1. The nurse cares for the client diagnosed as being in the manic phase of bipolar disorder. Which behavior indicates to the nurse the client condition is improving?
a. The client offers suggestions to other clients on the unit
b. The client begins to write a book about life
c. The client sits and eats with other clients on unit
d. The client talks with other clients a group meeting
2. The health care provider orders a continuous intravenous aminophylline infusion for a two year old client. It is most important for the nurse to intervene for which situation?
a. The client heart rate is 100 bpm
b. The clients blood pressure is 100/60 mmHg
c. The clients serum theophylline level is 25 mcg/mL
d. The client is sleepy
3. The nurse teaches the client about the schedule cardiac catheterization. Which statement, if made by the client to the nurse, indicates that the teaching was effective?
a. “I understand that there is little or no risk associated with this procedure.”
b. “I may experience a little pounding sensation in my chest during the procedure.”
c. “I will be in and out of the procedure room in about 30 minutes.”
d. “I will be able to walk in the hall soon after the procedure is completed.”
4. During the second stage of labor, the client’s partner asks the nurse, “Can I go get a cup of coffee from the cafeteria?” Which response by the nurse is best?
a. “I will get you a cup of coffee.”
b. “It would be best if you stayed here at this time.”
c. “Ask your partner if it is acceptable to leave.”
d. “Why do you want to leave the room?”
5. The nurse discovers that client lying face down on the floor. Which action does the nurse take first?
a. Assess the patency of the client’s airway b. Determine whether the client is responsive
c. Check the client’s carotid pulse
d. Reposition the client onto the back
6. A nurse works 3 weeks at a 100-bed suburban hospital after working several months at a 40-bed rural hospital. The nurse prefers the total client care delivery system that was used at the rural hospital, rather then the team leading system of client care that is used at the suburban hospital. Which action does the nurse take?
a. Works with in the system at the hospital to change the type of client care delivery
b. Discuss his thoughts about the type of client care delivery system with the nurses supervisor
c. Asks the nurses peers why this type of client care delivery system is used
d. Suggests a change in the type of client care delivery system to the director of nursing
7. The nurse cares for the client diagnosed with a left traumatic below knee amputation (BKA) with a tourniquet in place. The client also has a tear from the perineum to the rectum. Which action is the nurse take first?
a. Apply anti-shock trousers
b. Assesses the clients level of consciousness
c. Remove the tourniquet
d. Check the client’s blood pressure and pulse
8. During morning rounds, the client diagnosed with schizophrenia tells the nurse, “I know you are conspiring with my spouse to keep me locked away.” Which statement by the nurse is the most appropriate?
a. “What makes you think your spouse is trying to hide your existence?”
b. “Are you saying that you think your spouse doesn’t love you?”
c. “I can see that you are frightened about being here but I am a nurse in a hospital.”
d. “I’m not conspiring with your spouse. I first met your spouse when you are admitted to the hospital.”
9. During a routine prenatal visit, the nurse auscultates the fetal heart rate (FHR). If the fetal position is left sacrum posterior (LSP), at which site does the nurse expect to find the fetal heart (FHT)?
a. Below umbilicus, on the mothers right
b. Below umbilicus, on the mothers left c. Above umbilicus, on the mothers left
d. Above umbilicus, on the mothers right
10. The nurse makes environmental rounds on the client care unit. Which problem does the nurse addressed first?
a. A wheel of the medication cart is broken
b. The needle disposal unit in unoccupied room is full c. The call light and occupied isolation room is broken
d. The ice machine and the visitors lounge is leaking water on the floor
11. The nurse observes a nursing assistive personnel (NAP) enter the room of the client diagnosed with tuberculosis (TB) to provide morning care. Which observation, if you made by the nurse, does not require an intervention?
a. The NAP enters the room while wearing goggles and a hair covering
b. That NAP enters the room while wearing a mask and sterile gloves
c. The NAP enters the room while wearing a gown and clean gloves
d. The NAP enters the room while wearing a particulate respirator and a gown
12. The nurse teaches the client about ferrous sulfate. Which statement by the client indicates to the nurse that the client understands the education?
a. “I should take this medication when I take my antacid.” b. “I should take this medication with orange juice.”
c. “I should increase my intake of foods that contain calcium.”
d. “I should take this medication at bedtime.”
13. The nurse gives discharge instructions about home care for orchitis to the client. Which statement indicates to the nurse that teaching has been successful?
a. “I should make an appointment to have a circumcision.” b. “It will help if I use a scrotal support.”
c. “I should restrict my athletic activities for about 6 weeks.”
d. “I need to stay in bed for at least 10 days.”
14. The nurse cares for the client having a left total hip arthroplasty period in which position does the nurse placed the client after surgery?
a. Legs abducted with the toes pointing upward
b. Legs adducted with a bed cradle in place
c. Flat on the bed with a foot board in place
d. Legs elevated on two pillows with the knees flexed
15. The adolescent receives 10 units of intermediate-acting insulin every morning at 0700. If the client requires the insulin dosage reduced, the nurse expects the client to present with which symptom?
a. Declines lunch at 1200
b. Reports hunger at 0900
c. Experiences confusion at 1600
d. Becomes sleepy at 2100
16. The nurse discovers the client in the bathroom attempting self-harm. Which action does the nurse take first?
a. Removes the client from the bathroom and escorts the client to the bedroom b. Stays with the client and continually monitors for self-destructive behaviors
c. Initiates a discussion with the client concerning reasons for self-harm
d. Distracts the client from trying to hurt self by talking about the family.
17. The nurse admits a 2-month-old infant for surgical correction of hypospadias. Which assessment does the nurse complete?
a. Check this scrotal sac and palpate the testes b. Inspect the position of the urinary meatus
c. Obtained a urine sample for analysis
d. Measure intake and output hourly
18. The patient of an 18 month old toddler ask the nurse, (Which toy is most appropriate for my child?) The nurse from recommend which toy?
a. A story book
b. A stuffed animal
c. A colorful mobile
d. A large yo-yo
19. The nurse cares for the client prior to cataract surgery. The nurse administers the preoperative medication. Ten minutes later, the nurse finds the client on the floor at the foot of the bed. Which action does the nurse takes initially?
a. a. Notifies the healthcare provider, and receive new orders
b. b. Complete accident report documenting the fall c. c. Stays with the client and calls for assistance
d. d. Moves the client back onto the bed providing support to the cervical area
20. The nurse teaches the client what to expect during a cardiac catheterization. Which statement if made by the client, indicates further teaching is necessary?
a. “I may feel a fluttering sensation in my chest during the test.”
b. “I may kill chest pain during the test.”
c. “I may have chest pain for several days following the test.”
d. “I may have some pain at the catheter insertion site.”
