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Chapter One. Practice Exam 1 and Rationales

Chapter One. Practice Exam 1 and Rationales

1.The nurse is caring for a client scheduled for removal of the pituitary gland. The nurse should be particularly alert for:

A.Nasal congestion

B.Abdominal tenderness

C.Muscle tetany

D.Oliguria


Quick Answers: 50

Detailed Answer: 53

2.A client with cancer is admitted to the oncology unit. Stat lab values reveal Hgb 12.6, WBC 6500, K+ 1.9, uric acid 7.0, Na+ 136, and platelets 178,000. The nurse evaluates that the client is experiencing which of the following?

A.Hypernatremia

B.Hypokalemia

C.Myelosuppression

D.Leukocytosis


Quick Answers: 50

Detailed Answer: 53

3.A 24-year-old female client is scheduled for surgery in the morning. Which of the following is the primary responsibility of the nurse?

A.Taking the vital signs

B.Obtaining the permit

C.Explaining the procedure

D.Checking the lab work


Quick Answers: 50

Detailed Answer: 53

4.The nurse is working in the emergency room when a client arrives with severe burns of the left arm, hands, face, and neck. Which action should receive priority?

A.Starting an IV

B.Applying oxygen

C.Obtaining blood gases

D.Medicating the client for pain


Quick Answers: 50

Detailed Answer: 53

5.The nurse is visiting a home health client with osteoporosis. The client has a new prescription for alendronate (Fosamax). Which instruction should be given to the client?

A.Rest in bed after taking the medication for at least30 minutes

B.Avoid rapid movements after taking the medication

C.Take the medication with water only

D.Allow at least 1 hour between taking the medicine and taking other medications


Quick Answers: 50

Detailed Answer: 53

6.The nurse is making initial rounds on a client with a C5 fracture and crutchfield tongs. Which equipment should be kept at the bedside?

A.A pair of forceps

B.A torque wrench

C.A pair of wire cutters

D.A screwdriver


Quick Answers: 50

Detailed Answer: 53

7.An infant weighs 7 pounds at birth. The expected weight by 1 year should be:

A.10 pounds

B.12 pounds

C.18 pounds

D.21 pounds


Quick Answers: 50

Detailed Answer: 53

8.A client is admitted with a Ewing’s sarcoma. Which symptoms would be expected due to this tumor’s location?

A.Hemiplegia

B.Aphasia

C.Nausea

D.Bone pain


Quick Answers: 50

Detailed Answer: 53

9.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.Uric acid of 5mg/dL

B.Hematocrit of 33%

C.WBC 2,000 per cubic millimeter

D.Platelets 150,000 per cubic millimeter


Quick Answers: 50

Detailed Answer: 53

10.A 6-month-old client is admitted with possible intussuception. Which question during the nursing history is least helpful in obtaining information regarding this diagnosis?

A.“Tell me about his pain.”

B.“What does his vomit look like?”

C.“Describe his usual diet.”

D.“Have you noticed changes in his abdominal size?”


Quick Answers: 50

Detailed Answer: 53

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

A.Bran

B.Fresh peaches

C.Cucumber salad

D.Yeast rolls


Quick Answers: 50

Detailed Answer: 53

12.A client has rectal cancer and is scheduled for an abdominal perineal resection. What should be the priority nursing care during the post-op period?

A.Teaching how to irrigate the illeostomy

B.Stopping electrolyte loss in the incisional area

C.Encouraging a high-fiber diet

D.Facilitating perineal wound drainage


Quick Answers: 50

Detailed Answer: 53

13.The nurse is performing discharge teaching on a client with diverticulitis who has been placed on a low-roughage diet. Which food would have to be eliminated from this client’s diet?

A.Roasted chicken

B.Noodles

C.Cooked broccoli

D.Custard


Quick Answers: 50

Detailed Answer: 54

14.The nurse is caring for a new mother. The mother asks why her baby has lost weight since he was born. The best explanation of the weight loss is:

A.The baby is dehydrated due to polyuria.

B.The baby is hypoglycemic due to lack of glucose.

C.The baby is allergic to the formula the mother is giving him.

D.The baby can lose up to 10% of weight due to meconium stool, loss of extracellular fluid, and initiation of breastfeeding.


Quick Answers: 50

Detailed Answer: 54

15.The nurse is caring for a client with laryngeal cancer. Which finding ascertained in the health history would not be common for this diagnosis?

A.Foul breath

B.Dysphagia

C.Diarrhea

D.Chronic hiccups


Quick Answers: 50

Detailed Answer: 54

16.A removal of the left lower lobe of the lung is performed on a client with lung cancer. Which post-operative measure would usually be included in the plan?

A.Closed chest drainage

B.A tracheostomy

C.A mediastenal tube

D.Percussion vibration and drainage


Quick Answers: 50

Detailed Answer: 54

17.Six hours after birth, the infant is found to have an area of swelling over the right parietal area that does not cross the suture line. The nurse should chart this finding as:

A.A cephalohematoma

B.Molding

C.Subdural hematoma

D.Caput succedaneum


Quick Answers: 50

Detailed Answer: 54

18.The nurse is performing discharge instruction to a client with an implantable defibrillator. What discharge instruction is essential?

A.“You cannot eat food prepared in a microwave.”

B.“You should avoid moving the shoulder on the side of the pacemaker site for 6 weeks.”

C.“You should use your cellphone on your right side.”

D.“You will not be able to fly on a commercial airliner with the defibrillator in place.”


Quick Answers: 50

Detailed Answer: 54

19.A client in the cardiac step-down unit requires suctioning for excess mucous secretions. The nurse should be most careful to monitor the client for which dysrhythmia during this procedure?

A.Bradycardia

B.Tachycardia

C.Premature ventricular beats

D.Heart block


Quick Answers: 50

Detailed Answer: 54

20.The nurse is caring for a client scheduled for a surgical repair of a sacular 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


Quick Answers: 50

Detailed Answer: 54

21.A client with suspected renal disease is to undergo a renal biopsy. The nurse plans to include which statement in the teaching session?

A.“You will be sitting for the examination procedure.”

B.“Portions of the procedure will cause pain or discomfort.”

C.“You will be given some medication to anesthetize the area.”

D.“You will not be able to drink fluids for 24 hours before the study.”


Quick Answers: 50

Detailed Answer: 54

22.The nurse is performing an assessment on a client with possible pernicious anemia. Which data would support this diagnosis?

A.A weight loss of 10 pounds in 2 weeks

B.Complaints of numbness and tingling in the extremities

C.A red, beefy tongue

D.A hemoglobin level of 12.0gm/dL


Quick Answers: 50

Detailed Answer: 54

23.A client arrives in the emergency room with a possible fractured femur. The nurse should anticipate an order for:

A.Trendelenburg position

B.Ice to the entire extremity

C.Buck’s traction

D.An abduction pillow


Quick Answers: 50

Detailed Answer: 55

24.A client with cancer is to undergo an intravenous pyelogram. The nurse should:

A.Force fluids 24 hours before the procedure

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


Quick Answers: 50

Detailed Answer: 55

25.The nurse is caring for a client with a malignancy. The classification of the primary tumor is Tis. The nurse should plan care for a tumor:

A.That cannot be assessed

B.That is in situ

C.With increasing lymph node involvement

D.With distant metastasis


Quick Answers: 50

Detailed Answer: 55

26.A client is 2 days post-operative colon resection. After a coughing episode, the client’s wound eviscerates. Which nursing action is most appropriate?

A.Reinsert the protruding organ and cover with 4×4s

B.Cover the wound with a sterile 4×4 and ABD dressing

C.Cover the wound with a sterile saline-soaked dressing

D.Apply an abdominal binder and manual pressure to the wound


Quick Answers: 50

Detailed Answer: 55

27.The nurse is preparing a client for surgery. Which item is most important to remove before sending the client to surgery?

