which medication will be ordered for the client?
| A. | Sublimaze (fentanyl) | | B. | Pavulon (pancuronium bromide) | | C. | Versed (midazolam) | | D. | Atarax (hydroxyzine) |
|
| 111. | A client with a history of diverticulitis complains of abdominal pain, fever, and diarrhea. Which food is responsible for the client’s symptoms?
| A. | Mashed potatoes | | B. | Steamed carrots | | C. | Baked fish | | D. | Whole-grain cereal |
|
| 112. | The home health nurse is visiting a client with Paget’s disease. An important part of preventive care for the client with Paget’s disease is:
| A. | Keeping the environment free of clutter | | B. | Advising the client to see the dentist regularly | | C. | Encouraging the client to take the influenza vaccine | | D. | Telling the client to take a daily multivitamin |
|
| 113. | The physician has scheduled a Whipple procedure for a client with pancreatic cancer. The nurse recognizes that the client’s cancer is located in:
| A. | The tail of the pancreas | | B. | The head of the pancreas | | C. | The body of the pancreas | | D. | The entire pancreas |
|
| 114. | A child with cystic fibrosis is being treated with inhalation therapy with Pulmozyme (dornase alfa). A side effect of the medication is:
| A. | Weight gain | | B. | Hair loss | | C. | Sore throat | | D. | Brittle nails |
|
| 115. | Four days after delivery, a client develops complications of postpartal hemorrhage. The most common cause of late postpartal hemorrhage is:
| A. | Uterine atony | | B. | Retained placental fragments | | C. | Cervical laceration | | D. | Perineal tears |
|
| 116. | On a home visit, the nurse finds four young children alone. The youngest of the children has bruises on the face and back and circular burns on the inner aspect of the right forearm. The nurse should:
| A. | Contact child welfare services | | B. | Transport the child to the emergency room | | C. | Take the children to an abuse shelter | | D. | Stay with the children until an adult arrives |
|
| 117. | A client is diagnosed with post-traumatic stress disorder following a rape by an unknown assailant. The nurse should give priority to:
| A. | Providing a supportive environment | | B. | Controlling the client’s feelings of anger | | C. | Discussing the details of the attack | | D. | Administering a hypnotic for sleep |
|
| 118. | The doctor has ordered Percocet (oxycodone) for a client following abdominal surgery. The primary objective of nursing care for the client receiving an opiate analgesic is:
| A. | Preventing addiction | | B. | Alleviating pain | | C. | Facilitating mobility | | D. | Preventing nausea |
|
| 119. | A client with emphysema is receiving intravenous aminophylline. Which aminophylline level is associated with signs of toxicity?
| A. | 5 micrograms/mL | | B. | 10 micrograms/mL | | C. | 20 micrograms/mL | | D. | 25 micrograms/mL |
|
| 120. | Which finding is the best indication that a client with ineffective airway clearance needs suctioning?
| A. | Oxygen saturation | | B. | Respiratory rate | | C. | Breath sounds | | D. | Arterial blood gases |
|
| 121. | A client with tuberculosis has a prescription for Myambutol (ethambutol HCl). The nurse should tell the client to notify the doctor immediately if he notices:
| A. | Gastric distress | | B. | Changes in hearing | | C. | Red discoloration of body fluids | | D. | Changes in color vision |
|
| 122. | The primary cause of anemia in a client with chronic renal failure is:
| A. | Poor iron absorption | | B. | Destruction of red blood cells | | C. | Lack of intrinsic factor | | D. | Insufficient erythropoietin |
|
| 123. | Which of the following nursing interventions has the highest priority for the client scheduled for an intravenous pyelogram?
| A. | Providing the client with a favorite meal for dinner | | B. | Asking if the client has allergies to shellfish | | C. | Encouraging fluids the evening before the test | | D. | Telling the client what to expect during the test |
|
| 124. | A client has ataxia following a cerebral vascular accident. The nurse should:
| A. | Supervise the client’s ambulation. | | B. | Measure the client’s intake and output. | | C. | Request a consult for speech therapy. | | D. | Provide the client with a magic slate. |
|
| 125. | The doctor has prescribed aspirin 325mg daily for a client with transient ischemic attacks. The nurse explains that aspirin was prescribed to:
| A. | Prevent headaches | | B. | Boost coagulation | | C. | Prevent cerebral anoxia | | D. | Decrease platelet aggregation |
|
| 126. | The nurse is preparing to administer regular insulin by continuous IV infusion to a client with diabetic ketoacidosis. The nurse should:
| A. | Mix the insulin with Dextrose 5% in water. | | B. | Flush the IV tubing with the insulin solution and discard the first 50mL. | | C. | Avoid using a pump or controller with the infusion. | | D. | Mix the insulin with Ringer’s lactate. |
|
| 127. | While reviewing the chart of a client with a history of hepatitis B, the nurse finds a serologic marker of HB8 AG. The nurse recognizes that the client:
| A. | Has chronic hepatitis B | | B. | Has recovered from hepatitis B infection | | C. | Has immunity to infection with hepatitis C | | D. | Has no chance of spreading the infection to others |
|
| 128. | A client with tuberculosis who has been on combined therapy with rifampin and isoniazid asks the nurse how long he will have to take medication. The nurse should tell the client that:
| A. | Medication is rarely needed after two weeks. | | B. | He will need to take medication the rest of his life. | | C. | The course of therapy is usually six months. | | D. | He will be re-evaluated in one month to see if further medication is needed. |
|
| 129. | Which developmental milestone puts the four-month-old infant at greatest risk for injury?