21. The parents of the 18 month old toddler with a fractured femur visits with the child in the hospital. The parents say they must go home, the child screams, cries, and hits the parents. Which statement does the nurse suggest the parents tell the child?
a. “We will return in a little while.”
b. “We will come back at 1000 hours.”
c. “We will return when the sun comes up.”
d. “We will come back as soon as we can.”
22. The nurse supervises a nursing assistive personnel (NAP) caring for the client after abdominal surgery. Which observation requires an intervention by the nurse?
a. a. The NAP massages the client’s leg using long, firm strokes
b. b. The NAP massages the client arms using smooth, gentle strokes
c. c. The NAP assist the client to put the joints through range of motion exercises
d. d. The NAP positions the client side-lying and applies lotion to the back
23. The nurse cares for the client diagnosed with anorexia nervosa. Which goal is the highest priority initially?
a. Stabilize the clients weight
b. Encourage the client to gain insight about body image c. Maintain the clients fluid and electrolyte balance
d. Increase the clients caloric intake
24. The nurse administers medications to the client diagnosed with bipolar disorder. The client approaches the nurse and begins to throw things. Which action does the nurse take?
a. Get another nurse to assist with the client
b. Give the client the medications, so the client will calm down
c. Admonishes the client, and suggested the client collect self d. Sits down and asks the client what is bothering the client
25. The nurse prepares to assess the blood pressure of the six year old child following an accident. A blood pressure cuff of appropriate size is unavailable. Which action does the nurse take?
a. Uses another site appropriate for the size of the bailable cost to obtaining reading
b. Wait until proper equipment is available before proceeding to check the blood pressure
c. Use a smaller blood pressure cuff and checked to reading in both arms
d. Uses a larger cost, and add 10 mm Hg to the systolic reading
26. The healthcare provider orders tobramycin for a 3-year-old child. The nurse enters the clients room to administer the medication and discovers that the child does not have an identification bracelet. Which action by the nurse is the most appropriate?
a. Ask a coworker to identify the child before giving the medication b. Ask the parents at the child’s bedside to state their child’s name
c. Hold the medication until an identification bracelet can be obtained from the admitting office
d. Ask the child to save the child’s first and last name
27. The nurse changes the dressing on a client two days after a bowel resection. After opening a sterile pack and putting on the sterile gloves at the clients bedside, the nurse notes the dressing needed for the dressing change are missing. Which action does the nurse take next?
a. Remove the gloves, obtained the missing dressings, and replaces the clubs to continue with the procedure
b. Closes the pack, obtained the missing dressing and new gloves, and reopen the pack to continue with procedure
c. Presses the call light, ask the nurse assistive personnel to bring the missing dressings to the clients room, and then continues with the procedure
d. Remains in place at the clients bedside while the nursing assistive personnel obtains the missing dressings, and then continues with the procedure
28. 29. The client receives parenteral nutrition (PN) via the internal jugular vein. Which action does the nurse take if the next container of PN solution is not available when it is needed?
a. Slows down the PN infusion until the new solution is available
b. Hangs a container of 0.9% NaCl until the new solution is available c. Hangs a container of 10% D/W until the new solution is available
d. Uses a heparin lock until the new solution is available
29. The nurse cares for the client with a history of chronic alcohol abuse, nutritional problems, and confabulation. In planning for the clients nursing care, which action is the first priority of the nurse?
a. Restrict visitors to minimize environmental stimuli
b. Provide a high-calorie, high- protein diet as ordered
c. Start a intravenous line of D5W with thiamine as ordered
d. Monitor behaviors for documentation of confabulation
30. The nurse cares for the school– aged Child diagnosed with cystic fibrosis (CF). The healthcare provider orders aerosol therapy. The nurse knows which is the expected outcome?
a. The child’s appetite improves
b. The child displays no evidence of infection
c. The child manages respiratory secretions without difficulty
d. The child’s activity level increases
31. Which situation suggests a nurse is addicted to the use of alcohol or habit-forming medications?
a. The nurse questions a client’s medication order left by a healthcare provider
b. The nurse volunteers to “Float” to another unit at the hospital
c. The nurse cannot be found on the unit for half an hour during the assigned shift
d. The nurse questions a client about paying before administering a narcotic analgesic
32. The nurse assesses the intravenous (IV) site on the left forearm of the child. Which finding causes the nurse to rule out the occurrence of infiltration of the IV?
a. The fluid in that IV tubing becomes pink tinged when the tubing is pinched
b. The end of the needle can be palpated in the vein in the left forearm
c. The amount of fluid infused through the IV site is a half- hour behind schedule
d. The skin on the left arm distal to the IV insertion site is cool and dry
33. The nurse cares for the client diagnosed with a left tibia fracture. The client has a long – leg walking cast applied. Several hours later, the client states, “I can’t feel my toes.” It is most important for the nurse to take a which action?
a. Ask the client to wiggle the toes
b. Observe the foot for edema
c. Assess the clients femoral pulse
d. Check the skin temperature of the foot
34. The charge nurse notes that during a staff meeting designed to discuss client care concerns, a nurse that is a non- native speaker of English remains silent. Which action does the charge nurse take?
a. Require all the nurses at the meeting to verbalize their thoughts about the topic under discussion b. Allow extra time during the meeting for questions and summarize the discussion of the group
c. Take the none-native nurse a side after the meeting and restate the major conclusions of the discussion
d. Check with the non-native nurse before the conclusion of the discussion to see if the discussion topics were understood
35. The nurse cares for the client with a chest tube attach to a three-chamber water sealed drainage system. While attempting to get out of bed, the client accidentally disconnect the chest tube from the water-seal drainage system. Which action does the nurse take first?
a. Inserts the end of the chest tube in a container of sterile saline solution
b. Clamps the chest tube near the water- seal drainage system
c. Applies a dressing to the chest tube insertion site
d. Obtains a new water- seal drainage system
36. The nurse teaches the client, scheduled for a total right hip arthroplasty, preoperatively. Teaching includes postoperative exercises. Which exercise, if perform by the client, indicates further teaching is necessary?
a. The client performs straight leg lifts
b. The client performs plantar and dorsiflexion exercises
c. The client demonstrates quadriceps and gluteal setting
d. The client demonstrate active range of motion exercises of the ankle
37. The nurse cares for the client receiving peritoneal dialysis. Which finding, if observed by the nurse during the procedure, indicate a malfunction in the system?
a. There is a leak of fluid onto the dressing in the bed
b. The client reports rectal pain on infusion of the dialysate
c. More dialysate is returned then was infused
d. The clients blood pressure decreases
38. The client scheduled for a vaginal hysterectomy tells the nurse, “I want to read my medical record.” Which action does the nurse take?
a. Asks the clients health care provider if the client can read the medical record.
b. Relays the clients request to read medical medical record to the nurses supervisor
c. Gives the medical record to the client, and remains with the client while the client reads it
d. Tells the client the medical record is the property of the hospital
39. The nurse cares for a client diagnosed with primary adrenocorticol insufficiency. The nurse expects to observe which laboratory finding?
a. Decreased sodium and glucose; increased potassium
b. Decrease sodium and potassium; increased glucose
c. Increased sodium and potassium; decreased glucose
d. Increased sodium and glucose; decreased potassium
40. The nurse works with the client who has a history of alcoholism. Which statement, if made by the client to the nurse, indicates that the client has gained some insight into alcoholism?
a. “I know I can stop drinking if I put my mind to it.”
b. “For the sake of my family, I will never drink again.”
c. “I know this is a lifelong problem, and I’ll need continued support.”
d. “I know that Alcoholics Anonymous (AA) is available in case the problem gets worse.”
