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Chapter 5. Practice Exam 5 and Rationales

Chapter 5. Practice Exam 5 and Rationales

1.The nurse at a college campus is preparing to medicate several students who have been exposed to meningococcal meningitis. Which would the nurse most likely administer?

A.Ampicillin (Omnipen)
B.Ciprofoxacin (Cipro)
C.Vancomycin (Vancocin)
D.Piperacillin/Tazobactam (Zosyn)

2.A 65-year-old client is admitted after a stroke. Which nursing intervention would best improve tissue perfusion to prevent skin problems?

A.Assessing the skin daily for breakdown
B.Massaging any erythematous areas on the skin
C.Changing incontinence pads as soon as they become soiled with urine or feces
D.Performing range-of-motion exercises and turning and repositioning the client

3.Which diet selection by a client with a decubitus ulcer would indicate a clear understanding of the proper diet for healing of the ulcer?

A.Tossed salad, milk, and a slice of caramel cake
B.Vegetable soup and crackers, and a glass of iced tea
C.Baked chicken breast, broccoli, wheat roll, and an orange
D.Hamburger, French fries, and corn on the cob

4.The nurse is assessing elderly clients at a community center. Which of the following findings would be the most cause for concern?

A.Dry mouth
B.Loss of one inch of height in the last year
C.Stiffened joints
D.Rales bilaterally on chest auscultation

5.A client with chronic pain is being treated with opioid administration via epidural route. Which medication would it be most important to have available due to a possible complication of this pain relief procedure?

A.Ketorolac (Toradol)
B.Naloxone (Narcan)
C.Diphenhydramine (Benadryl)
D.Promethazine (Phenergan)

6.The nurse is assessing a client for hypovolemia. Which laboratory result would help the nurse in confirming a volume deficit?

A.Hematocrit 55%
B.Potassium 5.0mEq/L
C.Urine specific gravity 1.016
D.BUN 18mg/dL

7.A nurse is triaging in the emergency room when a client enters complaining of muscle cramps and a feeling of exhaustion after a running competition. Which of the following would the nurse suspect?


8.A client was transferred to the hospital unit as a direct admit from a small community hospital. While the nurse is obtaining part of the admission history information, the client suddenly becomes semiconscious. Assessment reveals a systolic BP of 70, heart rate of 130, and respiratory rate of 24. What is the nurse’s initial action?

A.Lower the head of the client’s bed.
B.Initiate an IV with a large bore needle.
C.Notify the physician of the assessment results.
D.Call for the cardiopulmonary resuscitation team.

9.The nurse is caring for a client post-myocardial infarction on the cardiac unit. The client is exhibiting symptoms of shock. Which clinical manifestation is the best indicator that the shock is cardiogenic rather than anaphylactic?

A.BP 90/60
B.Chest pain
C.Increased anxiety
D.Temp 98.6°F

10.While reading the progress notes on a client with cancer, the nurse notes a TNM classification of T1, N1, M0. What does this classification indicate?

A.The tumor is in situ, no regional lymph nodes are involved, and there is no metastasis.
B.No evidence of primary tumor exists, lymph nodes can’t be assessed, and metastasis can’t be assessed.
C.The tumor is extended, with regional lymph node involvement and distant metastasis.
D.The tumor is extended and regional lymph nodes are involved, but there is no metastasis.

11.The nurse is caring for a client with leukemia who has received the drug Daunorubicin (Cerubidine). Which of the following common side effects would cause the most concern?


12.The nurse is caring for an organ donor client with a severe head injury from an MVA. Which of the following is most important when caring for the organ donor client?

A.Maintenance of the BP at 90mmHg or greater
B.Maintenance of a normal temperature
C.Keeping the hematocrit at less than 28%
D.Ensuring a urinary output of at least 300mL/hr

13.A client is being admitted with syndrome of inappropriate diuretic hormone. Which does the nurse expect to observe? Select all that apply.

A.Increased thirst
E.Muscle weakness

14.A client with a fractured leg is exhibiting shortness of breath, pain upon deep breathing, and hemoptysis. What do these clinical manifestations indicate to the nurse?

A.Congestive heart failure
B.Pulmonary embolus
C.Adult respiratory distress syndrome
D.Tension pneumothorax

15.A nurse is preparing to mix and administer chemotherapy. What equipment would be unnecessary to obtain?

A.Surgical gloves
B.Luer lok fitting IV tubing
C.Surgical hat cover
D.Disposable long-sleeve gown

16.The charge nurse is assigning staff for the day. Staff consists of an RN, an LPN, and a certified nursing assistant. Which client assignment should be given to the nursing assistant?

A.Exploratory laparotomy with a colon resection the previous shift
B.Client with a stroke who has been hospitalized for two days
C.A client with metastatic cancer on PCA morphine
D.A new admission with diverticulitis

17.The registered nurse is making shift assignments. Which client should be assigned to the licensed practical nurse (LPN)?

A.A client who is a diabetic with a foot ulcer
B.A client with a deep vein thrombosis receiving intravenous heparin
C.A client being weaned from a tracheostomy
D.A post-operative cholecystectomy with a T-tube

18.A client with metastatic cancer of the lung has just been told the prognosis by the oncologist. The nurse hears the client state, “I don’t believe the doctor; I think he has me confused with another patient.” This is an example of which of Kubler-Ross’ stages of dying?


19.The surgical nurse is preparing a patient for surgery on the lower abdomen. In which position would the nurse most likely place the client for surgery on this area?


20.The nurse is performing a history on a client admitted for surgery in the morning. Which long-term medication in the client’s history would be most important to report to the physician?

B.Lisinopril (Zestril)
C.Docusate (Colace)
D.Oscal D

21.A nurse is working in an endoscopy recovery area. Many of the clients are administered midazolam (Versed) to provide conscious sedation. Which medication is important to have available as an antidote for Versed?

A.Diazepam (Valium)
B.Naloxone (Narcan)
C.Flumazenil (Romazicon)
D.Florinef (Fludrocortisone)

22.The nurse is caring for a client with a cerebrovascular accident (CVA) who is complaining of being nauseated and is requesting an emesis basin. Which action would the nurse take first?

A.Administer an ordered antiemetic.
B.Obtain an ice bag and apply to the client’s throat.
C.Turn the client to one side.
D.Notify the physician.

23.The nurse is assessing a client who had a colon resection two days ago. The client states, “I feel like my stitches have burst loose.” Upon further assessment, dehiscence of the wound is noted. Which action should the nurse take?

A.Immediately place the client in the prone position.
B.Apply a sterile, saline-moistened dressing to the wound.
C.Administer atropine to decrease abdominal secretions.
D.Wrap the abdomen with an ACE bandage.

24.A client with hepatitis C is scheduled for a liver biopsy. Which would the nurse include in the teaching plan for this client?

A.The client should lie on the left side after the procedure.
B.Cleansing enemas should be given the morning of the procedure.
C.Blood coagulation studies might be done before the biopsy.
D.The procedure is noninvasive and causes no pain.

25.The nurse is caring for a client after a laryngectomy. The client is anxious, with a respiratory rate of 32 and an oxygen saturation of 88. What should be the initial nursing action?

A.Suction the client.
B.Increase the oxygen flow rate.
C.Notify the physician.
D.Recheck the O2 saturation reading.

26.The nurse is performing discharge teaching to a client who is on isoniazid (INH). Which diet selection by the client indicates to the nurse that further instruction is needed?

A.Tuna casserole
B.Ham salad sandwich
C.Baked potato
D.Broiled beef roast

27.A client with a head injury has an intracranial pressure (ICP) monitor in place. Cerebral perfusion pressure calculations are ordered. If the client’s ICP is 22 and the mean pressure reading is 70, what is the client’s cerebral perfusion pressure?


28.A student nurse is observing a neurological nurse perform an assessment. When the nurse asks the client to “stick out his tongue,” the nurse is assessing the function of which cranial nerve?

A.II optic
B.I olfactory
C.X vagus
D.XII hypoglossal

29.Which set of vital signs would best indicate to the nurse that a client has an increase in intracranial pressure?

A.BP 180/70, pulse 50, respirations 16, temperature 101°F
B.BP 100/70, pulse 64, respirations 20, temperature 98.6°F
C.BP 96/70, pulse 132, respirations 20, temperature 98.6°F
D.BP 130/80, pulse 50, respirations 18, temperature 99.6°F

30.The nurse is assessing the laboratory results of a client scheduled to receive phenytoin sodium (Dilantin). The Dilantin level, drawn two hours ago, is 30mcg/mL. What is the appropriate nursing action?

A.Administer the Dilantin as scheduled.
B.Hold the scheduled dose and notify the physician.
C.Decrease the dosage from 100mg to 50mg.
D.Increase the dosage to 200mg from 100mg.

31.A client with sickle cell disease is admitted in active labor. Which nursing intervention would be most helpful in preventing a sickling crisis?