| A. | Switching objects from one hand to another | | B. | Crawling | | C. | Standing | | D. | Rolling over |
|
| 130. | A newborn is diagnosed with congenital syphilis. Classic signs of congenital syphilis are:
| A. | Red papular rash, desquamation, white strawberry tongue | | B. | Rhinitis, maculopapular rash, hepatosplenomegaly | | C. | Red edematous cheeks, maculopapular rash on the trunk and extremities | | D. | Epicanthal folds, low-set ears, protruding tongue |
|
| 131. | Infants should be restrained in a car seat in a semi-reclined position facing the rear of the car until they weigh:
| A. | 10 pounds | | B. | 15 pounds | | C. | 20 pounds | | D. | 25 pounds |
|
| 132. | The nurse is caring for a client with irritable bowel syndrome. Irritable bowel syndrome is characterized by:
| A. | Development of pouches in the wall of the intestine | | B. | Alternating bouts of constipation and diarrhea | | C. | Swelling, thickening, and abscess formation | | D. | Hypocalcemia and iron-deficiency anemia |
|
| 133. | A client taking Dilantin (phenytoin) for tonic-clonic seizures is preparing for discharge. Which information should be included in the client’s discharge care plan?
| A. | The medication can cause dental staining. | | B. | The client will need to avoid a high-carbohydrate diet. | | C. | The client will need a regularly scheduled blood work. | | D. | The medication can cause problems with drowsiness. |
|
| 134. | Assessment of a newborn male reveals that the infant has hypospadias. The nurse knows that:
| A. | The infant should not be circumcised. | | B. | Surgical correction will be done by six months of age. | | C. | Surgical correction is delayed until six years of age. | | D. | The infant should be circumcised to facilitate voiding. |
|
| 135. | The nurse is providing dietary teaching for a client with elevated cholesterol levels. Which cooking oil is not suggested for the client on a low-cholesterol diet?
| A. | Safflower oil | | B. | Sunflower oil | | C. | Coconut oil | | D. | Canola oil |
|
| 136. | A client is hospitalized with signs of transplant rejection following a recent renal transplant. Assessment of the client would be expected to reveal:
| A. | A weight loss of two pounds in one day | | B. | A serum creatinine 1.25mg/dL | | C. | Urinary output of 50mL/hr | | D. | Rising blood pressure |
|
| 137. | A client is admitted with a blood alcohol level of 180mg/dL. The nurse recognizes that the alcohol in the client’s system should be fully metabolized within:
| A. | three hours | | B. | five hours | | C. | seven hours | | D. | nine hours |
|
| 138. | The nurse is caring for a client with stage III Alzheimer’s disease. A characteristic of this stage is:
| A. | Memory loss | | B. | Failing to recognize familiar objects | | C. | Wandering at night | | D. | Failing to communicate |
|
| 139. | The doctor has prescribed Cortone (cortisone) for a client with systemic lupus erythematosis. Which instruction should be given to the client?
| A. | Take the medication 30 minutes before eating. | | B. | Report changes in appetite and weight. | | C. | Wear sunglasses to prevent cataracts. | | D. | Schedule a time to take the influenza vaccine. |
|
| 140. | The nurse is caring for a client with an above-the-knee amputation (AKA). To prevent hip flexion contractures, the nurse should:
| A. | Place the client in a prone position 15–30 minutes twice a day. | | B. | Keep the foot of the bed elevated on shock blocks. | | C. | Place trochanter rolls on either side of the affected leg. | | D. | Keep the client’s leg elevated on two pillows. |
|
| 141. | The mother of a six-month-old asks when her child will have all his baby teeth. The nurse knows that most children have all their primary teeth by age:
| A. | 12 months | | B. | 18 months | | C. | 24 months | | D. | 30 months |
|
| 142. | A client with an esophageal tamponade develops symptoms of respiratory distress, including inspiratory stridor. The nurse should give priority to:
| A. | Applying oxygen at 4L via nasal cannula | | B. | Removing the tube after deflating the balloons | | C. | Elevating the head of the bed to 45° | | D. | Increasing the pressure in the esophageal balloon |
|
| 143. | The nurse is assessing the heart sounds of a client with mitral stenosis following a history of rheumatic fever. To hear a mitral murmur, the nurse should place the stethoscope at:
| A. | The third intercostal space right of the sternum | | B. | The third intercostal space left of the sternum | | C. | The fourth intercostal space beneath the sternum | | D. | The fourth intercostal space mid-clavicular line |
|
| 144. | While caring for a client with cervical cancer, the nurse notes that the radioactive implant is lying in the bed. The nurse should:
| A. | Place the implant in a biohazard bag and return it to the lab. | | B. | Give the client a pair of gloves and ask her to reinsert the implant. | | C. | Use tongs to pick up the implant and return it to a lead-lined container. | | D. | Discard the implant in the commode and double-flush. |
|
| 145. | The nurse is preparing to discharge a client following a laparoscopic cholecystectomy. The nurse should:
| A. | Tell the client to avoid a tub bath for 48 hours. | | B. | Tell the client to expect clay-colored stools. | | C. | Tell the client that she can expect lower abdominal pain for the next week. | | D. | Tell the client to report pain in the back or shoulders. |
|
| 146. | A high school student returns to school following a three-week absence due to mononucleosis. The school nurse knows it will be important for the client:
| A. | To drink additional fluids throughout the day | | B. | To avoid contact sports for 1–2 months | | C. | To have a snack twice a day to prevent hypoglycemia | | D. | To continue antibiotic therapy for six months |
|
| 147. | An adolescent with cystic fibrosis has an order for pancreatic enzyme replacement. The nurse knows that the medication should be given:
| A. | At bedtime | | B. | With meals and snacks | | C. | Twice daily | | D. | Daily in the morning |
|
| 148. | The doctor has prescribed a diet high in vitamin B12 for a client with pernicious anemia. Which foods are good sources of B12?