41. The parent arrives from overseas to visit. The child discovers the parent depressed, disheveled, and suspicious of family members. The nurse include which nursing order in the care plan?
a. Encourage family involvement in clients treatment.
b. Involve the local international community and the clients care
c. Set limits on family visits until the client is stable
d. Assign the client to structured group activity
42. The home health nurse changes dressings four times a week for the client diagnosed with stage III pressure ulcer. The hospital admitting nurse notes that the dressing was not applied as ordered. Which action is most important for the nurse to take?
a. Contact the nursing supervisor in the hospital to report the discrepancy
b. Contact the home health nurse who has been caring for the client to report the discrepancy
c. Contact the home health supervisor to report the discrepancy
d. Document the discrepancy between what was ordered and the condition of the dressing
43. The nurse gives a client morphine 10mg intramuscularly (IM). After administering the medication, the nurse notes the order for morphine was deleted by the healthcare provider the previous day and replaced with an order of hydromorphone 4mg IM. Which documentation is best?
a. “Morphine 10mg given IM into left ventrogluteal area for report of a domino pain. Healthcare provider notified.”
b. “Morphine 10 mg given IM for reports the pain. Hydromorphone 4 mg IM ordered. Incident report completed.”
c. “Morphine 10 mg given IM for reports of abdominal pain instead of hydromorphone 4mg IM. Incident reported to healthcare provider.“
d. “Morphine given for report of incisional pain. Vital signs unchanged. Client resting resting comfortably. States pain is relieved.”
44. 45. The spouse of the 60 – year – old client brings the client to the clinic. The spouse states that during the last week the client has become confused and has been drinking large quantities of water. Lab values indicate: blood glucose 1,215 mg/dL (67.43 mmol/L), see osomolality 400 mOsmol/kg H2O (400 mmol/kg H2O), potassium 4.5 mEq/L
(4.5 mmol/L), sodium 145 mEq/L (145 mmol/L), and serum negative for ketones. The nurse expects the healthcare provider to initially order which treatment?
a. 0.45% NaCl IV and isophane insulin IV
b. D5 0.9% NaCl IV and isophane insulin SQ
c. D5W IV and regular insulin SQ
d. 0.9% NaCl IV and regular insulin IV
45. The parents bring their 9-month-old child to the clinic. Which observation by the nurse indicates a delay in development?
a. The child begins to cry when the nurse approaches
b. The child can sit unsupported
c. The child uses a Palmer grasp to hold objects
d. The child can clap the hand when asked to do so
46. An hour and a half after admission to the nursery, the nurse observe spontaneous jerky movements of the lambs and infant born to a mother with just station on diabetes mellitus (GDM). Based on these signs, which condition does the nurse expect in the infant?
a. Hyperbilirubinemia
b. Cold stress c. Hypoglycemia
d. Neurological impairment
47. The nurse cares for the client with an above-knee (AKA) amputation performed four days ago. The nurse teaches the client about care of the residual limb prior to being fitted with a temporary prosthesis. Which intervention is most important for the nurse to include an instruction?
a. Expose the residual limb to air 30 minutes daily
b. Elevate the residual limb on pillows at night
c. Wrap the residual limb with an elastic bandage during the day
d. Inspect the residual limb daily
48. To ensure a safe hospital environment for a 2-year-old toddler, which intervention does the nurse implement?
a. Arranges for one of the parents to stay with the client
b. Pads the rails of the clients crib
c. Places the client and they use bed
d. Remove equipment from the bedside table
49. The nurse cares for the client diagnosed with a loss of ability to use language following a stroke. Which action does the nurse take?
a. Involve the family members as translators
b. Utilize both verbal and nonverbal communication
c. Write out all information on an erasable board
d. Focus efforts on reducing the clients frustration when communicating
50. The nurse assesses the client who has a chest tube and a three-chamber water-seal drainage system connected dissection. Which occurrence requires an intervention by the nurse?
a. The collection container contains 100 mL of serosanguineous fluid
b. There is continuous bubbling in the section control chamber c. There is continuous bubbling in the water-seal chamber
d. The fluid in the chest tube fluctuates with the clients respirations
51. The clients adult children bring their 70-year-old parent, in the early stages of Alzheimer’s disease, to the medical clinic. Which symptom does the nurse expect the client to exhibit?
a. The client walks with a slow, staggering gate
b. The client cannot remember what the client had for breakfast that morning
c. The client reports generalized body aches
d. The client cannot remember the clients children’s names
52. The nurse takes care of the client admitted to rule out epilepsy. Which action is the highest priority for the nurse?
a. Protect the client from injury
b. Accurately document any seizures the client might have
c. Monitor the client from medication side effects
d. Provide for client assessment and teaching
53. The nurse observes cardiopulmonary resuscitation (CPR) Being performed on an 8-months-old client. The nurse intervenes if which observation is made by the nurse?
a. The client’s nose and mouth are covered by the rescuers mouth b. The clients neck is hyperextended
c. The depth of chest compressions is about 1 1/2 inches deep
d. The rate of chest compressions is 100 per minute
54. The client at 32 weeks gestation visits the healthcare provider. While the nurse palpates the woman‘s abdomen, the woman suddenly says, “I feel dizzy. I feel as if I’m going to faint.” The nurse identifies which condition causes the clients response?
a. Maternal anxiety causing peripheral vasoconstriction
b. Postural hypotension resulting from a change of position
c. Inappropriate Leopold’s maneuvers compressing blood flow to the fetus d. Hypotensive syndrome causing a reduction in cardiac output
55. The nurse teaches the client newly diagnosed with type I diabetes. Which statement by the nurse best explains the rationale for rotating injection sites for this client?
a. “You may damage the tissues causing erratic absorption of insulin if you don’t rotate sites.”
b. “You may develop an infection if you use the same area too frequently
c. “You may damage to the superficial nerves in the skin and lose sensation if you use the same area to frequently.”
d. “your thighs will eventually becomes sore if you don’t change injection sites.”