A.Obtaining blood pressures every two hours
B.Administering pain medication every three hours as ordered
C.Monitoring arterial blood gas results
D.Administering IV fluids at ordered rate of 200mL/hr

32.A client is admitted with a diagnosis of pernicious anemia. Which of the following signs or symptoms would indicate that the client has been noncompliant with ordered B12 injections?

A.Hyperactivity in the evening hours
B.Weight gain
C.Paresthesia of hands and feet
D.Diarrhea stools

33.The nurse has performed nutritional teaching on a client with gout who is placed on a low-purine diet. Which selection by the client would indicate that teaching has been ineffective?

A.Boiled cabbage
C.Peach cobbler

34.The nurse is caring for a 70-year-old client with hypovolemia who is receiving a blood transfusion. Assessment findings reveal crackles on chest auscultation and distended neck veins. What is the nurse’s initial action?

A.Slow the transfusion.
B.Document the finding as the only action.
C.Stop the blood transfusion and turn on the normal saline.
D.Assess the client’s pupils.

35.The orthopedic nurse should be particularly alert for a fat embolus in which of the following clients having the greatest risk for this complication after a fracture?

A.A 50-year-old with a fractured fibula
B.A 20-year-old female with a wrist fracture
C.A 21-year-old male with a fractured femur
D.An 8-year-old with a fractured arm

36.The nurse has performed discharge teaching to a client in need of a high-iron diet. The nurse recognizes that teaching has been effective when the client selects which meal plan?

A.Hamburger, French fries, and orange juice
B.Sliced veal, spinach salad, and whole-wheat roll
C.Vegetable lasagna, Caesar salad, and toast
D.Bacon, lettuce, and tomato sandwich; potato chips; and tea

37.An elderly female is admitted with a fractured right femoral neck. Which clinical manifestation would the nurse expect to find?

A.Free movement of the right leg
B.Abduction of the right leg
C.Internal rotation of the right hip
D.Shortening of the right leg

38.The nurse is performing the skill of intramuscular injection by the Z track method. Which technique would the nurse utilize to prevent tracking of the medication?

A.Inject the medication in the deltoid muscle.
B.Use a 22-gauge needle when preparing the syringe.
C.Omit aspirating for blood before injecting.
D.Draw up 0.2mL of air after the proper medication dose.

39.A client with asthma has an order to begin an aminophylline IV infusion. Which piece of equipment is essential for the nurse to safely administer the medication?

A.Large bore intravenous catheter
B.IV inline filter
C.IV infusion device
D.Cover to prevent exposure of solution to light

40.The nurse caring for a client with anemia recognizes which clinical manifestation as the one that is specific for a hemolytic type of anemia?


41.A client with cancer who is receiving chemotherapeutic drugs has been given injections of pegfilgastrim (Neulasta). Which laboratory value reveals that the drug is producing the desired effect?

A.Hemoglobin of 13.5g/dL
B.White blood cells count of 6,000/mm
C.Platelet count of 300,000/mm
D.Hematocrit of 39%

42.The nurse is performing discharge teaching on a client with polycythemia vera. Which would be included in the teaching plan?

A.Avoid large crowds and exposure to people who are ill.
B.Keep the head of the bed elevated at night.
C.Wear socks and gloves when going outside.
D.Recognize clinical manifestations of thrombosis.

43.A client is being discharged after lithotripsy for removal of a kidney stone. Which statement by the client indicates understanding of the nurse’s instructions?

A.“I’ll need to strain my urine starting in the morning.”
B.“I will need to save all my urine.
C.“I will be careful to strain all the urine and save the stone.”
D.“I won’t need to strain my urine now that the procedure is complete.”

44.The nurse is caring for a client with osteoporosis who is being discharged on alendronate (Fosamax). Which statement would indicate a need for further teaching?

A.“I should take the medication immediately before bedtime every night.”
B.“I should remain in an upright position for 30 minutes after taking Fosamax.”
C.“The medication should be taken by mouth with water.”
D.“I should not have any food with this medication.”

45.A client is being evaluated for carpel tunnel syndrome. The nurse is observed tapping over the median nerve in the wrist and asking the client if there is pain or tingling. Which assessment is the nurse performing?

A.Phalen’s maneuver
B.Tinel’s sign
C.Kernig’s sign
D.Brudzinski’s sign

46.The nurse is caring for a client who is recovering from a fractured femur. Which diet selection would be best for this client?

A.Loaded baked potato, fried chicken, and tea
B.Dressed cheeseburger, French fries, and a Diet Coke
C.Tuna fish salad on sourdough bread, potato chips, and skim milk
D.Mandarin orange salad, broiled chicken, and milk

47.The nurse working in the emergency department realizes that it would be contraindicated to induce vomiting if someone had ingested which of the following?


48.A client with AIDS has impaired nutrition due to diarrhea. The nurse teaches the client about the need to avoid certain foods. Which diet selection by the client would indicate a need for further teaching?

A.Tossed salad
B.Baked chicken
C.Broiled fish
D.Steamed rice

49.The nurse has just received a report from the previous shift. Which of the following clients should the nurse visit first?

A.A 50-year-old COPD client with a PCO2 of 50
B.A 24-year-old admitted after an MVA complaining of shortness of breath
C.A client with cancer requesting pain medication
D.A one-day post-operative cholecystectomy with a temperature of 100°F

50.The nurse is performing a breast exam on a client when she discovers a mass. Which characteristic of the mass would best indicate a reason for concern?

A.Tender to the touch
B.Regular shape
C.Moves easily
D.Firm to the touch

51.The nurse is caring for a client after a motor vehicle accident. The client has a fractured tibia, and bone is noted protruding through the skin. Which action is of priority?

A.Provide manual traction above and below the leg.
B.Cover the bone area with a sterile dressing.
C.Apply an ACE bandage around the entire lower limb.
D.Place the client in the prone position.

52.The RN on the oncology unit is preparing to mix and administer amphoteracin B (Fungizone) to a client. Which action is contraindicated for administering this drug IV?

A.Mix the drug with normal saline solution.
B.Administer the drug over 4–6 hours.
C.Hydrate with IV fluids two hours before the infusion is scheduled to begin.
D.Premedicate the client with ordered acetaminophen (Tylenol) and diphenhydramine (Benadryl).

53.A nurse is administering a blood transfusion to a client on the oncology unit. Which clinical manifestation indicates an acute hemolytic reaction to the blood?

A.Low back pain
D.Neck vein distention

54.The nurse caring for a client diagnosed with metastatic cancer of the bone is exhibiting mental confusion and a BP of 150/100. Which laboratory value would correlate with the client’s symptoms reflecting a common complication with this diagnosis?

A.Potassium 5.2mEq/L
B.Calcium 13mg/dL
C.Inorganic phosphorus 1.7mEq/L
D.Sodium 138mEq/L

55.A client with a stroke and malnutrition has been placed on Total Parenteral Nutrition (TPN). The nurse notes air entering the client via the central line. Which initial action is most appropriate?

A.Notify the physician.
B.Elevate the head of the bed.
C.Place the client in the left lateral decubitus position.
D.Stop the TPN and hang D5 1/2 NS.

56.The nurse is preparing a client for cervical uterine radiation implant insertion. Which will be included in the teaching plan?

A.TV or telephone use will not be allowed while the implant is in place.
B.A Foley catheter is usually inserted.
C.A high-fiber diet is recommended.
D.Excretions will be considered radioactive.

57.The nurse is caring for a client with a head injury who has an intracranial pressure monitor in place. Assessment reveals an ICP reading of 66. What is the nurse’s best action?

A.Notify the physician.
B.Record the reading as the only action.
C.Turn the client and recheck the reading.
D.Place the client supine.

58.The nurse is caring for a client with leukemia who is receiving the drug doxorubicin (Adriamycin). Which toxic effects of this drug would be reported to the physician immediately?

A.Rales and distended neck veins
B.Red discoloration of the urine
C.Nausea and vomiting
D.Elevated BUN and dry, flaky skin

59.A client has developed diabetes insipidous after removal of a pituitary tumor. Which finding would the nurse expect?


60.A client with cancer received platelet infusions 24 hours ago. Which of the following assessment findings would indicate the most therapeutic effect from the transfusions?

A.Hemoglobin level increase from 8.9 to 10.6mg/dL
B.Temperature reading of 99.4°F
C.White blood cell count of 11,000/mm3
D.Decrease in oozing of blood from IV site

61.A client is admitted with Parkinson’s disease who has been taking Carbidopa/levodopa (Sinemet) for one year. Which clinical manifestation would be most important to report?

A.Dry mouth
B.Spasmodic eye winking
C.Dark urine color
D.Complaints of dizziness

62.The nurse who is caring for a client with cancer notes a WBC of 500/mm3 on the laboratory results. Which intervention would be most appropriate to include in the client’s plan of care?

A.Assess temperature every four hours because of risk for hypothermia.
B.Instruct the client to avoid large crowds and people who are sick.
C.Instruct in the use of a soft toothbrush.
D.Assess for signs of bleeding.