| A. | Meat, eggs, dairy products | | B. | Peanut butter, raisins, molasses | | C. | Broccoli, cauliflower, cabbage | | D. | Shrimp, legumes, bran cereals |
|
| 149. | A client with hypertension has begun an aerobic exercise program. The nurse should tell the client that the recommended exercise regimen should begin slowly and build up to:
| A. | 20–30 minutes three times a week | | B. | 45 minutes two times a week | | C. | one hour four times a week | | D. | one hour two times a week |
|
| 150. | A home health nurse is visiting a client who is receiving diuretic therapy for congestive heart failure. Which medication places the client at risk for the development of hypokalemia?
| A. | Aldactone (spironolactone) | | B. | Demadex (torsemide) | | C. | Dyrenium (triamterene) | | D. | Midamor (amiloride hydrochloride) |
|
| 151. | A client with breast cancer is returned to the room following a right total mastectomy. The nurse should:
| A. | Elevate the client’s right arm on pillows. | | B. | Place the client’s right arm in a dependent sling. | | C. | Keep the client’s right arm on the bed beside her. | | D. | Place the client’s right arm across her body. |
|
| 152. | The physician has ordered nitroglycerin buccal tablets for a client with stable angina. The nurse knows that nitroglycerin:
| A. | Slows contractions of the heart | | B. | Dilates coronary blood vessels | | C. | Increases the ventricular fill time | | D. | Strengthens contractions of the heart |
|
| 153. | A trauma client is admitted to the emergency room following a motor vehicle accident. Examination reveals that the left side of the chest moves inward when the client inhales. The finding is suggestive of:
| A. | Pneumothorax | | B. | Mediastinal shift | | C. | Pulmonary contusion | | D. | Flail chest |
|
| 154. | A neurological consult has been ordered for a pediatric client with suspected absence seizures. The client with absence seizures can be expected to have:
| A. | Short, abrupt muscle contractions | | B. | Quick, severe bilateral jerking movements | | C. | Abrupt loss of muscle tone | | D. | Brief lapse in consciousness |
|
| 155. | To decrease the likelihood of seizures and visual hallucinations in a client with alcohol withdrawal, the nurse should:
| A. | Keep the room darkened by pulling the curtains. | | B. | Keep the light over the bed on at all times. | | C. | Keep the room quiet and dim the lights. | | D. | Keep the television or radio turned on. |
|
| 156. | A client with schizoaffective disorder is exhibiting Parkinsonian symptoms. Which medication is responsible for the development of Parkinsonian symptoms?
| A. | Zyprexa (olanzapine) | | B. | Cogentin (benzatropine mesylate) | | C. | Benadryl (diphenhydramine) | | D. | Depakote (divalproex sodium) |
|
| 157. | Which activity is best suited to the 12-year-old with juvenile rheumatoid arthritis?
| A. | Playing video games | | B. | Swimming | | C. | Working crossword puzzles | | D. | Playing slow-pitch softball |
|
| 158. | The home health nurse is scheduled to visit four clients. Which client should she visit first?
| A. | A client with acquired immunodeficiency syndrome with a cough and reported temperature of 101°F | | B. | A client with peripheral vascular disease with an ulcer on the left lower leg | | C. | A client with diabetes mellitus who needs a diabetic control index drawn | | D. | A client with an autograft to burns of the chest and trunk |
|
| 159. | The glycosylated hemoglobin of a 40-year-old client with diabetes mellitus is 2.5%. The nurse understands that:
| A. | The client can have a higher-calorie diet. | | B. | The client has good control of her diabetes. | | C. | The client requires adjustment in her insulin dose. | | D. | The client has poor control of her diabetes. |
|
| 160. | A dexamethasone-suppression test has been ordered for a client with severe depression. The purpose of the dexamethasone suppression test is to:
| A. | Determine which social intervention will be best for the client | | B. | Help diagnose the seriousness of the client’s clinical symptoms | | C. | Determine whether the client will benefit from electroconvulsive therapy | | D. | Reverse the depressive symptoms the client is experiencing |
|
| 161. | The physician has ordered Stadol (butorphanol) for a post-operative client. The nurse knows that the medication is having its intended effect if the client:
| A. | Is asleep 30 minutes after the injection | | B. | Asks for extra servings on his meal tray | | C. | Has an increased urinary output | | D. | States that he is feeling less nauseated |
|
| 162. | The mother of a child with cystic fibrosis tells the nurse that her child makes “snoring” sounds when breathing. The nurse is aware that many children with cystic fibrosis have:
| A. | Choanal atresia | | B. | Nasal polyps | | C. | Septal deviations | | D. | Enlarged adenoids |
|
| 163. | The nurse is caring for a client with full thickness burns to the lower half of the torso and lower extremities. During the emergent phase of injury, the primary nursing diagnosis would focus on:
| A. | Imbalanced nutrition less than body requirements related to hypermetabolic state | | B. | Risk for infection related to altered skin integrity | | C. | Risk for fluid volume imbalance related to intracompartmental fluid shift | | D. | Acute pain related to burn injury |
|
| 164. | A client is hospitalized with hepatitis A. Which of the client’s regular medications is contraindicated due to the current illness?
| A. | Prilosec (omeprazole) | | B. | Synthroid (levothyroxine) | | C. | Premarin (conjugated estrogens) | | D. | Lipitor (atorvastatin) |
|
| 165. | Which activity is suitable for a client who suffered an uncomplicated myocardial infarction (MI) two days ago?