56. The nurse performs a venipuncture using an intravenous (IV) catheter for a client scheduled for surgery. Which technique does the nurse use?
a. Pierces the skin and the vein in one swift motion
b. Inserts the catheter through the skin and the 30° angle
c. Releases the tourniquet after cleaning the skin alcohol
d. Insert the catheter through the skin with the devil down
57. The nurse cares for the adolescent scheduled for surgery to repair extensive facial scarring sustained any motor vehicle accident. The nurse assesses the clients understanding of the operation. Which response, if made by the client to the nurse, indicated the client has the capacity for abstract thinking?
a. “When I was in the hospital right after the accident, the nurse who took care of me showed me what the skin graft with look like on a doll.”
b. “The first thing I am going to do when I finish with this operation is begin saving for my own car.”
c. “I’m scared that my face will look worse after the surgery than it does now. This operation sounds horrible.” d. d. “The healthcare provider talked to me about the different techniques involved and the risk of the skin
graft being rejected.”
58. The new patient holds the two week old neonate E erect with the feet touching the table top. The baby responds by flexing and extending the legs. The parent says to the nurse, “look my baby is trying to walk!” Which response, if made by the nurse to the parent, is best?
a. “Your baby is demonstrating the dance or step reflex. It will be replaced by deliberate movement in about 2 to 3 weeks.”
b. “Your baby won’t start to walk until the baby is about a year old. The baby is just performing random movements.”
c. “Your baby is advanced for two weeks of age. This type of movement is not usually seen into the baby is two months old.”
d. “Your baby is not trying to walk. That is physically impossible at this age.”
59. The nurse teaches the school age to how to use crutches correctly. Which action by the client requires intervention by the nurse?
a. The client rest win the client become short of breath or diaphoretic when walking
b. The tips of the crutches rest 8 to 10 inches in front into the side of the clients toes when the client stands
c. The clients arms are flexed when the client rests the hands on the hand pieces of the crutches d. The clients weight is supported by the foam-rubber pad on the under arm peace
60. The nurse cares for the client diagnosed with a severe head injury. In planning care for this client, the nurse understands that which priority is highest?
a. a. Turn the client every 2 hours
b. Maintain an intravenous intake of 125 mL per hour
c. Put all joints through a range of motion every 4 hours
d. Perform skincare every 2 hours
61. The client returns to the room after a subtotal thyroidectomy. The nurse is most concerned if a which observation is made?
a. The client is having difficulty speaking
b. There is a moderate amount of serosanguineous drainage on the neck dressing
c. The nasogastric (NG) tube attached to intermittent section is draining a moderate amount of translucent fluid
d. The client reports moderate pain at incision site
62. The 39 year old primipara come to the hospital at 29 weeks gestation and report symptoms of preterm labor. Which assessment by the nurse is most helpful in confirming this diagnosis?
a. Regular contractions are noted on a monitor tracing
b. The client says the water broke this morning
c. The presenting part is engaged
d. The client reports intermittent lower abdominal pain
63. To auscultate for breath sounds in the middle lobe of the long, the nurse places the stethoscope in which location? (picture)
a. 4th or 5th intercostal place on the right side
64. The nurse cares for a woman diagnosed with toxic shock syndrome. Which action does the nurse take first?
a. X-a. Teaches the client to use pads rather than tampons during the menstrual period
b. b. Sits with the client and let her know that she is not alone
c. c. Administers ciprofloxacin 400 mg q 12 hours via IV infusion over 60 minutes d. d. Administers 0.9% NaCl at hundred and 150 mL/hr into the clients right forearm
65. The client diagnosed with Alzheimer’s disease wanders around the unit disturbing other clients. The clients gate is steady. Which action by the nurse is most appropriate?
a. Remind the client to stay in the room
b. Escort the client back to the clients room
c. Restraining the client in an armchair in the hall
d. Allow the client to assist the staff in distributing the clean linen
66. The nurse teaches the client how to perform self monitoring blood glucose (SMBG) by using a blood glucose monitor. Which action, if performed by the client, indicates the teaching was successful?
a. The client washes the hand in cool water before the procedure
b. The client elevates the hand on a pillow before the procedure
c. The client sticks the center of the proximal phalanx
d. The client allows a large drop of blood to touch the test strip
67. The nurse cares for the client diagnosed with septic shock syndrome. An initial nursing assessment of this client would most likely reveal which symptoms?
a. Dysrhythmias and edema b. Fever and hypotension
c. Increased urinary output and dehydration
d. Nystagmus and photophobia
68. The nurse cares for the client is experiencing third trimester bleeding, consisting of dark red spotting. The client is not reporting uterine pain and tenderness. The nurse realizes that these symptoms are indicative of which situation?
a. a. Abruptio placentae b. b. Placenta previa
c. c. Missed abortion
d. d. Hdatidiform mole
69. The nurse teaches a client receiving amitriptyline. Which statement, is made by the client to the nurse, indicates an adequate understanding of amitriptyline?
a. a. “When I start to feel better, I can adjust my dosage of amitriptyline.”
b. b. “Amitriptyline works best when taken in the morning before breakfast.” c. c. “It maybe 3 to 4 weeks before I’ll see a change due to amitriptyline.”
d. d. “I can’t eat food such as age cheese, beer, red wine, and yogurt.”
70. The nurse cares for the client diagnosed with a dramatic amputation of the left leg during automobile accident. The client frequently presses the call light without reason and makes angry remarks to the nursing staff. Which statement best explains the reason for the clients behavior?
a. a. The client is behaving rebelliously because the client is in a structured setting
b. b. The client is using attention-getting behaviors because the client is unhappy
c. c. The client’s physical needs are not being met
d. d. The client is responding to the change in body image
71. Before discharge, the nurse teaches the client who underwent surgery for an ileal conduit. Which instruction, if provided by the nurse to the client, is most important?
a. a. “Dilate the stoma every day with your little finger.” b. b. “Drink at least 2000 mL of fluid every day.”
c. c. “Change the appliance several times each day to prevent odors.”
d. d. “Abstain from sexual intercourse for two weeks while the incision heals.”
72. During the admission assessment, the client with a history of schizophrenia tells the nurse, “I must submerge myself and hot water to atone for my sins.” The nurse is most concerned if which observation is made?
a. a. The client rings the hands and says, “I am a prisoner because of my past sins.” b. b. The client sits in the bathroom and turned the water faucet on full force
c. c. The client has a noticeable body odor, and the hair and skin are oily
d. d. The client is accompanied to the hospital by a sibling who leaves immediately
73. The nurse cares for the client in labor at 35 weeks gestation. Which statement, if found by the nurse in the clients medical records, is unexpected?
a. The client takes 20 units of intermediate acting insulin each morning, which maintains blood glucose within normal limits
b. Results of the complete blood count (CBC) reveal red blood cells (RBC) 4.9 million/mm3 (4.9 x 10^12/L), hematocrit 45% (0.45 the volume fraction), hemoglobin 15 g/dL (150 g/L)
c. The client is 41 years old and unmarried
d. The client smokes 15 cigarettes a day and drink a glass of red wine with dinner
74. The nurse discusses foods that are included on a diabetic diet. Which food, if selected by the client diagnosed with type I diabetes, indicates the nurse teaching is successful?