A.Hearing aid

B.Contact lenses

C.Wedding ring

D.Artificial eye


Quick Answers: 50

Detailed Answer: 55

28.The nurse on the 3–11 shift is assessing the chart of a client with an abdominal aneurysm scheduled for surgery in the morning 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 or her to 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


Quick Answers: 50

Detailed Answer: 55

29.When assessing a client for risk of hyperphosphatemia, which piece of information is most important for the nurse to obtain?

A.A history of radiation treatment in the neck region

B.A history of recent orthopedic surgery

C.A history of minimal physical activity

D.A history of the client’s food intake


Quick Answers: 50

Detailed Answer: 55

30.A client is admitted to the acute care unit. Initial laboratory values reveal serum sodium of 170meq/L. What behavior changes would be most common for this client?

A.Anger

B.Mania

C.Depression

D.Psychosis


Quick Answers: 50

Detailed Answer: 55

31.The nurse is obtaining a history of an 80-year-old client. Which statement made by the client might indicate 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 ice tea.”

D.“I sometimes have a problem with dribbling urine.”


Quick Answers: 50

Detailed Answer: 55

32.A client visits the clinic after the death of a parent. Which statement made by the client’s sister signifies abnormal grieving?

A.“My sister still has episodes of crying, and it’s been 3 months since Daddy died.”

B.“Sally seems to have forgotten the bad things that Daddy did in his lifetime.”

C.“She really had a hard time after Daddy’s funeral. She said that she had a sense of longing.”

D.“Sally has not been sad at all by Daddy’s death. She acts like nothing has happened.”


Quick Answers: 50

Detailed Answer: 55

33.The nurse recognizes that which of the following would be most appropriate to wear when providing direct care to a client with a cough?

A.Mask

B.Gown

C.Gloves

D.Shoe covers


Quick Answers: 50

Detailed Answer: 56

34.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.I.D.

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


Quick Answers: 50

Detailed Answer: 56

35.A client with pancreatitis has been transferred to the intensive care unit. Which order would the nurse anticipate?

A.Blood pressure every 15 minutes

B.Insertion of a Levine tube

C.Cardiac monitoring

D.Dressing changes two times per day


Quick Answers: 50

Detailed Answer: 56

36.The client is admitted to the unit after a cholescystectomy. Montgomery straps are utilized with this client. The nurse is aware that Montgomery straps are utilized on this client because:

A.The client is at risk for evisceration.

B.The client will require frequent dressing changes.

C.The straps provide support for drains that are inserted in the incision.

D.No sutures or clips are used to secure the incision.


Quick Answers: 50

Detailed Answer: 56

37.The nurse has an order for medication to be administered intrathecally. The nurse is aware that medications will be administered by which method?

A.Intravenously

B.Rectally

C.Intramuscularly

D.Into the cerebrospinal fluid


Quick Answers: 50

Detailed Answer: 56

38.Which client can best be assigned to the newly licensed nurse?

A.The client receiving chemotherapy

B.The client post–coronary bypass

C.The client with a TURP

D.The client with diverticulitis


Quick Answers: 50

Detailed Answer: 56

39.The nurse notes the patient care assistant looking through the personal items of the client with cancer. Which action should be taken by the registered nurse?

A.Notify the police department as a robbery

B.Report this behavior to the charge nurse

C.Monitor the situation and note whether any items are missing

D.Ignore the situation until items are reported missing


Quick Answers: 50

Detailed Answer: 56

40.The charge nurse overhears the patient care assistant speaking harshly to the client with dementia. The charge nurse should:

A.Change the nursing assistant’s assignment

B.Explore the interaction with the nursing assistant

C.Discuss the matter with the client’s family

D.Initiate a group session with the nursing assistant


Quick Answers: 50

Detailed Answer: 56

41.A home health nurse is planning for her daily visits. Which client should the home health nurse visit first?

A.A client with AIDS being treated with Foscarnet

B.A client with a fractured femur in a long leg cast

C.A client with laryngeal cancer with a laryngetomy

D.A client with diabetic ulcers to the left foot


Quick Answers: 50

Detailed Answer: 57

42.The nurse is assigned to care for an infant with physiologic jaundice. Which action by the nurse would facilitate elimination of the bilirubin?

A.Increasing the infant’s fluid intake

B.Maintaining the infant’s body temperature at 98.6°F

C.Minimizing tactile stimulation

D.Decreasing caloric intake


Quick Answers: 50

Detailed Answer: 57

43.The graduate nurse is assigned to care for the client on ventilator support, pending organ donation. Which goal should receive priority?

A.Maintain the client’s systolic blood pressure at 70mmHg or greater

B.Maintain the client’s urinary output greater than 300cc per hour

C.Maintain the client’s body temperature of greater than 33°F rectal

D.Maintain the client’s hematocrit less than 30%


Quick Answers: 50

Detailed Answer: 57

44.Which action by the novice nurse indicates a need for further teaching?

A.The nurse fails to wear gloves to remove a dressing.

B.The nurse applies an oxygen saturation monitor to the ear lobe.

C.The nurse elevates the head of the bed to check the blood pressure.

D.The nurse places the extremity in a dependent position to acquire a peripheral blood sample.


Quick Answers: 50

Detailed Answer: 57

45.The nurse is preparing a client for mammography. To prepare the client for a mammogram, the nurse should tell the client:

A.To restrict her fat intake for 1 week before the test

B.To omit creams, powders, or deodorants before the exam

C.That mammography replaces the need for self-breast exams

D.That mammography requires a higher dose of radiation than an x-ray


Quick Answers: 50

Detailed Answer: 57

46.Which of the following roommates would be best for the client newly admitted with gastric resection?

A.A client with Crohn’s disease

B.A client with pneumonia

C.A client with gastritis

D.A client with phlebitis


Quick Answers: 50

Detailed Answer: 57

47.The nurse is working with another nurse and a patient care assistant. Which of the following clients should be assigned to the registered nurse?

A.A client 2 days post-appendectomy

B.A client 1 week post-thyroidectomy

C.A client 3 days post-splenectomy

D.A client 2 days post-thoracotomy


Quick Answers: 50

Detailed Answer: 57

48.The nurse is observing a graduate nurse as she assesses the central venous pressure. Which observation would indicate that the graduate needs further teaching?

A.The graduate places the client in a supine position to read the manometer.

B.The graduate turns the stop-cock to the off position from the IV fluid to the client.

C.The graduate instructs the client to perform the Valsalva maneuver during the CVP reading.

D.The graduate notes the level at the top of the meniscus.


Quick Answers: 50

Detailed Answer: 57

49.Which of the following roommates would be most suitable for the client with myasthenia gravis?

A.A client with hypothyroidism

B.A client with Crohn’s disease

C.A client with pylonephritis

D.A client with bronchitis


Quick Answers: 50

Detailed Answer: 57

50.The nurse employed in the emergency room is responsible for triage of four clients injured in a motor vehicle accident. Which of the following clients should receive priority in care?

A.A 10-year-old with lacerations of the face

B.A 15-year-old with sternal bruises

C.A 34-year-old with a fractured femur

D.A 50-year-old with dislocation of the elbow


Quick Answers: 50

Detailed Answer: 57

51.The client is receiving peritoneal dialysis. If the dialysate returns cloudy, the nurse should:

A.Document the finding

B.Send a specimen to the lab

C.Strain the urine

D.Obtain a complete blood count


Quick Answers: 50

Detailed Answer: 58

52.The client with cirrhosis of the liver is receiving Lactulose. The nurse is aware that the rationale for the order for Lactulose is:

A.To lower the blood glucose level

B.To lower the uric acid level

C.To lower the ammonia level

D.To lower the creatinine level


Quick Answers: 50

Detailed Answer: 58

53.The client with diabetes is preparing for discharge. During discharge teaching, the nurse assesses the client’s ability to care for himself. Which statement made by the client would indicate a need for follow-up after discharge?

A.“I live by myself.”

B.“I have trouble seeing.”

C.“I have a cat in the house with me.”

D.“I usually drive myself to the doctor.”


Quick Answers: 50

Detailed Answer: 58

54.The client is receiving total parenteral nutrition (TPN). Which lab test should be evaluated while the client is receiving TPN?