63.A client with Crohn’s disease requires TPN to provide adequate nutrition. The nurse finds the TPN bag empty. What fluid would the nurse select to hang until another bag is prepared in the pharmacy?

A.Lactated Ringers
B.Normal saline
C.D10W solution
D.Normosol R

64.The nurse is caring for a client with possible cervical cancer. What clinical data would the nurse most likely find in the client’s history?

A.Post-coital vaginal bleeding
B.Nausea and vomiting
C.Foul-smelling vaginal discharge
D.Elevated temperature levels

65.The nurse is preparing to receive a client from admitting with tumor lysis syndrome (TLS). Which of the following would the nurse expect to find on the laboratory and patient history sections of the chart? Select all that apply.

A.Low blood pressure
E.Mental changes

66.A client is scheduled to undergo a bone marrow aspiration from the sternum. What position would the nurse assist the client into for this procedure?

A.Dorsal recumbent
C.High Fowler’s

67.The nurse is caring for a client with a head injury who has increased ICP. The physician plans to reduce the cerebral edema by constricting cerebral blood vessels. Which physician order would serve this purpose?

A.Hyperventilation per mechanical ventilation
B.Insertion of a ventricular shunt
C.Furosemide (Lasix)
D.Solu medrol

68.A client with a T6 injury six months ago develops facial flushing and a BP of 210/106. After elevating the head of the bed, which is the most appropriate nursing action?

A.Notify the physician.
B.Assess the client for a distended bladder.
C.Apply ordered oxygen via nasal cannula.
D.Increase the IV fluids.

69.The nurse is performing an admission history for a client recovering from a stroke. Medication history reveals the drug clopidogrel (Plavix). Which clinical manifestation alerts the nurse to an adverse effect of this drug?


70.The nurse caring for a client with a head injury would recognize which assessment finding as the most indicative of increased ICP?


71.A client with angina is experiencing migraine headaches. The physician has prescribed Sumatriptan succinate (Imitrex). Which nursing action is most appropriate?

A.Call the physician to question the prescription order.
B.Try to obtain samples for the client to take home.
C.Perform discharge teaching regarding this drug.
D.Consult social services for financial assistance with obtaining the drug.

72.A client with COPD is in respiratory failure. Which of the following results would be the most sensitive indicator that the client requires a mechanical ventilator?

A.PCO2 58
B.SaO2 90
C.PH 7.23
D.HCO3 30

73.The nurse in the emergency room is caring for a client with multiple rib fractures and a pulmonary contusion. Assessment reveals a respiratory rate of 38, a heart rate of 136, and restlessness. Which associated assessment finding would require immediate intervention?

A.Occasional small amounts of hemoptysis
B.Midline trachea with wheezing on auscultation
C.Subcutaneous air and absent breath sounds
D.Pain when breathing deeply, with rales in the upper lobes

74.The nurse is caring for a client with myasthenia gravis who is having trouble breathing. The nurse would encourage which of the following positions for maximal lung expansion?

A.Supine with no pillow, to maintain patent airway
B.Side-lying with back support
C.Prone with head turned to one side
D.Sitting or in high Fowler’s

75.The nurse is caring for clients on a respiratory unit. Upon receiving the following client reports, which client should be seen first?

A.Client with emphysema expecting discharge
B.Bronchitis client receiving IV antibiotics
C.Bronchitis client with edema and neck vein distention
D.COPD client with abnormal PO2

76.A client has sustained a severe head injury and damaged the pre-occipital lobe. The nurse should remain particularly alert for which of the following problems?

A.Visual impairment
B.Swallowing difficulty
C.Impaired judgment
D.Hearing impairment

77.The nurse is caring for a client with epilepsy who is to receive phenytoin sodium (Dilantin) 100mg IV push. The client has an IV of D51/2NS infusing at 100mL/hr. When administering the Dilantin, which is the appropriate initial nursing action?

A.Obtain an ambu bag and put it at bedside.
B.Insert a 16g IV catheter.
C.Flush the IV line with normal saline.
D.Premedicate with promethiazine (phenergan) IV push.

78.A client with increased intracranial pressure is receiving Osmitrol (Mannitol) and Furosemide (Lasix). The nurse recognizes that these two drugs are given to reverse which effect?

A.Energy failure
B.Excessive intracellular calcium
C.Cellular edema
D.Excessive glutamate release

79.The nurse is assessing a client upon arrival to the emergency department. Partial airway obstruction is suspected. Which clinical manifestation is a late sign of airway obstruction?

A.Rales in lungs
B.Restless behavior
C.Cyanotic ear lobes
D.Inspiratory stridor

80.The nurse is working in the trauma unit of the emergency room when a 24-year-old female is admitted after an MVA. The client is bleeding profusely and a blood transfusion is ordered. Which would the nurse be prepared to administer without a type and crossmatch?

A.AB positive
B.AB negative
C.O positive
D.O negative

81.When preparing a client for magnetic resonance imaging, the nurse should implement which of the following?

A.Obtain informed consent and administer atropine 0.4mg.
B.Scrub the injection site for 15 minutes.
C.Remove any jewelry and inquire about metal implants.
D.Administer Benadryl 50mg/mL IV.

82.Upon admission to the hospital, a client reports having “the worst headache I’ve ever had.” The nurse should give the highest priority to which action?

A.Administering pain medication
B.Starting oxygen
C.Performing neuro checks
D.Inserting a Foley catheter

83.A client has an order to administer cisplatin (Platinol). Which drug would the nurse expect to be ordered to reduce renal toxicity from the cisplatin infusion?

A.Amifostine (Ethyol)
B.Dexrazoxane (Zinecard)
C.Mesna (Mesenex)
D.Pamidronate (Aredia)

84.The client is admitted to the ER with multiple rib fractures on the right. The nurse’s assessment reveals that an area over the right clavicle is puffy and that there is a “crackling” noise with palpation. The nurse should further assess the client for which of the following problems?

A.Flail chest
B.Subcutaneous emphysema
C.Infiltrated subclavian IV

85.A client has an order for Demerol 75mg and atropine 0.4mg IM as a preoperative medication. The Demerol vial contains 50mg/mL, and atropine is available 0.4mg/mL. How much medication will the nurse administer in total?

D.3.0 mLs

86.Nimodipine (Nimotop) is ordered for the client with a ruptured cerebral aneurysm. What does the nurse recognize as a desired effect of this drug?

A.Prevent the influx of calcium into cells.
B.Restore a normal blood pressure reading.
C.Prevent the inflammatory process.
D.Dissolve the clot that has formed.

87.A client is admitted to the hospital with seizures. The client has jerking of the right arm and twitching of the face, but is alert and aware of the seizure. This behavior is characteristic of which type of seizure?

B.Complex partial
C.Simple partial

88.The intensive care unit is full and the emergency room just called in a report on a ventilator-dependent client who is being admitted to the medical surgical unit. It would be essential that the nurse have which piece of equipment at the client’s bedside?

A.Cardiac monitor
B.Intravenous controller
C.Manual resuscitator
D.Oxygen by nasal cannula

89.The nurse is caring for a client on a ventilator that is set on intermittent mandatory ventilation (IMV). Assessment on the ventilator is IMV mode of eight breaths per minute. The nurse assesses the client’s respiratory rate of 13 per minute. What do these findings indicate?

A.The client is “fighting” the ventilator and needs medication.
B.Pressure support ventilation is being used.
C.Additional breaths are being delivered by the ventilator.
D.The client is breathing five additional breaths on his own.

90.The nurse has given instructions on pursed-lip breathing to a client with COPD. Which statement by the client would indicate effective teaching?

A.“I should inhale through my mouth very deeply.”
B.“I should tighten my abdominal muscles with inhalation.”
C.“I should contract my abdominal muscles with exhalation.”
D.“I should make inhalation twice as long as exhalation.”

91.A client is receiving aminophylline IV. The nurse monitors the theophylline blood level and assesses that the level is within therapeutic range at which of the following levels?


92.The nurse is assessing the arterial blood gases (ABG) of a chest trauma client with the results of pH 7.35, PO2 85, PCO2 55, and HCO3 27. What do these values indicate?

A.Uncompensated respiratory acidosis
B.Uncompensated metabolic acidosis
C.Compensated respiratory acidosis
D.Compensated metabolic acidosis

93.A pneumonectomy is performed on a client with lung cancer. Which of the following would probably be omitted from the client’s plan of care?

A.Closed chest drainage
B.Pain-control measures
C.Supplemental oxygen administration
D.Coughing and deep-breathing exercises

94.When planning the care for a client after a posterior fossa (infratentorial) craniotomy, which action is contraindicated?

A.Keeping the client flat on one side
B.Elevating the head of the bed 30°
C.Log-rolling or turning as a unit
D.Keeping the neck in a neutral position

95.The nurse is performing discharge teaching on a client with ulcerative colitis who has been placed on a low-residue diet. Which food would need to be eliminated from this client’s diet?

A.Roasted chicken
C.Cooked broccoli
D.Roast beef

96.The nurse is assisting a client with diverticulitis to select appropriate foods. Which food should be avoided?