| A. | Sitting in the bedside chair for 15 minutes three times a day | | B. | Remaining on strict bed rest with bedside commode privileges | | C. | Ambulating in the room and hall as tolerated | | D. | Sitting on the bedside for five minutes three times a day with assistance |
|
| 166. | The nurse has been teaching the role of diet in regulating blood pressure to a client with hypertension. Which meal selection indicates the client understands his new diet?
| A. | Cornflakes, whole milk, banana, and coffee | | B. | Scrambled eggs, bacon, toast, and coffee | | C. | Oatmeal, apple juice, dry toast, and coffee | | D. | Pancakes, ham, tomato juice, and coffee |
|
| 167. | An 18-month-old is being discharged following hypospadias repair. Which instruction should be included in the nurse’s discharge teaching?
| A. | The child should not play on his rocking horse. | | B. | Applying warm compresses will decrease pain. | | C. | Diapering should be avoided for 1–2 weeks. | | D. | The child will need a special diet to promote healing. |
|
| 168. | An obstetrical client calls the clinic with complaints of morning sickness. The nurse should tell the client to:
| A. | Keep crackers at the bedside for eating before she arises | | B. | Drink a glass of whole milk before going to sleep at night | | C. | Skip breakfast but eat a larger lunch and dinner | | D. | Drink a glass of orange juice after adding a couple of teaspoons of sugar |
|
| 169. | The nurse is making assignments for the day. The staff consists of an RN, a novice RN, an LPN, and a nursing assistant. Which client should be assigned to the RN?
| A. | A client with peptic ulcer disease | | B. | A client with skeletal traction for a fractured femur | | C. | A client with an abdominal cholecystectomy | | D. | A client with an esophageal tamponade |
|
| 170. | A child with Tetralogy of Fallot is scheduled for a modified Blalock Taussig procedure. The nurse understands that the surgery will:
| A. | Reverse the direction of the blood flow | | B. | Allow better blood supply to the lungs | | C. | Relieve pressure on the ventricles | | D. | Prevent the need for further correction |
|
| 171. | The nurse has taken the blood pressure of a client hospitalized with methicillin-resistant staphylococcus aureus (MRSA). Which action by the nurse indicates an understanding regarding the care of clients with MRSA?
| A. | The nurse leaves the stethoscope in the client’s room for future use. | | B. | The nurse cleans the stethoscope with alcohol and returns it to the exam room. | | C. | The nurse uses the stethoscope to assess the blood pressure of other assigned clients. | | D. | The nurse cleans the stethoscope with water, dries it, and returns it to the nurse’s station. |
|
| 172. | The physician has discussed the need for medication with the parents of an infant with congenital hypothyroidism. The nurse can reinforce the physician’s teaching by telling the parents that:
| A. | The medication will be needed only during times of rapid growth. | | B. | The medication will be needed throughout the child’s lifetime. | | C. | The medication schedule can be arranged to allow for drug holidays. | | D. | The medication is given one time daily every other day. |
|
| 173. | A client with diabetes mellitus has a prescription for Glucotrol XL (glipizide). The client should be instructed to take the medication:
| A. | At bedtime | | B. | With breakfast | | C. | Before lunch | | D. | After dinner |
|
| 174. | The nurse is caring for a client admitted with suspected myasthenia gravis. Which finding is usually associated with a diagnosis of myasthenia gravis?
| A. | Visual disturbances, including diplopia | | B. | Ascending paralysis and loss of motor function | | C. | Cogwheel rigidity and loss of coordination | | D. | Progressive weakness that is worse at the day’s end |
|
| 175. | A preterm infant with sepsis is receiving Gentamycin (garamycin). Which physiological alteration places the preterm infant at increased risk for toxicity related to aminoglycoside therapy?
| A. | Lack of subcutaneous fat deposits | | B. | Immature central nervous system | | C. | Presence of fetal hemoglobin | | D. | Immaturity of the renal system |
|
| 176. | The nurse is teaching the parents of an infant with osteogenesis imperfecta. The nurse should tell the parents:
| A. | That the infant will need daily calcium supplements | | B. | That it is best to lift the infant by the buttocks when diapering | | C. | That the condition is a temporary one | | D. | That only the bones of the infant are affected by the disease |
|
| 177. | The home health nurse is visiting an elderly client following a hip replacement. Which finding requires further teaching?
| A. | The client shares her apartment with a cat. | | B. | The client has a grab bar near the commode. | | C. | The client usually sits on a soft, low sofa. | | D. | The client wears supportive shoes with nonskid soles. |
|
| 178. | Physician’s orders for a client with acute pancreatitis include the following: strict NPO and nasogastric tube to low intermittent suction. The nurse recognizes that withholding oral intake will:
| A. | Reduce the secretion of pancreatic enzymes | | B. | Decrease the client’s need for insulin | | C. | Prevent the secretion of gastric acid | | D. | Eliminate the need for pain medication |
|
| 179. | A client with diverticulitis is admitted with nausea, vomiting, and dehydration. Which finding suggests a complication of diverticulitis?
| A. | Pain in the left lower quadrant | | B. | Boardlike abdomen | | C. | Low-grade fever | | D. | Abdominal distention |
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| 180. | The physician has ordered Vancocin (vancomycin) 500mg IV every six hours for a client with MRSA. The medication should be administered:
| A. | IV push | | B. | Over 15 minutes | | C. | Over 30 minutes | | D. | Over 60 minutes |
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| 181. | The diagnostic work-up of a client hospitalized with complaints of progressive weakness and fatigue confirm a diagnosis of myasthenia gravis. The medication used to treat myasthenia gravis is:
| A. | Prostigmine (neostigmine) | | B. | Atropine (atropine sulfate) | | C. | Didronel (etidronate) | | D. | Tensilon (edrophonium) |
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| 182. | A client with AIDS complains of a weight loss of 20 pounds in the past month. Which diet is suggested for the client with AIDS?