A.Hemoglobin

B.Creatinine

C.Blood glucose

D.White blood cell count


Quick Answers: 50

Detailed Answer: 58

55.The client with a myocardial infarction comes to the nurse’s station stating that he is ready to go home because there is nothing wrong with him. Which defense mechanism is the client using?

A.Rationalization

B.Denial

C.Projection

D.Conversion reaction


Quick Answers: 50

Detailed Answer: 58

56.Which laboratory test would be the least effective in making the diagnosis of a myocardial infarction?

A.AST

B.Troponin

C.CK-MB

D.Myoglobin


Quick Answers: 50

Detailed Answer: 58

57.Which woman is not a candidate for RhoGam?

A.A gravida IV para 3 that is Rh negative with an Rh-positive baby

B.A gravida I para 1 that is Rh negative with an Rh-positive baby

C.A gravida II para 0 that is Rh negative admitted after a stillbirth delivery

D.A gravida IV para 2 that is Rh negative with an Rh-negative baby


Quick Answers: 50

Detailed Answer: 58

58.The first exercise that should be performed by the client who had a mastectomy is:

A.Walking the hand up the wall

B.Sweeping the floor

C.Combing her hair

D.Squeezing a ball


Quick Answers: 50

Detailed Answer: 58

59.The client is scheduled for a Tensilon test to check for Myasthenia Gravis. Which medication should be kept available during the test?

A.Atropine sulfate

B.Furosemide

C.Prostigmin

D.Promethazine


Quick Answers: 50

Detailed Answer: 58

60.The client is scheduled for a pericentesis. Which instruction should be given to the client before the exam?

A.“You will need to lay flat during the exam.”

B.“You need to empty your bladder before the procedure.”

C.“You will be asleep during the procedure.”

D.“The doctor will inject a medication to treat your illness during the procedure.”


Quick Answers: 50

Detailed Answer: 58

61.To ensure safety while administering a nitroglycerine patch, the nurse should:

A.Wear gloves

B.Shave the area where the patch will be applied

C.Wash the area thoroughly with soap and rinse with hot water

D.Apply the patch to the buttocks


Quick Answers: 50

Detailed Answer: 58

62.A 25-year-old male is brought to the emergency room with a piece of metal in his eye. Which action by the nurse is correct?

A.Use a magnet to remove the object.

B.Rinse the eye thoroughly with saline.

C.Cover both eyes with paper cups.

D.Patch the affected eye only.


Quick Answers: 50

Detailed Answer: 59

63.The physician has ordered sodium warfarin for the client with thrombophlebitis. The order should be entered to administer the medication at:

A.0900

B.1200

C.1700

D.2100


Quick Answers: 50

Detailed Answer: 59

64.The schizophrenic client has become disruptive and requires seclusion. Which staff member can institute seclusion?

A.The security guard

B.The registered nurse

C.The licensed practical nurse

D.The nursing assistant


Quick Answers: 50

Detailed Answer: 59

65.The client is admitted with chronic obstructive pulmonary disease. Blood gases reveal pH 7.36, CO2 45, O2 84, bicarb 28. The nurse would assess the client to be in:

A.Uncompensated acidosis

B.Compensated alkalosis

C.Compensated respiratory acidosis

D.Uncompensated metabolic acidosis


Quick Answers: 50

Detailed Answer: 59

66.The nurse is assessing the client recently returned from surgery. The nurse is aware that the best way to assess pain is to:

A.Take the blood pressure, pulse, and temperature

B.Ask the client to rate his pain on a scale of 0–5

C.Watch the client’s facial expression

D.Ask the client if he is in pain


Quick Answers: 50

Detailed Answer: 59

67.The client delivered a 9-pound infant two days ago. An effective means of managing discomfort from an episiotomy is:

A.Medicated suppository

B.Aspirin

C.Sitz baths

D.Ice packs


Quick Answers: 50

Detailed Answer: 59

68.Which of the following post-operative diets is most appropriate for the client who has had a hemorroidectomy?

A.High-fiber

B.Low-residue

C.Bland

D.Clear-liquid


Quick Answers: 50

Detailed Answer: 59

69.The physician has ordered a culture for the client with suspected gonorrhea. The nurse should obtain which type of culture?

A.Blood

B.Nasopharyngeal secretions

C.Stool

D.Genital secretions


Quick Answers: 50

Detailed Answer: 59

70.The nurse is caring for a client with cerebral palsy. The nurse should provide frequent rest periods because:

A.Grimacing and writhing movements decrease with relaxation and rest.

B.Hypoactive deep tendon reflexes become more active with rest.

C.Stretch reflexes are increased with rest.

D.Fine motor movements are improved.


Quick Answers: 50

Detailed Answer: 59

71.The nurse is making assignments for the day. The staff consists of an RN, an LPN, and a nursing assistant. Which client should be assigned to the nursing assistant?

A.A client with Alzheimer’s disease

B.A client with pneumonia

C.A client with appendicitis

D.A client with thrombophebitis


Quick Answers: 50

Detailed Answer: 59

72.A client with cancer develops xerostomia. The nurse can help alleviate the discomfort associated with xerostomia by:

A.Offering hard candy

B.Administering analgesic medications

C.Splinting swollen joints

D.Providing saliva substitute


Quick Answers: 50

Detailed Answer: 59

73.A home health nurse is making preparations for morning visits. Which one of the following clients should the nurse visit first?

A.A client with brain attack (stroke) with tube feedings

B.A client with congestive heart failure complaining of nighttime dyspnea

C.A client with a thoracotomy 6 months ago

D.A client with Parkinson’s disease


Quick Answers: 50

Detailed Answer: 60

74.A client with glomerulonephritis is placed on a low-sodium diet. Which of the following snacks is suitable for the client with sodium restriction?

A.Peanut butter cookies

B.Grilled cheese sandwich

C.Cottage cheese and fruit

D.Fresh peach


Quick Answers: 50

Detailed Answer: 60

75.Due to a high census, it has been necessary for a number of clients to be transferred to other units within the hospital. Which client should be transferred to the postpartum unit?

A.A 66-year-old female with a gastroenteritis

B.A 40-year-old female with a hysterectomy

C.A 27-year-old male with severe depression

D.A 28-year-old male with ulcerative colitis


Quick Answers: 50

Detailed Answer: 60

76.During the change of shift, the oncoming nurse notes a discrepancy in the number of percocette listed and the number present in the narcotic drawer. The nurse’s first action should be to:

A.Notify the hospital pharmacist

B.Notify the nursing supervisor

C.Notify the Board of Nursing

D.Notify the director of nursing


Quick Answers: 50

Detailed Answer: 60

77.The nurse is assigning staff for the day. Which assignment should be given to the nursing assistant?

A.Taking the vital signs of the 5-month-old with bronchiolitis

B.Taking the vital signs of the 10-year-old with a 2-day post-appendectomy

C.Administering medication to the 2-year-old with periorbital cellulites

D.Adjusting the traction of the 1-year-old with a fractured tibia


Quick Answers: 50

Detailed Answer: 60

78.A new nursing graduate indicates in charting entries that he is a licensed registered nurse, although he has not yet received the results of the licensing exam. The graduate’s action can result in what type of charge:

A.Fraud

B.Tort

C.Malpractice

D.Negligence


Quick Answers: 50

Detailed Answer: 60

79.A client with acute leukemia develops a low white blood cell count. In addition to the institution of isolation, the nurse should:

A.Request that foods be served with disposable utensils

B.Ask the client to wear a mask when visitors are present

C.Prep IV sites with mild soap and water and alcohol

D.Provide foods in sealed single-serving packages


Quick Answers: 50

Detailed Answer: 60

80.A 70-year-old male who is recovering from a stroke exhibits signs of unilateral neglect. Which behavior is suggestive of unilateral neglect?

A.The client is observed shaving only one side of his face.

B.The client is unable to distinguish between two tactile stimuli presented simultaneously.