B.Fresh peach
D.Dinner roll

97.A client is admitted with a possible bowel obstruction. Which question during the nursing history is least helpful in obtaining information regarding this diagnosis?

A.“Tell me about your pain.”
B.“What does your vomit look like?”
C.“Describe your usual diet.”
D.“Have you noticed an increase in abdominal size?”

98.The nurse is caring for a client with epilepsy who is being treated with carbamazepine (Tegretol). Which laboratory value might indicate a serious side effect of this drug?

A.BUN 10mg/dL
B.Hemoglobin 13.0gm/dL
C.WBC 4,000/mm3
D.Platelets 200,000/mm3

99.A client is admitted with a tumor in the parietal lobe. Which symptoms would be expected due to this tumor’s location?


100.A client weighing 150 pounds has received burns over 50% of his body at 1200 hours. Using the Parkland formula, calculate the expected amount of fluid that the client should receive by 2000 hours.


101.The nurse is caring for a client post-op femoral popliteal bypass graft. Which post-operative assessment finding would require immediate physician notification?

A.Edema of the extremity and pain at the incision site
B.A temperature of 99.6°F and redness of the incision
C.Serous drainage noted at the surgical area
D.A loss of posterior tibial and dorsalis pedis pulses

102.A client admitted with gastroenteritis and a potassium level of 2.9mEq/dL has been placed on telemetry. Which ECG finding would the nurse expect to find due to the client’s potassium results?

A.A depressed ST segment
B.An elevated T wave
C.An absent P wave
D.A flattened QRS

103.A client is experiencing acute abdominal pain. Which abdominal assessment sequence is appropriate for the nurse to use for examination of the abdomen?

A.Inspect, palpate, auscultate, percuss
B.Inspect, auscultate, percuss, palpate
C.Auscultate, inspect, palpate, percuss
D.Percuss, palpate, auscultate, inspect

104.The nurse is to administer a cleansing enema to a client scheduled for colon surgery. Which client position would be appropriate?

C.Left Sim’s
D.Dorsal recumbent

105.The nurse is caring for a client following a crushing injury to the chest. Which finding would be most indicative of a tension pneumothorax?

A.Expectoration of moderate amounts of frothy hemoptysis
B.Trachea shift toward the unaffected side of the chest
C.Subcutaneous emphysema noted at the anterior chest
D.Opening chest wound with a whistle sound emitting from the area

106.The nurse receives a report from the paramedic on four trauma victims. Which client would need to be treated first? A client with:

A.Lower rib fractures and a stable chest wall
B.Bruising on the anterior chest wall and a possible pulmonary contusion
C.Gun shot wound with open pneumothorax unstabilized
D.Dyspnea, stabilized with intubation and manual resuscitator

107.The nurse is discharging a client with asthma who has a prescription for zafirlukast (Accolate). Which comment by the client would indicate a need for further teaching?

A.“I should take this medication with meals.”
B.“I need to report flu-like symptoms to my doctor.”
C.“My doctor might order liver tests while I’m on this drug.”
D.“If I’m already having an asthma attack, this drug will not stop it.”

108.A client is four hours post-op left carotid endarterectomy. Which assessment finding would cause the nurse the most concern?

A.Temperature 99.4°F, heart rate 110, respiratory rate 24
B.Drowsiness, urinary output of 50mL in the past hour
C.BP 120/60, lethargic, right-sided weakness
D.Alert and oriented, BP 168/96, heart rate 70

109.The RN is making assignments on a 12-bed unit. Staff consists of one RN and two certified nursing assistants. Which client should be self-assigned?

A.A client receiving decadron for emphysema
B.A client with chest trauma and a new onset of hemoptysis
C.A client with rib fractures and an O2 saturation of 93%
D.A client two days post-operative lung surgery with a pulse oximetry of 92%

110.The nurse is accessing a venous access port of a client about to receive chemotherapy.

Place the following steps in proper sequential order.

A.Apply clean gloves.
B.Clean the skin with antimicrobial and let air dry.
C.Insert needle into port at a 90° angle.
D.Connect 10 mL NS into extension of huber needle and prime.
E.Instill heparin solution.
F.Stabilize the part by using middle and index fingers.
G.Wash hands and apply sterile gloves.
H.Inject saline and assess for infiltration.
I.Check placement of needle.

111.A client is being discharged on Coumadin after hospitalization for a deep vein thrombosis. The nurse recognizes that which food would be restricted while the client is on this medication?


112.Which assessment finding in a client with COPD indicates to the nurse that the respiratory problem is chronic?

A.Wheezing on exhalation
B.Productive cough
C.Clubbing of fingers
D.Generalized cyanosis

113.A client who has just undergone a laparoscopic cholecystectomy complains of “free air pain.” What would be your best action?

A.Ambulate the client.
B.Instruct the client to breathe deeply and cough.
C.Maintain the client on bed rest with his legs elevated.
D.Insert an NG tube.

114.The RN is planning client assignments. Which is the least appropriate task for the nursing assistant?

A.Assisting a COPD client admitted two days ago to get up in the chair.
B.Feeding a client with bronchitis who is paralyzed on the right side.
C.Accompanying a discharged emphysema client to the transportation area.
D.Assessing an emphysema client complaining of difficulty breathing.

115.When providing care for a client with pancreatitis, the nurse would anticipate which of the following orders?

A.Force fluids to 3,000mL/24 hours.
B.Insert a nasogastric tube to low intermittent suction.
C.Place the client in reverse Trendelenburg position.
D.Place the client in enteric isolation.

116.The nurse is performing a neurological assessment on a client admitted with TIAs. Assessment findings reveal an absence of the gag reflex. The nurse suspects injury to which of the following cranial nerves?

A.XII (hypoglossal)
B.X (vagus)
C.IX (glossopharyngeal)
D.VII (facial)

117.The nurse arrives at a motorcycle accident and finds the client unresponsive, apneic, and pulseless. After calling for a spectator to help, what would be the nurse’s next action?

A.Ventilate with a mouth-to-mask device.
B.Begin chest compressions.
C.Administer a precordial thump.
D.Open the client’s airway.

118.A client with gallstones and obstructive jaundice is experiencing severe itching. The physician has prescribed cholestyramine (Questran). The client asks, “How does this drug work?” What is the nurse’s best response?

A.“It blocks histamine, reducing the allergic response.”
B.“It inhibits the enzyme responsible for bile excretion.”
C.“It decreases the amount of bile in the gallbladder.”
D.“It binds with bile acids and is excreted in bowel movements with stool.”

119.A client with inflammatory bowel disease (IBD) requires an ileostomy. The nurse would instruct the client to do which of the following measures as an essential part of caring for the stoma?

A.Perform massage of the stoma three times a day.
B.Include high-fiber foods in the diet, especially nuts.
C.Limit fluid intake to prevent loose stools.
D.Cleanse the peristomal skin meticulously.

120.Diphenoxylate hydrochloride and atropine sulfate (Lomotil) is prescribed for the client with ulcerative colitis. Which of the following nursing observations indicates that the drug is having a therapeutic effect?

A.There is an absence of peristalsis.
B.The number of diarrhea stools decreases.
C.Cramping in the abdomen has increased.
D.Abdominal girth size increases.

121.A nurse is assisting the physician with chest tube removal. Which client instruction is appropriate during removal of the tube?

A.Take a deep breath, exhale, and bear down.
B.Hold the breath for two minutes and exhale slowly.
C.Exhale upon actual removal of the tube.
D.Continually breathe deeply in and out during removal.

122.A client with advanced Alzheimer’s disease has been prescribed haloperidol (Haldol). What clinical manifestation suggests that the client is experiencing side effects from this medication?

D.Pitting edema

123.A student in a cardiac unit is performing auscultation of a client’s heart. Which stethoscope placement would indicate to the nurse that the student is performing pulmonic auscultation correctly?

A.Between the apex and the sternum
B.At the fifth intercostal space at the left midclavicular line
C.At the second intercostal space, left of the sternum
D.At the manubrium area of the chest

124.A client with Alzheimer’s disease has been prescribed donepezil (Aricept). Which information should the nurse include in the teaching plan for a client on Aricept?

A.“Take the medication with meals.”
B.“The medicine can cause dizziness, so rise slowly.”
C.“If a dose is skipped, take two the next time.”
D.“The pill can cause an increase in heart rate.”

125.A client who had major abdominal surgery is having delayed healing of the wound. Which laboratory test result would most closely correlate with this problem?

A.Decreased albumin
B.Decreased creatinine
C.Increased calcium
D.Increased sodium

126.A client is admitted to the medical-surgical unit with a report of severe hematemesis. What is the priority nursing action?

A.Performing an assessment
B.Obtaining a blood permit
C.Initiating an IV
D.Inserting an NG tube

127.The nurse caring for a client with a suspected peptic ulcer recognizes which exam as the one most reliable in diagnosing the disease?