| A. | High calorie, high protein, high fat | | B. | High calorie, high carbohydrate, low protein | | C. | High calorie, low carbohydrate, high fat | | D. | High calorie, high protein, low fat |
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| 183. | The nurse is caring for a four-year-old with cerebral palsy. Which nursing intervention will help ready the child for rehabilitative services?
| A. | Patching one of the eyes to help strengthen the ocular muscles | | B. | Providing suckers and pinwheels to help strengthen tongue movement | | C. | Providing musical tapes to provide auditory training | | D. | Encouraging play with a video game to improve muscle coordination |
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| 184. | A client is admitted with a diagnosis of duodenal ulcer. A common complaint of the client with a duodenal ulcer is:
| A. | Epigastric pain that is relieved by eating | | B. | Weight loss | | C. | Epigastric pain that is worse after eating | | D. | Vomiting after eating |
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| 185. | A client with otosclerosis is scheduled for a stapedectomy. Which finding suggests a complication involving the seventh cranial nerve?
| A. | Diminished hearing | | B. | Sensation of fullness in the ear | | C. | Inability to move the tongue side to side | | D. | Changes in facial sensation |
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| 186. | At the six-week check-up, the mother asks when she can expect the baby to sleep all night. The nurse should tell the mother that most infants begin to sleep all night by age:
| A. | one month | | B. | two months | | C. | 3–4 months | | D. | 5–6 months |
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| 187. | A client with emphysema has been receiving oxygen at 3L per minute by nasal cannula. The nurse knows that the goal of the client’s oxygen therapy is achieved when the client’s PaO2 reading is:
| A. | 50–60mm Hg | | B. | 70–80mm Hg | | C. | 80–90mm Hg | | D. | 90–98mm Hg |
|
| 188. | A client with diabetes insipidus is receiving DDAVP (desmopressin acetate). Which lab finding indicates that the medication is having its intended effect?
| A. | Blood glucose 92mg/dL | | B. | Urine specific gravity 1.020 | | C. | White blood count of 7,500 | | D. | Glycosylated hemoglobin 3.5mg/dL |
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| 189. | Which of the following pediatric clients is at greatest risk for latex allergy?
| A. | The child with a myelomeningocele | | B. | The child with epispadias | | C. | The child with coxa plana | | D. | The child with rheumatic fever |
|
| 190. | The physician has ordered a serum aminophylline level for a client with chronic obstructive lung disease. The nurse knows that the therapeutic range for aminophylline is:
| A. | 1–3 micrograms/mL | | B. | 4–6 micrograms/mL | | C. | 7–9 micrograms/mL | | D. | 10–20 micrograms/mL |
|
| 191. | The nurse is developing a plan of care for a client with acromegaly. Which nursing diagnosis should receive priority?
| A. | Alteration in body image related to change in facial features | | B. | Risk for immobility related to joint pain | | C. | Risk for ineffective airway clearance related to obstruction of airway by tongue | | D. | Sexual dysfunction related to altered hormone secretion |
|
| 192. | A client with acute respiratory distress syndrome (ARDS) is placed on mechanical ventilation. To increase ventilation and perfusion to all areas of the lungs, the nurse should:
| A. | Tell the client to inhale deeply during the inspiratory cycle. | | B. | Increase the positive end expiratory pressure (PEEP). | | C. | Turn the client every hour. | | D. | Administer medication to prevent the client from fighting the ventilator. |
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| 193. | The nurse is teaching the mother of a child with cystic fibrosis how to do chest percussion. The nurse should tell the mother to:
| A. | Use the heel of her hand during percussion. | | B. | Change the child’s position every 20 minutes during percussion sessions. | | C. | Do percussion after the child eats and at bedtime. | | D. | Use cupped hands during percussion. |
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| 194. | A client with Addison’s disease asks the nurse what he needs to know to manage his condition. The nurse should give priority to:
| A. | Emphasizing the need for strict adherence to his medication regimen | | B. | Teaching the client to avoid lotions and skin preparations containing alcohol | | C. | Explaining the need to avoid extremes of temperature | | D. | Assisting the client to choose a diet that contains adequate protein, fat, and carbohydrates |
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| 195. | The nurse is caring for a client following the removal of a central line catheter when the client suddenly develops dyspnea and complains of substernal chest pain. The client is noticeably confused and fearful. Based on the client’s symptoms, the nurse should suspect which complication of central line use?
| A. | Myocardial infarction | | B. | Air embolus | | C. | Intrathoracic bleeding | | D. | Vagal response |
|
| 196. | The nurse calculates the amount of an antibiotic for injection to be given to an infant. The amount of medication to be administered is 1.25mL. The nurse should:
| A. | Divide the amount into two injections and administer in each vastus lateralis muscle. | | B. | Give the medication in one injection in the dorsogluteal muscle. | | C. | Divide the amount in two injections and give one in the ventrogluteal muscle and one in the vastus lateralis muscle. | | D. | Give the medication in one injection in the ventrogluteal muscle. |
|
| 197. | A client with schizophrenia is receiving depot injections of Haldol Decanoate (haloperidol decanoate). The client should be told to return for his next injection in:
| A. | one week | | B. | two weeks | | C. | four weeks | | D. | six weeks |
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| 198. | The physician is preparing to remove a central line. The nurse should tell the client to:
| A. | Breathe normally | | B. | Take slow, deep breaths | | C. | Take a deep breath and hold it | | D. | Breathe as quickly as possible |
|
| 199. | Cystic fibrosis is an exocrine disorder that affects several systems of the body. The earliest sign associated with a diagnosis of cystic fibrosis is:
| A. | Steatorrhea | | B. | Frequent respiratory infections | | C. | Increased sweating | | D. | Meconium ileus |
|
| 200. | A three-year-old is immobilized in a hip spica cast. Which discharge instruction should be given to the parents?