C.The client is unable to complete a range of vision without turning his head side to side.

D.The client is unable to carry out cognitive and motor activity at the same time.


Quick Answers: 50

Detailed Answer: 60

81.The nurse is providing discharge teaching for a client taking dissulfiram (Antabuse). The nurse should instruct the client to avoid eating:

A.Peanuts, dates, raisins

B.Figs, chocolate, eggplant

C.Pickles, salad with vinaigrette dressing, beef

D.Milk, cottage cheese, ice cream


Quick Answers: 50

Detailed Answer: 60

82.A client has been receiving cyanocobalamine (B12) injections for the past 6 weeks. Which laboratory finding indicates that the medication is having the desired effect?

A.Neutrophil count of 60%

B.Basophil count of 0.5%

C.Monocyte count of 2%

D.Reticulocyte count of 1%


Quick Answers: 50

Detailed Answer: 60

83.The nurse has just received a change-of-shift report. Which client should the nurse assess first?

A.A client 2 hours post-lobectomy with 150ccs drainage

B.A client 2 days post-gastrectomy with scant drainage

C.A client with pneumonia with an oral temperature of 102°F

D.A client with a fractured hip in Buck’s traction


Quick Answers: 50

Detailed Answer: 60

84.Several clients are admitted to the emergency room following a three-car vehicle accident. Which clients can be assigned to share a room in the emergency department during the disaster?

A.The schizophrenic client having visual and auditory hallucinations and the client with ulcerative colitis

B.The client who is 6 months pregnant with abdominal pain and the client with facial lacerations and a broken arm

C.A child whose pupils are fixed and dilated and his parents, and the client with a frontal head injury

D.The client who arrives with a large puncture wound to the abdomen and the client with chest pain


Quick Answers: 50

Detailed Answer: 61

85.The home health nurse is planning for the day’s visits. Which client should be seen first?

A.The 78-year-old who had a gastrectomy 3 weeks ago with a PEG tube

B.The 5-month-old discharged 1 week ago with pneumonia who is being treated with amoxicillin liquid suspension

C.The 50-year-old with MRSA being treated with Vancomycin via a PICC line

D.The 30-year-old with an exacerbation of multiple sclerosis being treated with cortisone via a centrally placed venous catheter


Quick Answers: 50

Detailed Answer: 61

86.The nurse is found to be guilty of charting blood glucose results without actually performing the procedure. After talking to the nurse, the charge nurse should:

A.Call the Board of Nursing

B.File a formal reprimand

C.Terminate the nurse

D.Charge the nurse with a tort


Quick Answers: 50

Detailed Answer: 61

87.Which information should be reported to the state Board of Nursing?

A.The facility fails to provide literature in both Spanish and English.

B.The narcotic count has been incorrect on the unit for the past 3 days.

C.The client fails to receive an itemized account of his bills and services received during his hospital stay.

D.The nursing assistant assigned to the client with hepatitis fails to feed the client and give the bath.


Quick Answers: 50

Detailed Answer: 61

88.Which nurse should be assigned to care for the postpartal client with preeclampsia?

A.The nurse with 2 weeks of experience on postpartum

B.The nurse with 3 years of experience in labor and delivery

C.The nurse with 10 years of experience in surgery

D.The nurse with 1 year of experience in the neonatal intensive care unit


Quick Answers: 51

Detailed Answer: 61

89.The client returns to the unit from surgery with a blood pressure of 90/50, pulse 132, respirations 30. Which action by the nurse should receive priority?

A.Continue to monitor the vital signs

B.Contact the physician

C.Ask the client how he feels

D.Ask the LPN to continue the post-op care


Quick Answers: 51

Detailed Answer: 61

90.Which assignment should not be performed by the licensed practical nurse?

A.Inserting a Foley catheter

B.Discontinuing a nasogastric tube

C.Obtaining a sputum specimen

D.Initiating a blood transfusion


Quick Answers: 51

Detailed Answer: 61

91.The charge nurse witnesses the nursing assistant hitting the client in the long-term care facility. The nursing assistant can be charged with:

A.Negligence

B.Tort

C.Assault

D.Malpractice


Quick Answers: 51

Detailed Answer: 61

92.The nurse is planning room assignments for the day. Which client should be assigned to a private room if only one is available?

A.The client with Cushing’s disease

B.The client with diabetes

C.The client with acromegaly

D.The client with myxedema


Quick Answers: 51

Detailed Answer: 61

93.The nurse is making assignments for the day. Which client should be assigned to the pregnant nurse?

A.The client receiving linear accelerator radiation therapy for lung cancer

B.The client with a radium implant for cervical cancer

C.The client who has just been administered soluble brachytherapy for thyroid cancer

D.The client who returned from placement of iridium seeds for prostate cancer


Quick Answers: 51

Detailed Answer: 62

94.The client is receiving heparin for thrombophlebitis of the left lower extremity. Which of the following drugs reverses the effects of heparin?

A.Cyanocobalamine

B.Protamine sulfate

C.Streptokinase

D.Sodium warfarin


Quick Answers: 51

Detailed Answer: 62

95.The client is admitted with a BP of 210/120. Her doctor orders furosemide (Lasix) 40mg IV stat. How should the nurse administer the prescribed furosemide to this client?

A.By giving it over 1–2 minutes

B.By hanging it IV piggyback

C.With normal saline only

D.By administering it through a venous access device


Quick Answers: 51

Detailed Answer: 62

96.The physician prescribes captopril (Capoten) 25mg po tid for the client with hypertension. Which of the following adverse reactions can occur with administration of Capoten?

A.Tinnitus

B.Persistent cough

C.Muscle weakness

D.Diarrhea


Quick Answers: 51

Detailed Answer: 62

97.The doctor orders 2% nitroglycerin ointment in a 1-inch dose every 12 hours. Proper application of nitroglycerin ointment includes:

A.Rotating application sites

B.Limiting applications to the chest

C.Rubbing it into the skin

D.Covering it with a gauze dressing


Quick Answers: 51

Detailed Answer: 62

98.Lidocaine is a medication frequently ordered for the client experiencing:

A.Atrial tachycardia

B.Ventricular tachycardia

C.Heart block

D.Ventricular brachycardia


Quick Answers: 51

Detailed Answer: 62

99.The client is admitted to the emergency room with shortness of breath, anxiety, and tachycardia. His ECG reveals atrial fibrillation with a ventricular response rate of 130 beats per minute. The doctor orders quinidine sulfate. While he is receiving quinidine, the nurse should monitor his ECG for:

A.Peaked P wave

B.Elevated ST segment

C.Inverted T wave

D.Prolonged QT interval


Quick Answers: 51

Detailed Answer: 62

100.The physician has prescribed tranylcypromine sulfate (Parnate) 10mg bid. The nurse should teach the client to refrain from eating foods containing tyramine because it may cause:

A.Hypertension

B.Hyperthermia

C.Melanoma

D.Urinary retention


Quick Answers: 51

Detailed Answer: 62

101.The child with seizure disorder is being treated with Dilantin. Which of the following statements by the patient’s mother indicates to the nurse that the patient is experiencing a side effect of Dilantin therapy?

A.“She is very irritable lately.”

B.“She sleeps quite a bit of the time.”

C.“Her gums look too big for her teeth.”

D.“She has gained about 10 pounds in the last 6 months.”


Quick Answers: 51

Detailed Answer: 63

102.A 5-year-old is admitted to the unit following a tonsillectomy. Which of the following would indicate a complication of the surgery?

A.Decreased appetite

B.A low-grade fever

C.Chest congestion

D.Constant swallowing


Quick Answers: 51

Detailed Answer: 63

103.A 6-year-old with cerebral palsy functions at the level of an 18-month-old. Which finding would support that assessment?

A.She dresses herself.

B.She pulls a toy behind her.

C.She can build a tower of eight blocks.

D.She can copy a horizontal or vertical line.


Quick Answers: 51

Detailed Answer: 63

104.Which information obtained from the mother of a child with cerebral palsy most likely correlates to the diagnosis?