A.Upper-gastrointestinal x-ray
B.Gastric analysis
C.Endoscopy procedure
D.Barium studies x-ray

128.On the second post-operative day after a subtotal thyroidectomy, the client tells the nurse, “I feel numbness and my face is twitching.” What is the nurse’s best initial action?

A.Offer mouth care.
B.Loosen the neck dressing.
C.Notify the physician.
D.Document the finding as the only action.

129.A client with adult respiratory distress syndrome has been placed on mechanical ventilation with PEEP. Which finding would indicate to the nurse that the client is experiencing the undesirable effect of an increase in airway and chest pressure?

A.A PO2 of 88
B.Rales on auscultation
C.Blood pressure decrease to 90/48 from 120/70
D.A decrease in spontaneous respirations

130.A nurse is teaching a group of teenagers the correct technique for applying a condom. Which point would the nurse include in the teaching plan?

A.The condom can be reused one time.
B.Unroll the condom all the way over the erect penis.
C.Apply petroleum jelly to reduce irritation.
D.Place water in the tip of the condom before use.

131.A client with rheumatoid arthritis is being discharged with a prescription for etanercept (Enbrel). Which should the nurse teach the client to report immediately?

A.Redness, itching, edema at injection site
B.Exposure to chickenpox or shingles

132.The nurse in the ER has received report of four clients en route to the emergency department. Which client should the nurse see first? A client with:

A.Third-degree burns to the face and neck area, with singed nasal hairs
B.Second-degree burns to each leg and thigh area, who is alert and oriented
C.A chemical burn that has been removed and liberally flushed before admission
D.An electrical burn entering and leaving on the same side of the body

133.Which clinical manifestations would the nurse expect a client with a diagnosis of acute osteomyelitis to exhibit? Select all that apply.

A.Leukemia and normal sedimentation rate
B.Pain and fever
C.Low blood count
D.Tenderness in affected area
E.Edema and pus from the wound

134.The nurse recognizes which of the following clients as having the highest risk for pulmonary complications after surgery?

A.A 24-year-old with open reduction internal fixation of the ulnar
B.A 45-year-old with an open cholecystectomy
C.A 36-year-old after a hysterectomy
D.A 50-year-old after a lumbar laminectomy

135.Which clinical manifestation is most indicative to the nurse that a possible carbon monoxide poisoning has occurred?

A.Pulse oximetry reading of 80%
B.Expiratory stridor and nasal flaring
C.Cherry red color to the mucous membranes
D.Presence of carbonaceous particles in the sputum

136.A client is admitted with a ruptured spleen following a four-wheeler accident. In preparation for surgery, the nurse suspects that the client is in the compensatory stage of shock because of which clinical manifestation?

A.Blood pressure 120/70, confusion, heart rate 120
B.Crackles on chest auscultation, mottled skin, lethargy
C.Jaundice, urine output less than 30mL in the past hour, heart rate 170
D.Rapid shallow respirations, unconscious, petechiae anterior chest

137.A client reports to the nurse that he believes he has an ulcer and wants to be checked for H. pylori. Which of the following medications in the client’s history would make the test invalid?

A.Omeprazole (Prilosec)
B.Furosemide (Lasix)
C.Propoxyphene napsylate (Darvocet)
D.Ibuprofen (Advil)

138.A client arrives in the emergency room with severe burns of the hands, right arm, face, and neck. The nurse needs to start an IV. Which site would be most suitable for this client?

A.Top of client’s right hand
B.Left antecubital fossa
C.Top of either foot
D.Left forearm

139.Which client clinical manifestation during a bone marrow transplantation procedure alerts the nurse to the possibility of an adverse reaction?

B.Red colored urine
D.Shortness of breath

140.The nurse is assessing the integumentary system of a dark-skinned individual. Which area would be the most likely to show a skin cancer lesion?


141.A client with a gastrointestinal bleed has an NG tube to low continuous wall suction. Which technique is the correct procedure for the nurse to utilize when assessing bowel sounds?

A.Obtain a sample of the NG drainage and test the pH.
B.Clamp the tube while listening to the abdomen with a stethoscope.
C.Irrigate the tube with 30mL of NS while auscultating the abdomen.
D.Turn the suction on high and auscultate over the naval area.

142.A burn client’s care plan reveals an expected outcome of no localized or systemic infection. Which assessment by the nurse supports this outcome?

A.Wound culture results showing minimal bacteria
B.Cloudy, foul-smelling urine
C.White blood cell count of 14,000/mm3
D.Temperature elevation of 101°F

143.The nurse is discharging a client with a prescription of eyedrops. Which observation by the nurse would indicate a need for further client teaching?

A.Shaking of the suspension to mix the medication
B.Administering a second eyedrop medication immediately after the first one was instilled
C.Washing the hands before and after the administration of the drops
D.Holding the lower lid down without pressing the eyeball to instill the drops

144.The nurse is caring for a client with pneumonia who is allergic to penicillin. Which antibiotic is safest to administer to this client?

A.Cefazolin (Ancef)
C.Erythrocin (Erythromycin)
D.Ceftriaxone (Rocephin)

145.The nurse notes the following laboratory test results on a 24-hour post-burn client. Which abnormality should be reported to the physician immediately?

A.Potassium 7.5mEq/L
B.Sodium 131mEq/L
C.Arterial pH 7.34
D.Hematocrit 52%

146.The nurse is observing a student nurse administering ear drops to a two-year-old. Which observation by the nurse would indicate correct technique?

A.Holds the child’s head up and extended
B.Places the head in chin-tuck position
C.Pulls the pinna down and back
D.Irrigates the ear before administering medication

147.The nurse is caring for a client with scalding burns across the face, neck, upper half of the anterior chest, and entire right arm. Using the rule of nines, estimate the percentage of body burned.


148.The nurse caring for a client in shock recognizes that the glomerular filtration rate of the kidneys will fail if the client’s mean arterial pressure falls below which of the following levels?


149.The nurse is caring for a child with a diagnosis of possible hydrocephalus. Which assessment data on the admission history would be the most objective?

C.Head measurement
D.Temperature reading

150.A client is admitted after a motor vehicle accident. Based on the following results, what physician’s prescription will the nurse anticipate?

CBCChemistry profileArterial blood gases (ABGs)
Hgb 13.6g/dLPotassium 3.9 mEq/LpH 7.23
Hct 42%Chloride 102 mEq/LpC02 63
WBC 8000/mm3 (script)Glucose 100mg/dLHCO3 23 mEq/L
Platelets 250,000 P02 50
  02 saturation 84

A.Blood transfusion
B.Potassium IVPB
C.Mechanical ventilator
D.Platelet transfusion

151.The nurse is caring for a client after a burn. Which assessment finding best indicates that the client’s respiratory efforts are currently adequate?

A.The client is able to talk.
B.The client is alert and oriented.
C.The client’s O2 saturation is 97%.
D.The client’s chest movements are uninhibited.

152.The nurse is performing discharge teaching to the parents of a seven-year-old who has been diagnosed with asthma. Which sports activity would be most appropriate for this client?


153.The leukemic client is prescribed a low-bacteria diet. Which does the nurse expect to be included in this diet?

A.Cooked spinach and sautéed celery
B.Lettuce and alfalfa sprouts
C.Fresh strawberries and whipped cream
D.Raw cauliflower or broccoli

154.A child is to receive heparin sodium five units per kilogram of body weight by subcutaneous route every four hours. The child weighs 52.8 lb. How many units should the child receive in a 24-hour period?


155.A client with cancer is experiencing a common side effect of chemotherapy administration. Which laboratory assessment finding would cause the most concern?

A.A sodium level of 50mg/dL
B.A blood glucose of 110mg/dL
C.A platelet count of 100,000/mm3
D.A white cell count of 5,000/mm3

156.A client’s admission history reveals complaints of fatigue, chronic sore throat, and enlarged lymph nodes in the axilla and neck. Which exam would assist the physician to make a tentative diagnosis of leukemia?

A.A complete blood count
B.An x-ray of the chest
C.A bone marrow aspiration
D.A CT scan of the abdomen

157.A client is admitted with symptoms of vertigo and syncope. Diagnostic tests indicate left subclavian artery obstruction. What additional findings would the nurse expect?

A.Memory loss and disorientation
B.Numbness in the face, mouth, and tongue
C.Radial pulse differences over 10bpm
D.Frontal headache with associated nausea or emesis

158.The nurse is performing discharge teaching on a client at high risk for the development of skin cancer. Which instruction should be included in the client teaching?

A.“You should see the doctor every six months.”
B.“Sunbathing should be done between the hours of noon and 3 p.m.”
C.“If you have a mole, it should be removed and biopsied.”
D.“You should wear sunscreen when going outside.”

159.A client with pancreatitis has been transferred to the intensive care unit. The nurse assesses a pulmonary arterial wedge pressure (PAWP) of 14mmHg. Based on this finding, the nurse would want to further assess for what additional correlating wedge pressure data?

A.A drop in blood pressure
B.Rales on chest auscultation
C.A temperature elevation
D.Dry mucous membranes

160.The nurse is caring for a client with a diagnosis of hepatitis who is experiencing pruritis. Which would be the most appropriate nursing intervention?