| A. | Keep the bed flat, with a small pillow beneath the cast. | | B. | Provide crayons and a coloring book for play activity. | | C. | Increase her intake of high-calorie foods for healing. | | D. | Tuck a disposable diaper beneath the cast at the perineal opening. |
|
| 201. | The nurse is caring for a client following the reimplantation of the thumb and index finger. Which finding should be reported to the physician immediately?
| A. | Temperature of 100°F | | B. | Coolness and discoloration of the digits | | C. | Complaints of pain | | D. | Difficulty moving the digits |
|
| 202. | Which client is at greatest risk for a Caesarean section due to cephalopelvic disproportion (CPD)?
| A. | A 25-year-old gravida 2, para 1 | | B. | A 30-year-old gravida 3, para 2 | | C. | A 17-year-old gravida 1, para 0 | | D. | A 32-year-old gravida 1, para 0 |
|
| 203. | The nurse is caring for a client with amyotrophic lateral sclerosis (ALS, Lou Gehrig’s disease). The nurse should give priority to:
| A. | Assessing the client’s respiratory status | | B. | Providing an alternate means of communication | | C. | Referring the client and family to community support groups | | D. | Instituting a routine of active range-of-motion exercises |
|
| 204. | The physician has ordered Claforan (cefotaxime) 1g every six hours. The pharmacy sends the medication premixed in 100mL of D5W with instructions to infuse the medication over one hour. The IV set delivers 20 drops per milliliter. The nurse should set the IV rate at:
| A. | 50 drops per minute | | B. | 33 drops per minute | | C. | 25 drops per minute | | D. | 12 drops per minute |
|
| 205. | When assessing the urinary output of a client who has had extracorporeal lithotripsy, the nurse can expect to find:
| A. | Cherry-red urine that gradually becomes clearer | | B. | Orange-tinged urine containing particles of calculi | | C. | Dark red urine that becomes cloudy in appearance | | D. | Dark, smoky-colored urine with high specific gravity |
|
| 206. | A client scheduled for an atherectomy asks the nurse about the procedure. The nurse understands that:
| A. | Plaque will be removed by rotational or directional catheters. | | B. | Plaque will be destroyed by a laser. | | C. | A balloon-tipped catheter will compress fatty lesions against the vessel wall. | | D. | Medication will be used to dissolve the build-up of plaque. |
|
| 207. | An elderly client has a stage II pressure ulcer on her sacrum. During assessment of the client’s skin, the nurse would expect to find:
| A. | A deep crater with a nonpainful wound base | | B. | A craterous area with a nonpainful wound base | | C. | Cracks and blisters with redness and induration | | D. | Nonblanchable redness with tenderness and pain |
|
| 208. | The physician has prescribed Cognex (tacrine) for a client with dementia. The nurse should monitor the client for adverse reactions, which include:
| A. | Hypoglycemia | | B. | Jaundice | | C. | Urinary retention | | D. | Tinnitus |
|
| 209. | The suggested diet for a child with cystic fibrosis is one that contains:
| A. | High calories, high protein, moderate fat | | B. | High calories, moderate protein, low fat | | C. | Moderate calories, moderate protein, moderate fat | | D. | Low calories, high protein, low fat |
|
| 210. | The physician has ordered a low-potassium diet for a client with acute glomerulonephritis. Which snack is suitable for the client with potassium restrictions?
| A. | Raisins | | B. | Orange | | C. | Apple | | D. | Banana |
|
| 211. | A client with increased intracranial pressure is placed on mechanical ventilation with hyperventilation. The nurse knows that the purpose of the hyperventilation is to:
| A. | Prevent the development of acute respiratory failure | | B. | Decrease cerebral blood flow | | C. | Increase systemic tissue perfusion | | D. | Prevent cerebral anoxia |
|
| 212. | The physician has ordered a blood test for H. pylori. The nurse should prepare the client by:
| A. | Withholding oral intake after midnight | | B. | Telling the client that no special preparation is needed | | C. | Explaining that a small dose of radioactive isotope will be used | | D. | Giving an oral suspension of glucose one hour before the test |
|
| 213. | The nurse is preparing to give an oral potassium supplement. The nurse should give the medication:
| A. | Without diluting it | | B. | With 4oz. of juice | | C. | With water only | | D. | On an empty stomach |
|
| 214. | A client with acute alcohol intoxication is being treated for hypomagnesemia. During assessment of the client, the nurse would expect to find:
| A. | Bradycardia | | B. | Negative Chvostek’s sign | | C. | Hypertension | | D. | Positive Trousseau’s sign |
|
| 215. | The physician has ordered cultures for cytomegalovirus (CMV). Which statement is true of the collection of cultures for cytomegalovirus?