A.She was born at 42 weeks gestation.

B.She had meningitis when she was 6 months old.

C.She had physiologic jaundice after delivery.

D.She has frequent sore throats.


Quick Answers: 51

Detailed Answer: 63

105.The 10-year-old is being treated for asthma. Before administering Theodur, the nurse should check the:

A.Urinary output

B.Blood pressure

C.Pulse

D.Temperature


Quick Answers: 51

Detailed Answer: 63

106.An elderly client is diagnosed with ovarian cancer. She has surgery followed by chemotherapy with a fluorouracil (Adrucil) IV. What should the nurse do if she notices crystals and cloudiness in the IV medication?

A.Discard the solution and order a new bag

B.Warm the solution

C.Continue the infusion and document the finding

D.Discontinue the medication


Quick Answers: 51

Detailed Answer: 63

107.The client is diagnosed with multiple myoloma. The doctor has ordered cyclophosphamide (Cytoxan). Which instruction should be given to the client?

A.“Walk about a mile a day to prevent calcium loss.”

B.“Increase the fiber in your diet.”

C.“Report nausea to the doctor immediately.”

D.“Drink at least eight large glasses of water a day.”


Quick Answers: 51

Detailed Answer: 63

108.The client is taking rifampin 600mg po daily to treat his tuberculosis. Which action by the nurse indicates understanding of the medication?

A.Telling the client that the medication will need to be taken with juice

B.Telling the client that the medication will change the color of the urine

C.Telling the client to take the medication before going to bed at night

D.Telling the client to take the medication if night sweats occur


Quick Answers: 51

Detailed Answer: 63

109.The client is taking prednisone 7.5mg po each morning to treat his systemic lupus errythymatosis. Which statement best explains the reason for taking the prednisone in the morning?

A.There is less chance of forgetting the medication if taken in the morning.

B.There will be less fluid retention if taken in the morning.

C.Prednisone is absorbed best with the breakfast meal.

D.Morning administration mimics the body’s natural secretion of corticosteroid.


Quick Answers: 51

Detailed Answer: 63

110.A 20-year-old female has a prescription for tetracycline. While teaching the client how to take her medicine, the nurse learns that the client is also taking Ortho-Novum oral contraceptive pills. Which instructions should be included in the teaching plan?

A.The oral contraceptives will decrease the effectiveness of the tetracycline.

B.Nausea often results from taking oral contraceptives and antibiotics.

C.Toxicity can result when taking these two medications together.

D.Antibiotics can decrease the effectiveness of oral contraceptives, so the client should use an alternate method of birth control.


Quick Answers: 51

Detailed Answer: 63

111.A 60-year-old diabetic is taking glyburide (diaBeta) 1.25mg daily to treat Type II diabetes mellitus. Which statement indicates the need for further teaching?

A.“I will keep candy with me just in case my blood sugar drops.”

B.“I need to stay out of the sun as much as possible.”

C.“I often skip dinner because I don’t feel hungry.”

D.“I always wear my medical identification.”


Quick Answers: 51

Detailed Answer: 63

112.The physician prescribes regular insulin, 5 units subcutaneous. Regular insulin begins to exert an effect:

A.In 5–10 minutes

B.In 10–20 minutes

C.In 30–60 minutes

D.In 60–120 minutes


Quick Answers: 51

Detailed Answer: 63

113.The client is admitted from the emergency room with multiple injuries sustained from an auto accident. His doctor prescribes a histamine blocker. The reason for this order is:

A.To treat general discomfort

B.To correct electrolyte imbalances

C.To prevent stress ulcers

D.To treat nausea


Quick Answers: 51

Detailed Answer: 63

114.The client with a recent liver transplant asks the nurse how long he will have to take cyclosporin. Which response is correct?

A.1 year

B.5 years

C.10 years

D.The rest of his life


Quick Answers: 51

Detailed Answer: 64

115.Shortly after the client was admitted to the postpartum unit, the nurse notes heavy lochia rubra with large clots. The nurse should anticipate an order for:

A.Methergine

B.Stadol

C.Magnesium sulfate

D.Phenergan


Quick Answers: 51

Detailed Answer: 64

116.The client is scheduled to have an intravenous cholangiogram. Before the procedure, the nurse should assess the patient for:

A.Shellfish allergies

B.Reactions to blood transfusions

C.Gallbladder disease

D.Egg allergies


Quick Answers: 51

Detailed Answer: 64

117.A new diabetic is learning to administer his insulin. He receives 10U of NPH and 12U of regular insulin each morning. Which of the following statements reflects understanding of the nurse’s teaching?

A.“When drawing up my insulin, I should draw up the regular insulin first.”

B.“When drawing up my insulin, I should draw up the NPH insulin first.”

C.“It doesn’t matter which insulin I draw up first.”

D.“I cannot mix the insulin, so I will need two shots.”


Quick Answers: 51

Detailed Answer: 64

118.A client with osteomylitis has an order for a trough level to be done because he is taking Gentamycin. When should the nurse call the lab to obtain the trough level?

A.Before the first dose

B.30 minutes before the fourth dose

C.30 minutes after the first dose

D.30 minutes after the fourth dose


Quick Answers: 51

Detailed Answer: 64

119.A 4-year-old with cystic fibrosis has a prescription for Viokase pancreatic enzymes to prevent malabsorption. The correct time to give pancreatic enzyme is:

A.1 hour before meals

B.2 hours after meals

C.With each meal and snack

D.On an empty stomach


Quick Answers: 51

Detailed Answer: 64

120.Isoniazid (INH) has been prescribed for a family member exposed to tuberculosis. The nurse is aware that the length of time that the medication will be taken is:

A.6 months

B.3 months

C.18 months

D.24 months


Quick Answers: 51

Detailed Answer: 64

121.The client is admitted to the postpartum unit with an order to continue the infusion of Pitocin. Which finding indicates that the Pitocin is having the desired effect?

A.The fundus is deviated to the left.

B.The fundus is firm and in the midline.

C.The fundus is boggy.

D.The fundus is two finger breadths below the umbilicus.


Quick Answers: 51

Detailed Answer: 64

122.The nurse is teaching a group of new graduates about the safety needs of the client receiving chemotherapy. Before administering chemotherapy, the nurse should:

A.Administer a bolus of IV fluid

B.Administer pain medication

C.Administer an antiemetic

D.Allow the patient a chance to eat


Quick Answers: 51

Detailed Answer: 64

123.Before administering Methytrexate orally to the client with cancer, the nurse should check the:

A.IV site

B.Electrolytes

C.Blood gases

D.Vital signs


Quick Answers: 51

Detailed Answer: 64

124.Vitamin K is administered to a newborn shortly after birth for which of the following reasons?

A.To prevent dehydration

B.To treat infection

C.To replace electrolytes

D.To facilitate clotting


Quick Answers: 51

Detailed Answer: 64

125.The client with an ileostomy is being discharged. Which teaching should be included in the plan of care?

A.Use Karaya powder to seal the bag.

B.Irrigate the ileostomy daily.

C.Stomahesive is the best skin protector.

D.Neosporin ointment can be used to protect the skin.


Quick Answers: 51

Detailed Answer: 65

126.The client has an order for FeSo4 liquid. Which method of administration would be best?

A.Administer the medication with milk

B.Administer the medication with a meal

C.Administer the medication with orange juice

D.Administer the medication undiluted


Quick Answers: 51

Detailed Answer: 65

127.The client arrives in the emergency room with a hyphema. Which action by the nurse would be best?

A.Elevate the head of the bed and apply ice to the eye

B.Place the client in a supine position and apply heat to the knee

C.Insert a Foley catheter and measure the intake and output

D.Perform a vaginal exam and check for a discharge


Quick Answers: 51

Detailed Answer: 65

128.The nurse is making assignments for the day. Which client should be assigned to the nursing assistant?