A.Suggest that the client take warm showers.
B.Add baby oil to the client’s bath water.
C.Apply powder to the client’s skin.
D.Suggest a hot-water rinse after bathing.

161.The school nurse assessed and referred a 14-year-old with scoliosis. An 18° curvature of the spine was diagnosed. Which treatment plan would the nurse expect?

A.Application of a Milwaukee brace
B.Electrical stimulation to the outward side of the curve
C.Re-evaluation, with no treatment at this time
D.Surgical realignment of the spine

162.The physician has ordered a homocysteine blood level on a client. The nurse recognizes that the results will be increased in a client with a deficiency in which of the following:

A.Vitamin B12
B.Vitamin C
C.Vitamin A
D.Vitamin E

163.The registered nurse is assigning staff for four clients on the 3–11 shift. Which client should be assigned to the LPN?

A.A client with a diagnosis of adult respiratory distress syndrome (ARDS) who was transferred from the critical care unit at 1400
B.A one-hour post-operative colon resection
C.A client with pneumonia expecting discharge in the morning
D.A client with cirrhosis of the liver experiencing bleeding from esophageal varices

164.A client with multiple sclerosis has an order to receive Solu Medrol 200mg IV push. The available dose is Solu Medrol 250mg per mL. How much medication will the nurse administer?

A.0.5 mL
B.0.8 mL
C.1.1 mL
D.1.4 mL

165.The nurse is obtaining a history on a 74-year-old client. Which statement made by the client would most alert the nurse to a possible fluid and electrolyte imbalance?

A.“My skin is always so dry.”
B.“I often use a laxative for constipation.”
C.“I have always liked to drink a lot of water.”
D.“I sometimes have a problem with dribbling urine.”

166.The nurse is caring for a client in the acute care unit. Initial laboratory values reveal serum sodium of 156mEq/L. What behavior changes would the nurse expect the client to exhibit?

B.Manic behavior
D.Muscle cramps

167.The nurse is completing the preoperative checklist on a client scheduled for surgery and finds that the consent form has been signed, but the client is unclear about the surgery and possible complications. Which is the most appropriate action?

A.Call the surgeon and ask him to come see the client to clarify the information.
B.Explain the procedure and complications to the client.
C.Check in the physician’s progress notes to see if understanding has been documented.
D.Check with the client’s family to see if they understand the procedure fully.

168.When preparing a client for admission to the surgical suite, the nurse recognizes that which one of the following items is most important to remove before sending the client to surgery?

A.Hearing aid
B.Contact lenses
C.Wedding ring

169.A client with cancer is to undergo a bone scan. The nurse should perform which of the following actions?

A.Force fluids 24 hours before the procedure is scheduled to begin.
B.Ask the client to void immediately before the study.
C.Hold medication that affects the central nervous system for 12 hours pre- and post-test.
D.Cover the client’s reproductive organs with an x-ray shield during the procedure.

170.A client with suspected leukemia is to undergo a bone marrow aspiration. The nurse plans to include which statement in the teaching session?

A.“You will be lying on your abdomen for the examination procedure.”
B.“Portions of the procedure will cause pain or discomfort.”
C.“You will be given some medication to cause amnesia of the test.”
D.“You will not be able to drink fluids for 24 hours before the study.”

171.The nurse is caring for a client scheduled for a surgical repair of an abdominal aortic aneurysm. Which assessment is most crucial during the preoperative period?

A.Assessment of the client’s level of anxiety
B.Evaluation of the client’s exercise tolerance
C.Identification of peripheral pulses
D.Assessment of bowel sounds and activity

172.The nurse should carefully monitor the client for which common dysrhythmia that can occur during suctioning?

C.Ventricular ectopic beats
D.Sick sinus syndrome

173.The nurse is performing discharge instruction for a client with an implantable permanent pacemaker. What discharge instruction is an essential part of the plan?

A.“You cannot eat food prepared in a microwave.”
B.“You should avoid moving the shoulder on the side of the pacemaker site for six weeks.”
C.“You will have to learn to take your own pulse.”
D.“You will not be able to fly on a commercial airliner with the pacemaker in place.”

174.The nurse is completing admission on a client with possible esophageal cancer. Which finding would not be common for this diagnosis?

A.Foul breath
D.Chronic hiccups

175.A client arrives from surgery following an abdominal perineal resection with a permanent ileostomy. What should be the priority nursing care during the post-op period?

A.Teaching how to irrigate the ileostomy
B.Stopping electrolyte loss through the stoma
C.Encouraging a high-fiber diet
D.Facilitating perineal wound drainage

176.The nurse is making initial rounds on a client with a C5 fracture. The client is in a halo vest and is receiving O2 at 40% via mask to a tracheostomy. Assessment reveals a respiratory rate of 40 and O2 saturation of 88. The client is restless. Which initial nursing action is most indicated?

A.Notifying the physician
B.Performing tracheal suctioning
C.Repositioning the client to the left side
D.Rechecking the client’s O2 saturation

177.A client has just finished her lunch, consisting of shrimp with rice, fruit salad, and a roll. The client calls for the nurse, stating, “My throat feels thick and I’m having trouble breathing.” What action should the nurse implement first?

A.Place the bed in Trendelenburg position and call the physician.
B.Take the client’s vital signs and administer Benadryl 50mg PO.
C.Place the bed in high Fowler’s position and call the physician.
D.Start an Aminophylline drip and call the physician.

178.The nurse is caring for a client with cirrhosis of the liver. Which is the best method to use for determining that the client has ascites?

A.Inspection of the abdomen for enlargement
B.Bimanual palpation for hepatomegaly
C.Daily measurement of abdominal girth
D.Assessment for a fluid wave

179.A client arrives in the emergency room after a motor vehicle accident. Witnesses tell the nurse that they observed the client’s head hit the side of the car door. Nursing assessment findings include BP 70/34, heart rate 130, and respirations 22. Based on the information provided, which is the priority nursing care focus?

A.Brain tissue perfusion
B.Regaining fluid volume
C.Clearance of the client’s airway
D.Measures to increase sensation

180.The home health nurse is visiting a 30-year-old with sickle cell disease. Assessment findings include spleenomegaly. What information obtained on the visit would cause the most concern? The client:

A.Eats fast food daily for lunch
B.Drinks a beer occasionally
C.Sometimes feels fatigued
D.Works as a furniture mover

181.The nurse on the oncology unit is caring for a client with a WBC of 1500/mm3. During evening visitation, a visitor brings in a fruit basket. What action should the nurse take?

A.Encourage the client to eat small snacks of the fruit.
B.Remove fruits that are not high in vitamin C.
C.Instruct the client to avoid the high-fiber fruits.
D.Remove the fruits from the client’s room.

182.The nurse is giving an end-of-shift report when a client with a chest tube is noted in the hallway with the tube disconnected. What is the most appropriate action?

A.Clamp the chest tube immediately.
B.Put the end of the chest tube into a cup of sterile normal saline.
C.Assist the client back to the room and place him on his left side.
D.Reconnect the chest tube to the chest tube system.

183.A client with deep vein thrombosis is receiving a continuous heparin infusion and Coumadin PO. INR lab test result is 8.0. Which intervention would be most important to include in the nursing care plan?

A.Assess for signs of abnormal bleeding.
B.Anticipate an increase in the heparin drip rate.
C.Instruct the client regarding the drug therapy.
D.Increase the frequency of vascular assessments.

184.Which breakfast selection by a client with osteoporosis indicates that the client understands the dietary management of the disease?

A.Scrambled eggs, toast, and coffee
B.Bran muffin with margarine
C.Granola bar and half of a grapefruit
D.Bagel with jam and skim milk

185.A client with hepatitis C who has cirrhosis changes has just returned from a liver biopsy. The nurse will place the client in which position?

C.Right side-lying
D.Left Sim’s

186.The nurse is caring for a client who was admitted to the burn unit four hours after the injury with second-degree burns to the trunk and head. Which finding would the nurse least expect to find during this time period?

B.Laryngeal edema

187.The nurse is evaluating nutritional outcomes for a client with anorexia nervosa. Which one of the following is the most objective favorable outcome for the client?

A.The client eats all the food on her tray.
B.The client requests that family bring special foods.
C.The client’s weight has increased.
D.The client weighs herself each morning.

188.The client who is two weeks post-burn with a 40% deep partial-thickness injury still has open wounds. The nurse’s assessment reveals the following findings: temperature 96.5°F, BP 87/40, and severe diarrhea stools. What problem does the nurse most likely suspect?

A.Findings are normal, not suspicious of a problem
B.Systemic gram—positive infection
C.Systemic gram—negative infection
D.Systemic fungal infection

189.The nurse assesses a new order for a blood transfusion. The order is to transfuse one unit of packed red blood cells (contains 250mL) in a two-hour period. What will be the hourly rate of infusion?