| A. | Stool cultures are preferred for definitive diagnosis. | | B. | Pregnant caregivers may obtain cultures. | | C. | Collection of one specimen is sufficient. | | D. | Accurate diagnosis depends on fresh specimens. |
|
| 216. | A home health nurse has four clients assigned for morning visits. The nurse should give priority to visiting the client with:
| A. | Diabetes mellitus with a nongranulated ulcer of the right foot | | B. | Congestive heart failure who reports coughing up frothy sputum | | C. | Hemiplegia with tenderness in the right flank and cloudy urine | | D. | Rheumatoid arthritis with soft tissue swelling behind the right knee |
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| 217. | Four clients are admitted to a medical unit. If only one private room is available, it should be assigned to:
| A. | The client with ulcerative colitis | | B. | The client with neutropenia | | C. | The client with cholecystitis | | D. | The client with polycythemia vera |
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| 218. | The RN is making assignments for the morning staff. Which client should be cared for by the RN?
| A. | A client with hemianopsia | | B. | A client with asterixis | | C. | A client with akathesia | | D. | A client with hemoptysis |
|
| 219. | The nurse is reviewing the lab reports on several clients. Which one should be reported to the physician immediately?
| A. | A serum creatinine of 5.2mg/dL in a client with chronic renal failure | | B. | A positive C reactive protein in a client with rheumatic fever | | C. | A hematocrit of 52% in a client with gastroenteritis | | D. | A white cell count of 2,200cu/mm in a client taking Dilantin (phenytoin) |
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| 220. | The following clients are to be assigned for daily care. The newly licensed nurse should not be assigned to provide primary care for the client with:
| A. | Full-thickness burns of the abdomen and upper thighs | | B. | A fractured hip scheduled for hip replacement | | C. | Ileal reservoir following a cystectomy | | D. | Noncardiogenic pulmonary edema (ARDS) |
|
| 221. | The RN is making assignments for clients hospitalized on a neurological unit. Which client should be assigned to the LPN?
| A. | A client with a C3 injury immobilized by Crutchfield tongs | | B. | A client with exacerbation of multiple sclerosis | | C. | A client with a lumbar laminectomy | | D. | A client with hemiplegia and a urinary tract infection |
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| 222. | The nurse has just received the change of shift report. The nurse should give priority to assessing the client with:
| A. | A thoracotomy with 110mL of drainage in the past hour | | B. | A cholecystectomy with an oral temperature of 100°F | | C. | A transurethral prostatectomy who complains of urgency to void | | D. | A stapedectomy who reports diminished hearing in the past hour |
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| 223. | A client with primary sclerosing cholangitis has received a liver transplant. The nurse should give priority to assessing the client for complications. Which findings are associated with an acute rejection of the new liver?
| A. | Increased jaundice and prolonged prothrombin time | | B. | Fever and foul-smelling bile drainage | | C. | Abdominal distention and clay-colored stools | | D. | Increased uric acid and increased creatinine |
|
| 224. | The nurse is planning care for a client with adrenal insufficiency. The nurse should give priority to ?
| A. | Monitoring the client for signs of dehydration | | B. | Promoting sleep and rest | | C. | Providing high calorie snacks | | D. | Promoting a healthy body image |
|
| 225. | A pediatric client with burns to the hands and arms has dressing changes with Sulfamylon (mafenide acetate) cream. The nurse is aware that the medication:
| A. | Will cause dark staining of the surrounding skin | | B. | Produces a cooling sensation when applied | | C. | Can alter the function of the thyroid | | D. | Produces a burning sensation when applied |
|
| 226. | The physician has ordered Dilantin (phenytoin) for a client with generalized seizures. When planning the client’s care the nurse should:
| A. | Maintain strict intake and output. | | B. | Check the pulse before giving the medication. | | C. | Administer the medication 30 minutes before meals. | | D. | Provide oral hygiene and gum care every shift. |
|
| 227. | The nurse is caring for a client receiving Capoten (captopril). The nurse should be alert for adverse reactions to the drug, which include:
| A. | Increased red cell count | | B. | Decreased sodium level | | C. | Decreased white cell count | | D. | Increased calcium level |
|
| 228. | A client receiving chemotherapy for breast cancer has an order for Zofran (ondansetron) 8mg PO to be given 30 minutes before induction of the chemotherapy. The purpose of the medication is to:
| A. | Prevent anemia | | B. | Promote relaxation | | C. | Prevent nausea | | D. | Increase neutrophil counts |
|
| 229. | The physician has ordered Cortisporin ear drops for a two-year-old. To administer the ear drops, the nurse should:
| A. | Pull the ear down and back. | | B. | Pull the ear straight out. | | C. | Pull the ear up and back. | | D. | Leave the ear undisturbed. |
|
| 230. | A client with Lyme’s disease is being treated with Achromycin (tetracycline HCl). The nurse should tell the client that the medication will be rendered ineffective if taken with:
| A. | Antacids | | B. | Salicylates | | C. | Antihistamines | | D. | Sedative-hypnotics |
|
| 231. | A client with schizophrenia has been taking Thorazine (chlorpromazine) 200mg four times a day. Which finding should be reported to the doctor immediately?