a. Roast beef, glazed carrots, and pudding b. Turkey, asparagus, and blueberries
c. Frankfurter, fried potatoes, and sherbet
d. Macaroni and cheese, yams, and Jell-O
75. The nurse cares for a client six hours after he traditional cholecystectomy. It is most beneficial for the nurse to take which action before encouraging the client to cough and deep breathe?
a. Auscultate breast sounds
b. Position the client and an upright position in the bed
c. Administer oxygen via nasal cannula d. Administer analgesics as prescribed
76. The results of a recent complete blood count (CBC) for the female client are white blood cells (WBC) 1000 cells/mm3 (1.0 x 10^9/L), Platelets 200,000/mm3 (200 x 10^9), Hemoglobin (Hgb) 14 g/dL (8.69 mmol/L), hematocrit (Hct) 39% (0.39). Which is the most important nursing goal for this client?
a. prevent infection
b. promote oral hydration
c. Promote rest
d. Prevent injury
77. The nurse cares for the client diagnosed with menopause. The client asks the nurse, “why is estrogen replacement therapy (ERT) given?” Which explanation by the nurse is most accurate?
a. “Estrogen decreases your testosterone production.”
b. “Estrogen delays the onset of menopause.”
c. “Estrogen may make your menses regular again.”
d. “Estrogen helps prevent the development of osteoporosis.“
78. The nurse finds one of the housekeeping staff sleeping in an unoccupied client room. Which action does the nurse take?
a. Continues to monitor the situation into the housekeeping person wakes up
b. Wake the housekeeping person, and tells the person to leave the client room c. Reports the situation to the nurses supervisor
d. Reports the situation to the housekeeping supervisor
79. The nurse cares for the client in the psychiatric Hospital. The client has not slept for several nights, talks rapidly, and pieces before wringing the hands. Which is the highest nursing priority during the first few days of hospitalization for this client?
a. Protect the client from manipulative impulses and mood swings b. Provide rest, food, and liquids for the client
c. Structure a routine to use the client energy in acceptable outlets
d. Isolate the client from interaction with other clients
80. A nurse, at the outpatient clinic, and cares for the client who uses crack cocaine several times a week. Which assessment, it’s made by the nurse, suggest that the client is in withdrawal?
a. The client walks with an unsteady gait
b. The client states, “Things I can’t see are touching me.”
c. The client states, “My feet feel glued to the floor.” d. Pupils are dilated, appears diaphoretic
81. A postpartum client reports tenderness in the groin and pain in the calf of the right leg. Which action does the nurse take first?
a. Encourage early in frequent ambulation
b. Apply warm soaks for 20 minutes every four hours to the right leg c. Check the areas for warmth and edema
d. Perform passive range of motion exercises three times daily
82. The client diagnosed with breast cancer receives tamoxifen citrate. The nurse identifies that tamoxifen has which action?
a. a. Causes an increase in the secretion of progesterone
b. b. Causes testosterone to be secreted by the pituitary gland
c. c. Enhances the action of the female hormones d. d. Acts as an estrogen antagonist
83. The nurse developed a care plan for a client diagnosed with acute phase rheumatoid arthritis. The nurse understands that which school of nursing care is primary?
a. Help the client and adjust to changes in self-concept
b. Reduce the clients pain and inflammation
c. Maintain optimal joint mobility, and prevent further deformity
d. Promote increased activity tolerance
84. The nurse performs discharge teaching with the client diagnosed with emphysema. Which statement, it’s made by the client, indicates teaching was successful?
a. “An intensive exercise program is important in regaining my strength.” b. “I should drink fluids with all my meals and in between meals.”
c. “My outside activity should be limited to one hour each day.”
d. “Cold weather will help my breathing problems.”
85. The nurse cares for a 10 day old infant being breast-fed. Which characteristics does the nurse expect the infant stool to have?
a. Dark green, sticky, and odorless
b. Light brown, firm, with a characteristic bowel movement odor c. Yellow, pasty, with a sour milk odor
d. Greenish brown, thin, containing milk curds
86. The nurse cares for the client reporting and odor from a new double barrel colostomy. Which action does the nurse taken initially?
a. Checks the appliance for leaks
b. Provides additional ventilation in the room
c. Suggests foods that are not gas-forming
d. Offers a room deodorant
87. The hospitalized client says to the nurse, “I’m not sure I want to stay here. I feel so frightened and alone.” Based on this statement, which approached by the nurse is most appropriate?
a. “I know what you mean. I’ll arrange for your family to stay with you.”
b. “Many clients feel frightened when first admitted to hospital. It will seemed better soon.” c. “A hospital can be a frightening place. I will stay with you.”
d. “You don’t need to feel alone. There are many nurses here to help you.”
88. The nurse cares for the clients scheduled for a liver biopsy. Which statement is made by the nurse is best?
a. “You will be given a general anesthetic before the biopsy.”
b. “You will drink a special dye so that x-rays may be taken.” c. “You will be asked to exhale and hold your breath.“
d. “You will change position several times during the procedure.”
89. The nurse performed a physical assessment of a school age child. Which behavior demonstrates the proper procedure for examining the deep tendon reflexes?
a. The nurse compares the reflexes on both sides of the body to see if they are symmetrically equivalent
b. The nurse asked the client to clinch the fist before checking the biceps reflex
c. The nurse positions the arm in an extended position before checking the triceps reflex
d. The nurse checks all the reflexes on one side of the body and then checks the contralateral side
90. The healthcare provider orders neomycin for a client diagnosed with hepatic encephalopathy. The nurse understands which is the primary purpose of this treatment?
a. Prevent rupture of esophageal varices by decreasing irritation of portal blood vessels
b. Prevent infection caused by decreased production of white blood cells
c. Convert ammonia levels in the blood to urea
d. Reduce bacterial production of ammonia in intestine and blood
91. The nurse cares for the client diagnosed with heart failure (HF). During a clinic visit, the client states, “I have not been feeling like my old self for about two weeks.” It is most important for the nurse to ask which question?
a. “Do your ankle becomes swollen at the end of the day?”
b. “How do you feel after you eat dinner?”
c. “Do you have chest pain when you inhale?”
d. “Where do you sleep at night?”
92. The client in the transition phase of labor reports lightheadedness and a tingling sensation in the fingers. Which action does the nurse take?