190.A client has signs of increased intracranial pressure. Which one of the following is an early indicator of deterioration in the client’s condition?

A.Widening pulse pressure
B.Decrease in the pulse rate
C.Dilated, fixed pupils
D.Decrease in level of consciousness

191.Which of the following statements by a client with a seizure disorder who is taking topiramate (Topamax) indicates that the client has understood the nurse’s instruction?

A.“I will take the medicine before going to bed.”
B.“I will drink 8 to 10 ten-ounce glasses of water a day.”
C.“I will eat plenty of fresh fruits.”
D.“I must take the medicine with a meal or snack.”

192.A client with terminal lung cancer is admitted to the unit. A family member asks the nurse, “How much longer will it be?” Which response by the nurse is most appropriate?

A.“This must be a terrible situation for you.”
B.“I don’t know. I’ll call the doctor.”
C.“I cannot say exactly. What are your concerns at this time?”
D.“Don’t worry, from the way things look it will be very soon.”

193.A client with a history of colon cancer is admitted to the oncology unit. Laboratory results reveal a WBC of 1600/mm3. What plans will the nurse add to the care plan because of the WBC reading? Select all that apply.

A.No sick visitors
B.Private room necessary
C.No Aspirin products
D.Low bacteria diet
E.Electric razors only

194.The nurse is caring for a client with a closed head injury. Fluid is assessed leaking from the ear. What is the nurse’s first action?

A.Irrigate the ear canal gently.
B.Notify the physician.
C.Test the drainage for glucose.
D.Apply an occlusive dressing.

195.The nurse has inserted an NG tube for enteral feedings. Which assessment result is the best indicator of the tube’s stomach placement?

A.Aspiration of tan-colored mucus
B.Green aspirate with a pH of 3
C.A swish auscultated with the injection of air
D.Bubbling noted when the end of the tube is placed in liquid

196.The nurse would identify which one of the following assessment findings as a normal response in a craniotomy client post-operatively?

A.A decrease in responsiveness the third post-op day
B.Sluggish pupil reaction the first 24–48 hours
C.Dressing changes three to four times a day for the first three days
D.Temperature range of 98.8°F to 99.6°F the first 2–3 days

197.A client with alcoholism has been instructed to increase his intake of thiamine. The nurse knows the client understands the instructions when he selects which food?

A.Roast beef
B.Broiled fish
C.Baked chicken
D.Sliced pork

198.The nurse is caring for a client who abuses narcotics. The client is exhibiting a respiratory rate of 10 and dilated pupils. Which drug would the nurse expect to administer?

A.Meperidine (Demerol)
B.Naloxone (Narcan)
C.Chlordiazepoxide (Librium)
D.Haloperidol (Haldol)

199.A client has a CVP monitor in place via a central line. Which would be included in the nursing care plan for this client?

A.Notify the physician of readings less than 3cm or more than 8cm of water.
B.Use the clean technique to change the dressing at the insertion site.
C.Elevate the head of the bed to 90° to obtain CVP readings.
D.The 0 mark on the manometer should align with the client’s right clavicle for the readings.

200.A client is admitted to the chemical dependency unit for poly-drug abuse. The client states, “I don’t know why you are all so worried; I am in control. I don’t have a problem.” Which defense mechanism is being utilized?


201.A client scheduled for a carotid endarterectomy requires insertion of an intra-arterial blood pressure-monitoring device. The nurse plans to perform the Allen test. Which observation indicates patency of the ulnar artery?

A.Blanching of the hand on compression and release of the ulnar artery
B.Muscular twitching of the bicep muscle with use of a tourniquet at the wrist
C.Hand turning pink after the nurse releases the pressure on the ulnar artery
D.Flexion of the wrist when tapping the ulnar artery with a reflex hammer

202.A client’s chest tube drainage device has continuous bubbling in the water seal chamber. What is the nurse checking for when she clamps different areas of the tube to find out where the bubbling stops?

A.An air leak in the system
B.The suction being too high
C.The suction being too low
D.A tension pneumothorax

203.The nurse should be particularly alert for which one of the following problems in a client with barbiturate overdose?

B.Cardiac tamponade

204.A client taking the drug disulfiram (Antabuse) is admitted to the ER. Which clinical manifestations are most indicative of recent alcohol ingestion?

A.Vomiting, heart rate 120, chest pain
B.Nausea, mild headache, bradycardia
C.Respirations 16, heart rate 62, diarrhea
D.Temp 101°F, tachycardia, respirations 20

205.A client with cancer and metastasis to the bone is admitted to the hospital. Which symptom of hypercalcemia causes the nurse the most concern?

C.Flaccid muscles
D.Cardiac changes

206.The nurse expects that a client with cocaine addiction would most likely be placed on which medication?

A.Amantidine (Symmetrel)
D.Disulfiram (Antabuse)

207.The nurse is reviewing the laboratory values of a client with a myocardial infarction. Which laboratory test is used to identify injury to the myocardium and can remain elevated for up to three weeks?

A.Total CK
D.Troponin T or I

208.A client with newly diagnosed epilepsy tells the nurse, “If I keep having seizures, I’m scared my husband will feel differently toward me.” Which response by the nurse would be most appropriate?

A.“You don’t know if you’ll ever have another seizure. Why don’t you wait and see what happens?”
B.“You seem to be concerned that there could be a change in the relationship with your husband.”
C.“You should focus on your children. They need you.”
D.“Let’s see how your husband reacts before getting upset.”

209.While interviewing a client who abuses alcohol, the nurse learns that the client has experienced “blackouts.” The wife asks what this means. What is the nurse’s best response at this time?

A.“Your husband has experienced short-term memory amnesia.”
B.“Your husband has experienced loss of remote memory.”
C.“Your husband has experienced a loss of consciousness.”
D.“Your husband has experienced a fainting spell.”

210.Which would the nurse include in the nursing care plan of a client experiencing severe delirium tremens?

A.Placing the client in a darkened room
B.Keeping the closet and bathroom doors closed
C.Administering a diuretic to decrease fluid excess
D.Checking vital signs every eight hours

211.The nurse is caring for a client admitted with a diagnosis of epilepsy. The client begins to have a seizure. Which action by the nurse is contraindicated?

A.Turning the client to the side-lying position
B.Inserting a padded tongue blade and oral airway
C.Loosening restrictive clothing
D.Removing the pillow and raising padded side rails

212.A client has been placed on the drug valproic acid (Depakene). Which would indicate to the nurse that the client is experiencing an adverse reaction to this medication?

B.Poor skin turgor
D.Reported visual disturbances

213.A client has an order for vancomycin (Vancocin) 1 gram IVPB in 250 mL normal saline to infuse over 60 minutes. The nurse would set the IV drop rate to deliver how many drops per minute if the IV set delivers 15gtts/mL? Fill in the blank


214.The nurse is performing fluid resuscitation on a burn client. Which piece of assessment data is the best indicator that it is effective?

A.Respirations 24, unlabored
B.Urine output of 30ml/hr
C.Capillary refill < 4 seconds
D.Apical pulse of 110/min

215.A client diagnosed with COPD is receiving theophylline (Theodur). Morning laboratory values reveal a theophylline level of 38mcg/mL. Which is the most appropriate nursing action?

A.Take no action; this is within normal range.
B.Notify the physician of the level results.
C.Administer Narcan 2mg IV push stat.
D.Give the client an extra dose of the medication.

216.A client has suffered a severe electrical burn. Which medication would the nurse expect to have ordered for application to the burned area?

A.Mafenide acetate (Sulfamylon)
B.Silver nitrate
C.Providone-iodine ointment
D.Silver sulfadiazine (Silvadene)

217.A client with a head injury develops syndrome of inappropriate antidiuretic hormone (SIADH). Which physician prescription would the nurse question?

A.D5W at 200mL/hr
B.Demeclocycline (Declomycin) 150mg Q6h
C.Daily weights
D.Monitor intake and output

218.The nurse is caring for a postpartum client. Which of the following assessment findings would be a reason for concern during the client’s postpartum stay?

A.Pulse rate of 70–90 the third postpartum day
B.Diuresis her second and third postpartum days
C.Vaginal discharge of rubra, serosa, then rubra
D.Diaphoresis her third postpartum day

219.The nurse is caring for a postpartum client two hours post-delivery who is unable to void. Which of the following nursing interventions should be considered first?

A.Insert a straight catheter for residual.
B.Encourage oral intake of fluids.
C.Check perineum for swelling or hematoma.
D.Palpate bladder for distention and position.

220.A client is admitted to the intensive care unit after falling on an icy sidewalk and striking the right side of the head. An MRI revealed a right-sided epidural hematoma. Which physical force explains the location of the client’s injury?


221.The nurse is preparing to teach a client about phenytoin sodium (Dilantin). Which fact would be most important to teach the client regarding why the drug should not be stopped suddenly?

A.Physical dependence can develop over time.
B.Status epilepticus can develop.
C.A hypoglycemic reaction can develop.
D.Heart block can develop.