A.The 18-year-old with a fracture to two cervical vertebrae

B.The infant with meningitis

C.The elderly client with a thyroidectomy 4 days ago

D.The client with a thoracotomy 2 days ago


Quick Answers: 51

Detailed Answer: 65

129.The client arrives in the emergency room with a “bull’s eye” rash. Which question would be most appropriate for the nurse to ask the client?

A.“Have you found any ticks on your body?”

B.“Have you had any nausea in the last 24 hours?”

C.“Have you been outside the country in the last 6 months?”

D.“Have you had any fever for the past few days?”


Quick Answers: 51

Detailed Answer: 65

130.Which of the following is the best indicator of the diagnosis of HIV?

A.White blood cell count

B.ELISA

C.Western Blot

D.Complete blood count


Quick Answers: 51

Detailed Answer: 65

131.The client has an order for gentamycin to be administered. Which lab results should be reported to the doctor before beginning the medication?

A.Hematocrit

B.Creatinine

C.White blood cell count

D.Erythrocyte count


Quick Answers: 51

Detailed Answer: 65

132.The nurse is caring for the client with a mastectomy. Which action would be contraindicated?

A.Taking the blood pressure in the side of the mastectomy

B.Elevating the arm on the side of the mastectomy

C.Positioning the client on the unaffected side

D.Performing a dextrostix on the unaffected side


Quick Answers: 51

Detailed Answer: 65

133.The charge nurse is making assignments for the day. After accepting the assignment to a client with leukemia, the nurse tells the charge nurse that her child has chickenpox. Which action should the charge nurse take?

A.Change the nurse’s assignment to another client

B.Explain to the nurse that there is no risk to the client

C.Ask the nurse if the chickenpox have scabbed

D.Ask the nurse if she has ever had the chickenpox


Quick Answers: 51

Detailed Answer: 65

134.The client with brain cancer refuses to care for herself. Which action by the nurse would be best?

A.Alternate nurses caring for the client so that the staff will not get tired of caring for this client

B.Talk to the client and explain the need for self-care

C.Explore the reason for the lack of motivation seen in the client

D.Talk to the doctor about the client’s lack of motivation


Quick Answers: 51

Detailed Answer: 66

135.The nurse is caring for the client who has been in a coma for 2 months. He has signed a donor card, but the wife is opposed to the idea of organ donation. How should the nurse handle the topic of organ donation with the wife?

A.Contact organ retrieval to come talk to the wife

B.Tell her that because her husband signed a donor card, the hospital has the right to take the organs upon the death of her husband

C.Drop the subject until a later time

D.Refrain from talking about the subject until after the death of her husband


Quick Answers: 51

Detailed Answer: 66

136.The nurse is assessing the abdomen. The nurse knows the best sequence to perform the assessment is:

A.Inspection, auscultation, palpation

B.Auscultation, palpation, inspection

C.Palpation, inspection, auscultation

D.Inspection, palpation, auscultation


Quick Answers: 51

Detailed Answer: 66

137.The nurse is assisting in the assessment of the patient admitted with abdominal pain. Why should the nurse ask about medications that the client is taking?

A.Interactions between medications can be identified.

B.Various medications taken by mouth can affect the alimentary tract.

C.This will provide an opportunity to educate the patient regarding the medications used.

D.The types of medications might be attributable to an abdominal pathology not already identified.


Quick Answers: 51

Detailed Answer: 66

138.The nurse is asked by the nurse aide, “Are peptic ulcers really caused by stress?” The nurse would be correct in replying with which of the following:

A.“Peptic ulcers result from overeating fatty foods.”

B.“Peptic ulcers are always caused from exposure to continual stress.”

C.“Peptic ulcers are like all other ulcers, which all result from stress.”

D.“Peptic ulcers are associated with H. pylori, although there are other ulcers that are associated with stress.”


Quick Answers: 51

Detailed Answer: 66

139.The client is newly diagnosed with juvenile onset diabetes. Which of the following nursing diagnoses is a priority?

A.Anxiety

B.Pain

C.Knowledge deficit

D.Altered thought process


Quick Answers: 51

Detailed Answer: 66

140.The nurse understands that the diagnosis of oral cancer is confirmed with:

A.Biopsy

B.Gram Stain

C.Scrape cytology

D.Oral washings for cytology


Quick Answers: 51

Detailed Answer: 66

141.The nurse is assisting in the care of a patient who is 2 days post-operative from a hemorroidectomy. The nurse would be correct in instructing the patient to:

A.Avoid a high-fiber diet because this can hasten the healing time

B.Continue to use ice packs until discharge and then when at home

C.Take 200mg of Colace bid to prevent constipation

D.Use a sitz bath after each bowel movement to promote cleanliness and comfort


Quick Answers: 51

Detailed Answer: 66

142.The nurse is caring for a patient with a colostomy. The patient asks, “Will I ever be able to swim again?” The nurse’s best response would be:

A.“Yes, you should be able to swim again, even with the colostomy.”

B.“You should avoid immersing the colostomy in water.”

C.“No, you should avoid getting the colostomy wet.”

D.“Don’t worry about that. You will be able to live just like you did before.”


Quick Answers: 51

Detailed Answer: 66

143.Which is true regarding the administration of antacids?

A.Antacids should be administered without regard to mealtimes.

B.Antacids should be administered with each meal and snack of the day.

C.Antacids should be administered within 1–2 hours of all other medications.

D.Antacids should be administered with all other medications, for maximal absorption.


Quick Answers: 51

Detailed Answer: 66

144.The nurse is preparing to administer a feeding via a nasogastric tube. The nurse would perform which of the following before initiating the feeding?

A.Assess for tube placement by aspirating stomach content

B.Place the patient in a left-lying position

C.Administer feeding with 50% H20 concentration

D.Ensure that the feeding solution has been warmed in a microwave for 2 minutes


Quick Answers: 51

Detailed Answer: 66

145.The patient is prescribed metronidazole (Flagyl) for adjunct treatment for a duodenal ulcer. When teaching about this medication, the nurse would say:

A.“This medication should be taken only until you begin to feel better.”

B.“This medication should be taken on an empty stomach to increase absorption.”

C.“While taking this medication, you do not have to be concerned about being in the sun.”

D.“While taking this medication, alcoholic beverages and products containing alcohol should be avoided.”


Quick Answers: 51

Detailed Answer: 67

146.In planning care for the patient with ulcerative colitis, the nurse identifies which nursing diagnoses as a priority?

A.Anxiety

B.Impaired skin integrity

C.Fluid volume deficit

D.Nutrition altered, less than body requirements


Quick Answers: 51

Detailed Answer: 67

147.The nurse is teaching about irritable bowel syndrome (IBS). Which of the following would be most important?

A.Reinforcing the need for a balanced diet

B.Encouraging the client to drink 16 ounces of fluid with each meal

C.Telling the client to eat a diet low in fiber

D.Instructing the client to limit his intake of fruits and vegetables


Quick Answers: 51

Detailed Answer: 67

148.The nurse is planning care for the patient with celiac disease. In teaching about the diet, the nurse should instruct the patient to avoid which of the following for breakfast?

A.Cream of wheat

B.Banana

C.Puffed rice

D.Cornflakes


Quick Answers: 51

Detailed Answer: 67

149.The nurse is caring for a patient with suspected diverticulitis. The nurse would be most prudent in questioning which of the following diagnostic tests ordered?

A.Colonoscopy

B.Barium enema

C.Complete blood count

D.Computed tomography (CT) scan


Quick Answers: 51

Detailed Answer: 67

150.When the nurse is gathering information for the assessment, the patient states, “My stomach hurts about 2 hours after I eat.” Based upon this information, the nurse knows the patient likely has a:

A.Gastric ulcer

B.Duodenal ulcer

C.Peptic ulcer

D.Curling’s ulcer


Quick Answers: 51

Detailed Answer: 67

151.The registered nurse is conducting an in-service for colleagues about peptic ulcers. The nurse would be correct in identifying which of the following as a causative factor?