93. a. Instructs the client to breathe into a paper bag help tightly against the mouth and nose
a. Instruct client to take a cleansing breath and refocuses the concentration
b. Tell the client to pants three times and then at scale against pursed lips
c. Encourages the client to pan and blow with the next contraction
94. The client diagnosed with human immunodeficiency virus (HIV) returns for evaluation of a Mantoux skin test. Which observation indicates the nurse this client has a significant reaction to the test?
a. There is a 10 mm area of erythema on the dorsal aspect of the left forearm b. There is a 5 mm area at induration on the inner aspect of the left forearm
c. There is a 6 mm area of erythema on the medial aspect of the left arm
d. There isn’t 8mm area of induration on the lateral aspect of the left arm
95. Which technique, if explain by the nurse to a client, best describes the correct way to mix intermediate acting (isophane) and short acting (Regular) insulin?
a. Intermediate acting insulin is drawn up first. Then the short acting insulin is added to the syringe
b. Either short acting insulin or intermediate acting insulin can be drawn up first if there is no mixing of the solutions
c. Short acting insulin is drawn up first. Then the intermediate acting is added to the syringe
d. Intermediate acting insulin and short acting insulin must be drawn up in separate syringes
96. The nurse provides care for a client following a left above knee amputation (AKA). The client tells the nurse, “I feel like I still have my left leg.” Which statement by the nurses best?
a. “this imaginary sensation is caused by your inability to deal with the changing your body image.”
b. “You are denying that you have lost her leg, and that causes you to feel as though it is still there.”
c. “The brain sends signals to the residual land that cause it feel like your leg is still there.”
d. “The trauma to your leg causes the neuronal network to send messages to your brain that your leg is still there.”
97. The nurse plans care for the client diagnosed with osteoporosis. The nurse recommends which exercise?
a. Aerobic dance class twice a week
b. Isometric exercise daily
c. Swimming one mile three times each week d. Walking 1 mile daily
98. The nurse cares for the adolescent diagnosed with orchitis. Which action is most important for the nurse to take?
a. Encourage a diet high in fiber
b. Insert a Foley catheter, as ordered
c. Prepare the area for surgery d. Elevate the scrotum on towels
99. The nurse uses an otoscope to examine the tympanic membrane of an adult as part of a physical assessment. Which behavior, if performed by the nurse, indicates an understanding of the procedure?
a. The nurse tips the client’s head toward the otoscope before beginning examination
b. The nurse warms the speculum before inserting it into the canal
c. The nurse pulls the auricle upward and backward to straighten the canal
d. The nurse watches through the otoscope as it is advanced into the canal
100. The college student has a Mantoux test performed as part of a routine physical examination. To evaluate the test, the nurse performs which action?
a. Inspects the test site area for the presence of erythema b. Palpate the injection site to assess front area of induration
c. Measures the diameter of any reddened areas at the injection site
d. Compares the skin appearance at the test site with the surrounding skin
101. The parent brings the preschooler to the clinic for every team check up. The parent claims that the child fears “monsters” and “bogeymen” In the bedroom at night. Which statement by the parent indicates that the parents are dealing with their child’s fears appropriately?
a. They’ve reassure the child there are no such things as monsters and bogeymen
b. They tell the child these fears will go away
c. They leave a night light on in the child’s room
d. They let the child sleep with them occasionally
102. The parent asked the nurse, “How can I tell if my teenage child under the influence of marijuana?” Which statement by the nurses best?
a. “When your child walks, the child would appear on court needed and unsteady on the feet.”
b. “Your child may appear belligerent and be looking for a fight.” c. “Your child would be hungry, especially for junk food.”
d. “Your child would be talkative with slurred speech.”
103. The nurse cares for the client receiving hemodialysis three times a week. The client takes the digoxin and furosemide, and a multivitamin. The nurse identifies that the digoxin should be given at which time?
a. After a low level is obtained
b. During dialysis
c. every 12 hours
d. Before dialysis
104. The nurse teaches the client how to use a walker. Which observation, if made by the nurse, indicates that client is using the walker correctly?
a. The client grasps the front bar of the walker with both hands and stands in the middle of the walker
b. Client tips the walker toward the client and then take several steps
c. The client sets the walker away from the client and then take several steps d. The client grasps the sides of the walker and stands between the back legs
105. A nurse who is three months pregnant is assigned to pass medications to a group of clients. The nurse asks another nurse to administer which medication?
a. Rifampin
b. Amphotericin B c. Cyclophosphamide
d. Mafenide
106. The nurse cares for a 6 lbs. 7 oz. (2947 gm) Baby delivered two hours ago. Which observation of the infant, if made by the nurse, is expected?
a. The infant has course rhonchi and a respiratory rate of 20 b. The infant has find crackles and a respiratory rate of 44
c. The infant has periods of apnea lasting 40 seconds any respiratory rate of 26
d. The infant has grunting restorations any respiratory rate of 60
107. The nurse performs a quality assurance evaluation of the client assignments given to members of the nursing staff. The nursing staff consists of three RNs in one LPN/LVN. The nurse determines the assignments are appropriate if the LPN/LVN is assigned to which client?
a. The client newly diagnosed with type I diabetes mellitus
b. The client diagnosed with a left femur fracture and being treated with traction
c. The client diagnosed with emphysema and schedule to be discharged later today
d. The client diagnosed with low back pain is scheduled for a myelogram in the afternoon
108. The nursing team consists of one RN, one LPN/LVN, and an experienced nursing assistive personnel (NAP). These tasks need to be completed: a straight catheterization for urinary retention for a client after a cholecystectomy, tracheostomy care for a client two days after a laryngectomy, and a blood glucose determination for a client receiving parenteral nutrition (PN) through a central venous catheter. Which task does the nurse assigned to each team member?
a. Performs a tracheostomy care, assign the catheterization to the LPN/LVN, and ask that NAP to check the blood glucose level
b. Perform the catheterization, ask the LPN/LVN to do the tracheostomy care, and ask the NAP to check the blood glucose level
c. Performed a tracheostomy care, I signed the LPN/LB in to check the blood glucose level, and ask the NAP to place the client with urinary retention on a bedpan
d. Obtain a blood glucose level, assign the tracheostomy care to the LPN/LVN, And asked the NAP to perform the catheterization
109. The nurse cares for four clients. Which client is the nurse see first?
a. A five-year-old child with croup and who has respirations of 35
b. A four-year-old child with pneumonia and who has a temperature of 10 1°F (38.3°C)
c. a three-year-old child receives parenteral nutrition (PN) through a peripherally inserted central catheter (PICC)
d. A two days after surgical repair of a strangulated abdominal hernia
110. The nurse observed the student nurse section a client. The nurse determines that proper suctioning technique is used if which action is observed?
a. Apply suction each time the client inhales
b. Apply suction as the catheter is both inserted and withdrawn for no more than 10 seconds
c. Apply suction as the catheter is withdrawn from no more than 10 seconds
d. Apply suction at the catheter is inserted for no more than 20 seconds
111. The nurse cares for the client following a right total hip arthroplasty. The client has an IV of 0.9% NaCl and has a Hemovac drain in place. Prior to discharge from the post anesthesia care unit, which finding justifies the nurse calling the healthcare provider?