| A. | The client complains of thirst. | | B. | The client has gained four pounds in the past two months. | | C. | The client complains of a sore throat. | | D. | The client naps throughout the day. |
|
| 232. | The doctor has prescribed Claritin (loratidine) for a client with seasonal allergies. The feature that separates Claritin from other antihistamines such as Benadryl (diphenhydramine) is that the medication:
| A. | Is nonsedating | | B. | Stimulates appetite | | C. | Is used for motion sickness | | D. | Is less expensive |
|
| 233. | A six-month-old is being treated for thrush with Nystatin (mycostatin) oral suspension. The nurse should administer the medication by:
| A. | Placing it in a small amount of applesauce | | B. | Using a cotton-tipped swab | | C. | Adding it to the infant’s formula | | D. | Placing it in 2–3oz. of water |
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| 234. | A client with iron-deficiency anemia is taking an oral iron supplement. The nurse should tell the client to take the medication with:
| A. | Orange juice | | B. | Water only | | C. | Milk | | D. | Apple juice |
|
| 235. | A child is admitted to the emergency room following ingestion of a bottle of Children’s Tylenol. The nurse is aware that Tylenol (acetaminophen) overdose is treated with:
| A. | Acetylcysteine | | B. | Deferoxamine | | C. | Edetate calcium disodium | | D. | Activated charcoal |
|
| 236. | The nurse knows that a client with right-sided hemiplegia understands teaching regarding ambulation with a cane if she states:
| A. | “I will hold the cane in my right hand.” | | B. | “I will advance my cane and my right leg at the same time.” | | C. | “I will be able to walk only by using a walker.” | | D. | “I will hold the cane in my left hand.” |
|
| 237. | A nursing assistant assigned to care for a client receiving linear accelerator radium therapy for laryngeal cancer states, “I don’t want to be assigned to that radioactive patient.” The best response by the nurse is to:
| A. | Tell the nursing assistant that the client is not radioactive. | | B. | Tell the nursing assistant to wear a radiation badge to detect the amount of radiation that she is receiving. | | C. | Instruct her regarding the use of a lead-lined apron. | | D. | Ask a co-worker to care for the client. |
|
| 238. | The nurse caring for a client scheduled for an angiogram should prepare the client for the procedure by telling him to expect:
| A. | Dizziness as the dye is injected | | B. | Nausea and vomiting after the procedure is completed | | C. | A decreased heart rate for several hours after the procedure is completed | | D. | A warm sensation as the dye is injected |
|
| 239. | A client with Parkinson’s disease complains of “choking” when he swallows. Which intervention will improve the client’s ability to swallow?
| A. | Withholding liquids until after meals | | B. | Providing semi-liquids when possible | | C. | Providing a full liquid diet | | D. | Offering small, more frequent meals |
|
| 240. | Which of the following statements best explains the rationale for placing the client in Trendelenburg position during the insertion of a central line catheter?
| A. | It will facilitate catheter insertion. | | B. | It will make the client more comfortable during the insertion. | | C. | It will prevent the occurrence of ventricular tachycardia. | | D. | It will prevent the development of pulmonary emboli. |
|
| 241. | The doctor has ordered the removal of a Davol drain. Which of the following instructions should the nurse give to the client before removing the drain?
| A. | The client should be told to breathe normally. | | B. | The client should be told to take two or three deep breaths as the drain is being removed. | | C. | The client should be told to hold his breath as the drain is being removed. | | D. | The client should breathe slowly as the drain is being removed. |
|
| 242. | Which of the following findings is associated with right-sided heart failure?
| A. | Shortness of breath | | B. | Nocturnal polyuria | | C. | Daytime oliguria | | D. | Crackles in the lungs |
|
| 243. | A client returns from surgery with a total knee replacement. Which of the following findings requires immediate nursing intervention?
| A. | Bloody drainage of 30mL from the Davol drain is present. | | B. | The CPM is set on 90° flexion. | | C. | The client is unable to ambulate to the bathroom. | | D. | The client is complaining of muscle spasms. |
|
| 244. | Which of the following postpartal clients is at greatest risk for hemorrhage?
| A. | A gravida 1 para 1 with an uncomplicated delivery of a 7-pound infant | | B. | A gravida 1 para 0 with a history of polycystic ovarian disease | | C. | A gravida 3 para 3 with a history of low–birth weight infants | | D. | A gravida 4 para 3 with a Caesarean section |
|
| 245. | An infant with a ventricular septal defect is discharged with a prescription for Lanoxin (digoxin) elixir 0.01mg PO q 12hrs. The bottle is labeled 0.10mg per 1/2 tsp. The nurse should instruct the mother to:
| A. | Administer the medication using a nipple. | | B. | Administer the medication using the calibrated dropper in the bottle. | | C. | Administer the medication using a plastic baby spoon. | | D. | Administer the medication in a baby bottle with 1oz. of water. |
|
| 246. | An elderly client with glaucoma is scheduled for a cholecystectomy. Which medication order should the nurse question?
| A. | Demerol (meperidine) | | B. | Tagamet (cimetidine) | | C. | Atropine (atropine) | | D. | Phenergan (promethazine) |
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| 247. | Which instruction would not be included in the discharge teaching of the client receiving Thorazine (chlorpromazine)?
| A. | “You will need to wear protective clothing or a sunscreen when you are outside.” | | B. | “You will need to avoid eating aged cheese.” | | C. | “You should carry hard candy with you to decrease dryness of the mouth.” | | D. | “You should report a sore throat immediately.” |
|
| 248. | An elderly client who experiences nighttime confusion wanders from his room into the room of another client. The nurse can best help with decreasing the client’s confusion by:
| A. | Assigning a nursing assistant to sit with him until he falls asleep | | B. | Allowing the client to room with another elderly client | | C. | Administering a bedtime sedative | | D. | Leaving a nightlight on during the evening and night shifts |
|
| 249. | A four-year-old is scheduled for a routine tonsillectomy. Which of the following lab findings should be reported to the doctor?
| A. | A hemoglobin of 12Gm | | B. | A platelet count of 200,000 | | C. | A white blood cell count of 16,000 | | D. | A urine specific gravity of 1.010 |
|
| 250. | A client with psychotic depression is receiving Haldol (haloperidol). Which one of the following adverse effects is associated with the use of haloperidol?
| A. | Akathisia | | B. | Cataracts | | C. | Diaphoresis | | D. | Polyuria |
|