A.N. gonorrhea

B.H. influenza

C.H. pylori

D.E. coli


Quick Answers: 51

Detailed Answer: 67

152.The nurse is caring for the patient’s post-surgical removal of a 6mm oral cancerous lesion. The priority nursing measure would be to:

A.Maintain a patent airway

B.Perform meticulous oral care every 2 hours

C.Ensure that the incisional area is kept as dry as possible

D.Assess the client frequently for pain using the visual analogue scale


Quick Answers: 51

Detailed Answer: 67

153.The nurse is assisting in the care of a patient with diverticulosis. Which of the following assessment findings would necessitate a report to the doctor?

A.Bowel sounds of 5–20 seconds

B.Intermittent left lower-quadrant pain

C.Constipation alternating with diarrhea

D.Hemoglobin 26% and hematocrit 32


Quick Answers: 51

Detailed Answer: 67

154.The nurse is assessing the client admitted for possible oral cancer. The nurse identifies which of the following as a late-occurring symptom of oral cancer?

A.Warmth

B.Odor

C.Pain

D.Ulcer with flat edges


Quick Answers: 51

Detailed Answer: 67

155.An obstetrical client decides to have an epidural anesthetic to relieve pain during labor. Following administration of the anesthesia, the nurse should:

A.Monitor the client for seizures

B.Monitor the client for orthostatic hypotension

C.Monitor the client for respiratory depression

D.Monitor the client for hematuria


Quick Answers: 51

Detailed Answer: 67

156.The nurse is performing an assessment of an elderly client with a total hip repair. Based on this assessment, the nurse decides to medicate the client with an analgesic. Which finding most likely prompted the nurse to decide to administer the analgesic?

A.The client’s blood pressure is 130/86.

B.The client is unable to concentrate.

C.The client’s pupils are dilated.

D.The client grimaces during care.


Quick Answers: 51

Detailed Answer: 68

157.A client who has chosen to breastfeed complains to the nurse that her nipples became very sore while she was breastfeeding her older child. Which measure will help her to avoid soreness of the nipples?

A.Feeding the baby during the first 48 hours after delivery

B.Breaking suction by placing a finger between the baby’s mouth and the breast when she terminates the feeding

C.Applying warm, moist soaks to the breast several times per day

D.Wearing a support bra


Quick Answers: 51

Detailed Answer: 68

158.The nurse asked the client if he has an advance directive. The reason for asking the client this question is:

A.She is curious about his plans regarding funeral arrangements.

B.Much confusion can occur with the client’s family if he does not have an advanced directive.

C.An advanced directive allows the medical personnel to make all decisions for the client.

D.An advanced directive allows active euthanasia.


Quick Answers: 51

Detailed Answer: 68

159.The doctor has ordered a Transcutaneous Electrical Nerve Stimulation (TENS) unit for the client with chronic back pain. The nurse teaching the client with a TENS unit should tell the client:

A.“You may be electrocuted if you use water with this unit.”

B.“Please report skin irritation to the doctor.”

C.“The unit may be used anywhere on the body without fear of adverse reactions.”

D.“A cream should be applied to the skin before applying the unit.”


Quick Answers: 51

Detailed Answer: 68

160.The doctor has ordered a patient-controlled analgesia (PCA) pump for the client with chronic pain. The client asks the nurse if he can become overdosed with pain medication using this machine. The nurse demonstrates understanding of the PCA if she states:

A.“The machine will administer only the amount that you need to control your pain without your taking any action.”

B.“The machine has a locking device that prevents overdosing to occur.”

C.“The machine will administer one large dose every 4 hours to relieve your pain.”

D.“The machine is set to deliver medication only if you need it.”


Quick Answers: 51

Detailed Answer: 68

161.The 84-year-old male has returned from the recovery room following a total hip repair. He complains of pain and is medicated by morphine sulfate and promethazine. Which medication should be kept available for the client being treated with opoid analgesics?

A.Nalozone (Narcan)

B.Ketorolac (Toradol)

C.Acetylsalicylic acid (aspirin)

D.Atropine sulfate (Atropine)


Quick Answers: 51

Detailed Answer: 68

162.The nurse is taking the vital signs of the client admitted with cancer of the pancreas. The nurse is aware that the fifth vital sign is:

A.Anorexia

B.Pain

C.Insomnia

D.Fatigue


Quick Answers: 51

Detailed Answer: 68

163.The client with AIDS tells the nurse that he has been using acupuncture to help with his pain. The nurse should question the client regarding this treatment because acupuncture:

A.Uses pressure from the fingers and hands to stimulate the energy points in the body

B.Uses oils extracted from plants and herbs

C.Uses needles to stimulate certain points on the body to treat pain

D.Uses manipulation of the skeletal muscles to relieve stress and pain


Quick Answers: 51

Detailed Answer: 68

164.The client has an order for heparin to prevent post-surgical thrombi. Immediately following a heparin injection, the nurse should:

A.Aspirate for blood

B.Check the pulse rate

C.Massage the site

D.Check the site for bleeding


Quick Answers: 51

Detailed Answer: 68

165.Which of the following lab studies should be done periodically if the client is taking sodium warfarin (Coumadin)?

A.Stool specimen for occult blood

B.White blood cell count

C.Blood glucose

D.Erthyrocyte count


Quick Answers: 51

Detailed Answer: 69

166.The doctor has ordered 80mg of furosemide (Lasix) two times per day. The nurse notes the patient’s potassium level to be 2.5meq/L. The nurse should:

A.Administer the Lasix as ordered

B.Administer half the dose

C.Offer the patient a potassium-rich food

D.Withhold the drug and call the doctor


Quick Answers: 51

Detailed Answer: 69

167.The doctor is preparing to remove chest tubes from the client’s left chest. In preparation for the removal, the nurse should instruct the client to:

A.Breathe normally

B.Hold his breath and bear down

C.Take a deep breath

D.Sneeze on command


Quick Answers: 51

Detailed Answer: 69

168.The nurse identifies ventricular tachycardia on the heart monitor. Which action should the nurse prepare to take?

A.Administer atropine sulfate

B.Check the potassium level

C.Administer an antiarrythmic medication such as Lidocaine

D.Defibrillate at 360 joules


Quick Answers: 51

Detailed Answer: 69

169.A client is being monitored using a central venous pressure monitor. If the pressure is 2cm of water, the nurse should:

A.Call the doctor immediately

B.Slow the intravenous infusion

C.Listen to the lungs for rales

D.Administer a diuretic


Quick Answers: 51

Detailed Answer: 69

170.The nurse is evaluating the client’s pulmonary artery pressure. The nurse is aware that this test will evaluate:

A.Pressure in the left ventricle

B.The systolic, diastolic, and mean pressure of the pulmonary artery

C.The pressure in the pulmonary veins

D.The pressure in the right ventricle


Quick Answers: 51

Detailed Answer: 69

171.The physician has ordered atropine sulfate 0.4mg IM before surgery. The medication is supplied in 0.8mg per milliliter. The nurse should administer how many milliliters of the medication?

A.0.25mL

B.0.5mL

C.1mL

D.1.25mL


Quick Answers: 51

Detailed Answer: 69

172.If the nurse is unable to illicit the deep tendon reflexes of the patella, the nurse should ask the client to:

A.Pull against the palms

B.Grimace the facial muscles

C.Cross the legs at the ankles

D.Perform Valsalva maneuver


Quick Answers: 51

Detailed Answer: 69

173.A client with an abdominal aortic aneurysm is admitted in preparation for surgery. Which of the following should be reported to the doctor?

A.An elevated white blood cell count

B.An abdominal bruit

C.A negative Babinski reflex

D.Pupils that are equal and reactive to light


Quick Answers: 51

Detailed Answer: 69

174.A 4-year-old male is admitted to the unit with nephotic syndrome. He is extremely edematous. To decrease the discomfort associated with scrotal edema, the nurse should:

A.Apply ice to the scrotum

B.Elevate the scrotum on a small pillow

C.Apply heat to the abdominal area

D.Administer a diuretic


Quick Answers: 51

Detailed Answer: 69

175.The nurse is taking the blood pressure of an obese client. If the blood pressure cuff is too small, the results will be:

A.A false elevation

B.A false low reading

C.A blood pressure reading that is correct

D.A subnormal finding


Quick Answers: 51

Detailed Answer: 69

176.The client is admitted with thrombophlebitis and an order for heparin. The medication should be administered using:

A.Buretrol

B.A tuberculin syringe

C.Intravenous controller

D.Three-way stop-cock


Quick Answers: 51

Detailed Answer: 70

177.The client is admitted to the hospital in chronic renal failure. A diet low in protein is ordered. The rationale for alow-protein diet is:

A.Protein breaks down into blood urea nitrogen and metabolic waste.