a. The client reports pain at incision site
b. There is 200 mL of blood in the Hemovac drain c. The client cannot move the toes of the right foot
d. There is a small amount of blood on the clients dressing
112. The client hospitalized for treatment of a bleeding peptic ulcer reports substernal chest pain. The nurse finds the client diaphoretic and cool with vital signs: BP 110/56 mm Hg, T 98.4°F (36.8°C), P 76 bpm, RR 28 breaths/min. The client IV of 0.9% NaCl in fuses at 80 mL/hr. Lab results show potassium 3.2 mEq/L (3.2 mmol/L), sodium 140 mEq/L (140 mmol/L), and chloride 93 mEq/L (93 mmol?L). Cardiac monitoring shows multifocal premature ventricular contractions (PVCs). The nurse identifies which condition is the most likely cause of the clients PVCs?
a. Hypoxemia
b. Hypokalemia
c. Hypovolemia
d. d. Hyponatremia
113. The nurse cares for the adolescent diagnosed with full thickness burns on the upper chest and partial thickness burns on the hands, arms, and face. Which method does the nurse encourage the client to use to communicate?
a. Winks
b. Paper and pencil c. The foot
d. Gestures
114. The parent of a preschooler with a tracheostomy asks the nurse, “Why is my child section so frequently?” The nurses response is based on the knowledge that it is not as important to section the child when which situation occurs?
a. The child secretions become tenacious
b. The child’s color worsens
c. The child’s respiratory rate decreases d. The child’s lung sounds are congested
115. Immediately after a percutaneous liver biopsy, the nurse places the client in which position?
a. Semi Fowler’s
b. Supine
c. Left side lying d. Right side lying
116. The adolescent client had surgery yesterday for repair of a torn rotator cuff in the right shoulder. Although fentanyl 100 mcg intravenously is ordered every three hours PRN, the client has refused the medication since surgery. During morning rounds, the the nurse notes the client has teeth clenched and is diaphoretic. Which action does the nurse take first?
a. Ask the client, “Why have you refused pain medication?”
b. Administer the fentanyl 100 mcg intravenously as ordered
c. Explain that taking medication will not lead to medication addiction d. Question the client, “Are you experiencing any pain?”
117. The nurse understands that the test for phenlketonuria (PKU) is most reliable at which timeframe?
a. After two weeks of age
b. After a source of protein has been ingested
c. After a source of fat has been ingested
d. After the danger of hyperbilirubinemia has passed
118. The nurse cares for the client after the delivery of an 8 lbs. 7 oz. newborn. Which measures by the nurse received the highest priority during the first day postpartum?
a. Check the signs of hypertension and albuminuria
b. Gently massage the fundus every four hours
c. Observed for signs of hemorrhage and infection
d. Encourage direct contact with the infant to facilitate bonding
119. The parent brings a five month old infant to the well baby clinic for a routine checkup. Which finding, if observed by the nurse is unexpected?
a. The child is able to sit erect if propped with a pillow
b. The child grasp objects with both hands
c. The child’s drools frequently
d. The child has slight head lag when pulled to sitting position
120. The nurse cares for the client who just delivered an 8 lbs. 4 oz. baby. The nurse knows which finding is most significant?
a. The woman reports a moderate amount of abdominal pain and cramping
b. The woman’s vital signs change from blood pressure (BP) 136/78 mm Hg, polls 76 bpm to BP 124/66 mm Hg, pulse 90 bpm
c. The woman voices ambivalent feelings about becoming a mother at her age
d. The woman saturates a peripad with sanguinous drainage in one hour
121. The nurse cares for the adolescent being evaluated for type I diabetes. Which statement does the nurse expect the parents to make?
a. My child has become very picky about the food choices
b. My child seems to get feet tangled and fall c. My child has started to wet the bed at night
d. My child has only one close friend at school
122. The nurse observes and LPN/LVN irrigate an abdominal wound for the client. Which action, if observed by the nurse, requires an intervention?
a. The LPN/LVN instills the irrigating solutions with flows away from the wound
b. The LPN/LVN remove the old dressing and then discard the gloves
c. The LPN/LB inputs on sterile gloves and pours the irrigating solution into the sterile container
d. The LPN/LVN warms the irrigating solution to 90 – 95°F (32.2 – 35°C)
123. The nurse cares for the client after a left total hip arthroplasty. The client post operative orders include turning. To implement this order the nurse places the client in which position?
a. Lying on the unoperated side with legs adducted
b. Lying on the operated side with legs adducted
c. Lying on the operated side with legs abducted d. Lying on the unoperated side with legs abducted
124. The nurse cares for the client diagnosed with low back pain. The clients partner tells the nurse, “My partner has increased alcohol intake since the back injury several months ago.” Based on this information, which symptoms does the nurse observe?
a. Hypotension, restlessness, and increased respirations
b. Course motor tremors, increased pulse, and increased anxiety
c. Blackouts, hallucinations, and convulsions
d. Loss in inhibition, drowsiness, and impaired judgment
125. The nurse teaches a client following a cholecystectomy. Which statement, if made by the client, indicates to the nurse that further instruction is needed?
a. “I should notify the healthcare provider if my stools get light for my urine turns dark.”
b. “I should avoid eating a lot a fat in my diet.”
c. “I will need weekly injections of vitamin K for six weeks.”
d. “I should not lift heavy objects for 4 to 6 weeks.”
126. The nurse begins an intermittent IV infusion of penicillin that is to infuse over a 20 minute period. Which action can the nurse take while this medication infuses?
a. Admit a 45 year old client diagnosed with graves disease
b. Resume teaching a recently diagnosed diabetic client about insulin injections
c. Change the dressing on a client with a stasis ulcer
d. Witness the signing of a consent form for a bronchoscopy
127. The nurse instructs the client how to apply nitroglycerin ointment. The nurse is concerned if the client makes which statement?
a. “I can’t put the ointment on my chest because I am so hairy.”
b. “I should place the ointment on the skin near my heart.”
c. “I should wipe away the ointment from the last dose before applying a new does.”
d. “I should wash my hands after applying the ointment.”