222.One week after discharge of a postpartum client, the client’s husband calls the postpartum unit and asks the nurse, “Is it normal for my wife to cry at the drop of a hat? I’m worried I’ve done something to upset her.” What is the nurse’s best initial response?

A.“Have you noticed any pattern to her periods of crying?”
B.“Try not to worry about it. I’m sure it’s just the postpartum blues.”
C.“Can you think of something you might have done to upset her?”
D.“Let’s consider some of the ways you can decrease her depression.”

223.A client is admitted with suspected Guillain-Barre syndrome. The nurse would expect the cerebrospinal fluid (CSF) analysis to reveal which of the following to confirm the diagnosis?

A.CSF protein 10mg/dL and WBC 2 cells/mm3
B.CSF protein of 60mg/dL and WBC 0 cells/mm3
C.CSF protein of 50mg/dL and WBC 20 cells/mm3
D.CSF protein of 5mg/dL and WBC 20 cells/mm3

224.A client with burns is admitted and fluid resuscitation has begun. The client’s CVP reading is 14cm/H2O. Which evaluation by the nurse would be most accurate?

A.The client has received enough fluid.
B.The client’s fluid status is unaltered.
C.The client has inadequate fluids.
D.The client has a volume excess.

225.The nurse is working on a neurological unit. If the following events occur simultaneously, which would receive RN priority?

A.A client with a cerebral aneurysm complains of sudden weakness on the right side.
B.A client with a suspected brain tumor complains of a frontal type headache.
C.A client post-op lumbar laminectomy vomits.
D.A client with Guillain-Barre syndrome has a temperature elevation.

226.The nurse assesses a client’s fundal height every 15 minutes during the first hour postpartum. What should the height of the fundus be during this hour ?

A.1–2 fingerbreadths under the umbilicus
B.four fingerbreadths under the umbilicus fingerbreadth above the umbilicus
D.four fingerbreadths above the umbilicus

227.The nurse assesses a client complaining of a headache. When the nurse shines a light on the frontal and maxillary sinuses, the light does not penetrate the tissues. What is the best interpretation of this finding?

A.This is a normal finding indicating no problem.
B.Inflammation is present in the sinuses.
C.The cavity likely contains fluid or pus.
D.The client has a sinus infection.

228.A client with chronic obstructive pulmonary disease (COPD) is admitted to the respiratory unit. Which physician prescription should the nurse question?

A.O2 at 5L/min by nasal cannula
B.Solu Medrol 125mg IV push every six hours
C.Ceftriaxone (Rocephin) 1gram IVPB daily
D.Darvocet N 100 po prn pain

229.A burn client begins treatments with silver sulfadiazine (Silvadene) applied to the wounds. The nurse should carefully monitor for which adverse affect associated with this drug?


230.The nurse is caring for clients on the postpartum unit. Which of the following should the nurse assess first?

A.A primapara who has delivered an 8-pound baby boy
B.A gravida IV para IV who experienced one hour of labor
C.A gravida II para II whose placenta was delivered 10 minutes after the infant
D.A primapara receiving 100mg of meperidine (Demerol) during her laboring experience

231.The nurse is assessing a client for tactile fremitus. Which of the following diagnoses would most likely reveal a decrease in tactile fremitus?

B.Bronchial pneumonia
D.Lung tumor

232.A client who has been diagnosed with lung cancer is starting a smoking-cessation program. Which of the following drugs would the nurse expect to be included in the program’s plan?

A.Bupropion SR (Zyban)
B.Metaproterenol (Alupent)
C.Oxitropuim (Oxivent)
D.Alprazolam (Xanax)

233.A client delivered a nine-pound infant two hours ago. The client has an IV of D5W with oxytocin. The nurse determines that the medication is achieving the desired effect when which of the following is assessed?

A.A rise in blood pressure
B.A decrease in pain
C.An increase in lochia rubra
D.A firm uterine fundus

234.The nurse is evaluating cerebral perfusion outcomes for a client with a subdural hematoma. The nurse evaluates which of the following as a favorable outcome for this client?

A.Arterial blood gas PO2 of 98
B.Increase in lethargy
C.Pupils slow to react to light
D.Temperature of 101°F

235.The nurse is caring for a client with COPD. Which of the associated disorders has changes that are reversible?

D.Chronic bronchitis

236.A client experienced a major burn over 55% of his body 36 hours ago. The client is restless and anxious, and states, “I am in pain.” There is a physician prescription for intravenous morphine. What should the nurse do first?

A.Administer the morphine
B.Assess respirations
C.Assess urine output
D.Check serum potassium levels

237.The nurse is caring for a client seven days post-burn injury with 60% body surface area involved. What should be the primary focus of nursing care during this time period?

A.Meticulous infection-control measures
B.Fluid-replacement evaluation
C.Psychological adjustment to the wound
D.Measurement and application of a pressure garment

238.The nurse is preparing a teaching plan for a client beginning external radiation treatments. Which of the following will be included in the teaching plan? Select all that apply.

A.Space activities with rest periods.
B.Avoid spicy and hot foods.
C.Expose radiated areas to sunlight daily.
D.Use moisturizers on skin.
E.Expect to have difficulty swallowing.

239.The nurse is performing discharge teaching for a client after a cardiac catheterization. Which statement by the client indicates a need for further teaching?

A.“I should not bend, strain, or lift heavy objects for one day.”
B.“If bleeding occurs, I should place an ice bag on the site for 10 minutes.”
C.“I need to call the doctor if my temperature goes above 101°F.”
D.“I should talk to the doctor to find out when I can go back to work.”

240.A burn client is in the acute phase of burn care. The nurse assesses jugular vein distention, edema, urine output of 20 mLin two hours, and crackles on auscultation. Which order would the nurse anticipate from the physician?

A.Furosemide (Lasix) 40 mg IV push
B.Irrigate the Foley catheter
C.Increase the IV fluids to 200mL/hr
D.Place the client in Trendelenburg position

241.The nurse is suctioning a tracheostomy, what is the maximum suction pressure the nurse should use?


242.A client admitted with transient ischemia attacks has returned from a cerebral arteriogram. The nurse performs an assessment and finds a newly formed hematoma in the right groin area. What is the nurse’s initial action?

A.Apply direct pressure to the site.
B.Check the pedal pulses on the right leg.
C.Notify the physician.
D.Turn the client to the prone position.

243.The nurse is assessing an ECG strip of a 42-year-old client and finds a regular rate greater than 100, a normal QRS complex, a normal P wave in front of each QRS, a PR interval between 0.12 and 0.20 seconds, and a P: QRS ratio of 1:1. What is the nurse’s interpretation of this rhythm?

A.Premature atrial complex
B.Sinus tachycardia
C.Atrial flutter
D.Supraventricular tachycardia

244.A client is complaining of chest pain. Nursing assessment reveals a BP of 78/40, shortness of breath, and third-degree AV block on the heart monitor. What is the most appropriate initial action?

A.Provide trancutaneous pacing.
B.Turn the client on his side.
C.Reassess the blood pressure.
D.Consult with cardiology.

245.The nurse is discussing cigarette smoking with an emphysema client. The client states, “I don’t know why I should worry about smoking.” The nurse’s response is based on the fact that smoking has which of the following negative effects to the emphysematous lung?

A.Affects peripheral blood vessels
B.Causes vasoconstriction to occur
C.Destroys the lung parenchyma
D.Paralyzes ciliary activity

246.The nurse is caring for a client admitted with congestive heart failure. Which finding would the nurse expect if the failure was on the right side of the heart?

A.Jugular vein distention
B.Dry, nonproductive cough
C.Dyspneic when supine
D.Crackles on chest auscultation

247.A client with chest pain is scheduled for a heart catheterization. Which of the following would the nurse include in the client’s care plan?

A.Keep the client NPO for 12 hours afterward.
B.Inform the client that general anesthesia will be administered throughout the procedure.
C.Assess the site for bleeding or hematoma once per shift.
D.Instruct the client that he might be asked to cough and breathe deeply during the procedure.

248.The nurse is caring for a COPD client who is discharged on p.o. Theophylline. Which of the following statements by the client would indicate a correct understanding of discharge instructions?

A.“A slow, regular pulse could be a side effect.”
B.“Take the pill with antacid or milk and crackers.”
C.“The doctor might order it intravenously if symptoms worsen.”
D.“Hold the drug if symptoms decrease.”

249.The nurse has just admitted a client with emphysema. Arterial blood gas results indicate hypoxia. Which physician prescription would the nurse implement for the best improvement in the client’s hypoxia?

A.Elevate the head of the bed 45°.
B.Encourage diaphragmatic breathing.
C.Initiate an Alupent nebulizer treatment.
D.Start O2 at 2L/min.

250.The nurse is assessing the chart of a client with a stroke. MRI results reveal a hemorrhagic stroke to the brain. Which physician prescription would the nurse question?

A.Normal saline IV at 50mL/hr
B.O2 at 3L/min by nasal cannula
C.Heparin infusion per pharmacist protocol
D.Insert a Foley catheter to bedside drainage


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