B.High protein increases the sodium and potassium levels.

C.A high-protein diet decreases albumin production.

D.A high-protein diet depletes calcium and phosphorous.


Quick Answers: 51

Detailed Answer: 70

178.The client is admitted to the unit after a motor vehicle accident with a temperature of 102°F rectally. The nurse is aware that the most likely explanation for the elevated temperature is:

A.There was damage to the hypothalamus.

B.He has an infection from the abrasions to the head and face.

C.He will require a cooling blanket to decrease the temperature.

D.There was damage to the frontal lobe of the brain.


Quick Answers: 51

Detailed Answer: 70

179.The nurse is caring for the client following a cerebral vascular accident. Which portion of the brain is responsible for taste, smell, and hearing?

A.Occipital

B.Frontal

C.Temporal

D.Parietal


Quick Answers: 51

Detailed Answer: 70

180.A 20-year-old is admitted to the rehabilitation unit following a motorcycle accident. Which would be the appropriate method for measuring the client for crutches?

A.Measuring five finger breaths under the axilla

B.Measuring 3 inches under the axilla

C.Measuring the client with the elbows flexed 10°

D.Measuring the client with the crutches 20 inches from the side of the foot


Quick Answers: 51

Detailed Answer: 70

181.The nurse is doing bowel and bladder retraining for the client with paraplegia. Which of the following is not a factor for the nurse to consider?

A.Dietary patterns

B.Mobility

C.Fluid intake

D.Sexual function


Quick Answers: 51

Detailed Answer: 70

182.The client returns to the recovery room following repair of an intrathoracic aneurysm. Which finding would require further investigation?

A.Pedal pulses bounding and regular

B.Urinary output 20mL in the past hour

C.Blood pressure 108/50

D.Oxygen saturation 97%


Quick Answers: 51

Detailed Answer: 70

183.The nurse is teaching the client regarding use of sodium warfarin. Which statement made by the client would require further teaching?

A.“I will have blood drawn every month.”

B.“I will assess my skin for a rash.”

C.“I take aspirin for a headache.”

D.“I will use an electric razor to shave.”


Quick Answers: 51

Detailed Answer: 70

184.A client with a femoral popliteal bypass graft is assigned to a semiprivate room. The most suitable roommate for this client is the client with:

A.Hypothyroidism

B.Diabetic ulcers

C.Ulcerative colitis

D.Pneumonia


Quick Answers: 52

Detailed Answer: 70

185.The nurse has just received shift report and is preparing to make rounds. Which client should be seen first?

A.The client who has a history of a cerebral aneurysm with an oxygen saturation rate of 99%

B.The client who is three days post–coronary artery bypass graft with a temperature of 100.2°F

C.The client who was admitted 1 hour ago with shortness of breath

D.The client who is being prepared for discharge following a femoral popliteal bypass graft


Quick Answers: 52

Detailed Answer: 70

186.The doctor has ordered antithrombolic stockings to be applied to the legs of the client with peripheral vascular disease. The nurse knows that the proper method of applying the stockings is:

A.Before rising in the morning

B.With the client in a standing position

C.After bathing and applying powder

D.Before retiring in the evening


Quick Answers: 52

Detailed Answer: 71

187.The nurse is preparing a client with an axillo-popliteal bypass graft for discharge. The client should be taught to avoid:

A.Using a recliner to rest

B.Resting in supine position

C.Sitting in a straight chair

D.Sleeping in right Sim’s position


Quick Answers: 52

Detailed Answer: 71

188.While caring for a client with hypertension, the nurse notes the following vital signs: BP of 140/20, pulse 120, respirations 36, temperature 100.8°F. The nurse’s initial action should be to:

A.Call the doctor

B.Recheck the vital signs

C.Obtain arterial blood gases

D.Obtain an ECG


Quick Answers: 52

Detailed Answer: 71

189.The nurse is caring for a client with peripheral vascular disease. To correctly assess the oxygen saturation level, the monitor may be placed on the:

A.Abdomen

B.Ankle

C.Earlobe

D.Chin


Quick Answers: 52

Detailed Answer: 71

190.Dalteparin (Fragmin) has been ordered for a client with pulmonary embolis. Which statement made by the graduate nurse indicates inadequate understanding of the medication?

A.“I will administer the medication before meals.”

B.“I will administer the medication in the abdomen.”

C.“I will check the PTT before administering the medication.”

D.“I will not need to aspirate when I give Dalteparin.”


Quick Answers: 52

Detailed Answer: 71

191.The client has a prescription for a calcium carbonate compound to neutralize stomach acid. The nurse should assess the client for:

A.Constipation

B.Hyperphosphatemia

C.Hypomagnesemia

D.Diarrhea


Quick Answers: 52

Detailed Answer: 71

192.A client who has been receiving urokinase has a large bloody bowel movement. What nursing action would be best for the nurse to take immediately?

A.Administer vitamin K IM

B.Discontinue the urokinase

C.Reduce the urokinase and administer heparin

D.Stop the urokinase, notify the physician, and prepare to administer amicar


Quick Answers: 52

Detailed Answer: 71

193.Which of the following best describes the language of a 24-month-old?

A.Doesn’t understand yes and no

B.Understands the meaning of words

C.Able to verbalize needs

D.Continually asks “Why?” to most topics


Quick Answers: 52

Detailed Answer: 71

194.In terms of cognitive development, a 2-year-old would be expected to:

A.Think abstractly

B.Use magical thinking

C.Understand conservation of matter

D.See things from the perspective of others


Quick Answers: 52

Detailed Answer: 71

195.The nurse is ready to begin an exam on a 9-month-old infant. The child is sitting in his mother’s lap. What should the nurse do first?

A.Check the Babinski reflex

B.Listen to the heart and lung sounds

C.Palpate the abdomen

D.Check tympanic membranes


Quick Answers: 52

Detailed Answer: 72

196.Which of the following examples represents parallel play?

A.Jenny and Tommy share their toys.

B.Jimmy plays with his car beside Mary, who is playing with her doll.

C.Kevin plays a game of Scrabble with Kathy and Sue.

D.Mary plays with a handheld game while sitting in her mother’s lap.


Quick Answers: 52

Detailed Answer: 72

197.Assuming that all have achieved normal cognitive and emotional development, which of the following children is at greatest risk for accidental poisoning?

A.A 6-month-old

B.A 4-year-old

C.A 10-year-old

D.A 13-year-old


Quick Answers: 52

Detailed Answer: 72

198.An important intervention in monitoring the dietary compliance of a client with bulimia is:

A.Allowing the client privacy during mealtimes

B.Praising her for eating all her meals

C.Observing her for 1–2 hours after meals

D.Encouraging her to choose foods she likes and to eat in moderation


Quick Answers: 52

Detailed Answer: 72

199.The client is admitted for evaluation of aggressive behavior and diagnosed with antisocial personality disorder. A key part of the care of such a client is:

A.Setting realistic limits

B.Encouraging the client to express remorse for behavior

C.Minimizing interactions with other clients

D.Encouraging the client to act out feelings of rage


Quick Answers: 52

Detailed Answer: 72

200.A client with a diagnosis of passive-aggressive personality disorder is seen at the local mental health clinic. A common characteristic of persons with passive-aggressive personality disorder is:

A.Superior intelligence

B.Underlying hostility

C.Dependence on others

D.Ability to share feelings


Quick Answers: 52

Detailed Answer: 72


  

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