128. The nurse is assigned to care for four clients. Which client is the nurse see first?
a. A 17 year old client who delivered a 5 lbs. 9 oz. baby two hours ago and he plans to breast feed b. An 18 year old client who had a C-section one hour ago and who has saturated three peripads
c. A 26-year-old client three hours after a normal badge in all delivery and he was experiencing hematuria
d. A 20 year old client who delivered a full term infant six hours ago and who has not voided
129. The nurse cares for the client diagnosed with right-sided pneumothorax. Which auscultation findings does the nurse hear?
a. Bilateral reduction in breath sounds
b. Crackles and wheezes on inspiration bilaterally
c. High pitched expiratory wheezes on the right side d. Reduction of breast sounds on the right side
130. The partner of a client with a history of myocardial infarction (MI) and heart failure (HF) Tells the nurse, “I do not want my partner to be kept alive on machines if the heart stops.” Which action is most important for the nurse to take?
a. Document the partners wishes in the medical record
b. Ask the family if they want the client resuscitated
c. Determine if the partner understands the consequences of this decision
d. Respect the wishes of the partner
131. The nurse needs to complete several tasks before getting the report to the next shift. The client on the second day after surgery needs the below knee amputation (BKA) re-wrapped. An elderly client needs discharge teaching about atenolol and hydrochlorothiazide. In which order does the nurse complete the tasks?
a. Free wraps the BKA, and gives the report to the next shift, and then teaches the clients adult child about medications
b. Teaches the clients adult child about the medications, give the report to the next shift, and then rewraps the BKA
c. Teaches the client’s adult child about the medications, ask another nurse to rewrap the BKA, and then gives the report to the next shift
d. Informs the next shift that report will be delayed 20 minutes, rewraps the BKA, and then teaches the client adult child about the medications
132. The nurse evaluates the lab results for the client diagnosed with rheumatoid arthritis. The nurse expects elevations in which laboratory data?
a. Serum alkaline phosphate and rheumatoid factor
b. C-reactive protein and erythrocye sedimentation rate (ESR)
c. Cortisol and plasma fibrinogen
d. White blood cell (WBC) count and serum creatinine
133. The nurse cares for the client after a right modified radical mastectomy. Which action does the nurse take?
a. Maintains the clients right arm in a position of adduction
b. Compresses the clients right arm with a dressing to reduce edema
c. elevate the clients right arm and keeps the hand at the highest point
d. Keep the client’s right arm and hand dependent to reduce venous return
134. The client diagnosed with drug abuse says, “I have been taking drugs for so long, I can’t imagine my life without them.” Which an initial response by the nurse is best?
a. “Using drugs has been the way that you have dealt with your problems.”
b. “Your life will be different now that you are involved in treatment.”
c. “Drugs have not helped you to cope with your life.”
d. “It is too soon for you to be concerned about what might happen.”
135. The client has a radium implant for treatment of cervical cancer. Which intervention to the nurse implement?
a. Requires that all family members where a lead apron when they visit
b. Monitors the client output in the bedside commode
c. Limits the time spent in the clients room to 30 minutes each shift d. Keeps the unused linen in the room until the implant is removed
136. The nurse teaches a school age child and the parents about diabetes mellitus type I prior to discharge. The nurse tells the parents to take which action at the child suddenly becomes unconscious?
a. Take the child to the hospital immediately
b. Inject regular insulin according to the sliding scale
c. Get the child 8 ounces of orange juice to drink
d. Inject glucagon according to the package directions
137. The nurse cares for the client following a total right hip arthroplasty. During the immediate postoperative period, it is most important for the nurse to assist the client with which activity?
a. Taking a few steps using a walker
b. Quadriceps and gluteal setting exercises c. Coughing and deep breathing
d. Using the commode to avoid
138. The nurse cares for the client receiving parenteral nutrition (PN) through a single lumen subclavian catheter. The client has an order for a unit of packed red blood cells (RBCs). Which action does the nurse take?
a. Administer the RBCs are a newly inserted peripheral IV line
b. Runs the RBCs piggyback with the PN solution into the subclavian catheter
c. Delays the administration of the RBCs into the PN solution infuses into the subclavian catheter
d. Temporarily discontinues the PN while the RBCs infused into the subclavian catheter
139. The nurse cares for the adolescent undergoing peritoneal dialysis. The nurse infuses 2000 mL of dialysate solution. Later 1000 mL of solution returns. What action does the nurse take next?
a. Presses on the clients abdomen.
b. Advances the catheter into the abdomen
c. Milk the catheter
d. Turns the client from side to side
140. A parent brings the 4 month old infant to the clinic for diphtheria, tetanus toxoid, acellular pertussis (DTaP) and in activated polio vaccine (IPV) immunizations. Which statement indicates to the nurse if the parent understands when the child should return for the next DTaP?
a. “My child will be able to sit without support when I bring my child back.”
b. “My child will be creeping when I bring my child back.”
c. “My child will be able to understand ‘no-no’ when I bring my child back.” d. “My child will be cutting the two lower teeth when I bring my child back.”
141. The client he was confused talks to the nurse about thoughts in relation to a fantasy world. Which action does the nurse take?
a. Helps the client reflect on the clients past and plan the future
b. Maintains patience with the client? And listens to the client talk without interruption
c. Immediately interrupt the clients daydreaming and interjects reality d. Speaks to the client in simple sentences about present events
142. The nurse provides morning care for the client with a cuffed tracheostomy tube. Before performing oral hygiene? The nurse notes the tracheostomy cuff is deflated. Which action does the nurse take next?
a. Inflate the tracheostomy cuff, and continues with oral hygiene
b. Documents that the tracheostomy cuff with deflated while oral hygiene was performed
c. Checks the medical record to see if the tracheostomy tube was deflated the last time oral hygiene was performed
d. Reviews the health care providers orders to see if the cost should be inflated before providing oral hygiene
143. The nurse cares for the client reporting retrosternal chest pain and shortness of breath. The blood pressure is 110/70 mm Hg; pulse rate 100 bpm and irregular; respirations 28 breaths/min. After attaching a cardiac monitor, which order does the nurse implement first?
a. Restrict the fluid and sodium intake
b. Take a 12 lead electrocardiogram
c. Administer morphine subcutaneously d. Administer oxygen per nasal prongs
144. The nurse cares for the client with a tracheostomy that was performed yesterday. Which symptom requires an intervention by the nurse?
a. a. The client secretions from the tracheostomy are thick, yellow, and dry
b. The clients lab results are: pH 7.4, paCO2 40 mmHg (5.32kPa), HCO3 23 mEq/L (23 mmol/L) pO2 95 mmHg (12.64 kPa)
c. The client costs when the suction catheter is advanced into the tracheostomy
d. The clients respirations are 12 per minute and deep
145. The healthcare provider orders pancreatin capsules for the preschool child. Which statement, it’s made by the parents to the nurse, indicates the need for further teaching about this medication?
a. “We should give our child a glass of juice immediately after giving this medication.”
b. “We should remind our child not to chew this medication when it is taken.” c. “We should give our child this medication first thing in the morning.”
d. “Our child can take this medication sprinkled on a small amount of cool, soft food.”
146. The nurse cares for the client seen in the emergency department after being assaulted and robbed any mall parking lot. Which intervention by the nurse is the most appropriate initial response?
a. Help the client to identify the clients immediate needs
b. Document the clients physical injuries in the medical records
c. Prepare the client to obtain specimens
d. Assist a client to fill out the police report
147. The nurse supervises care provided in a day care center. Which food, if offered during snack time to a four-year-old child, is best?
a. Two carrot sticks
b. Two celery sticks
c. A small box of raisins
d. A banana
148. The client receives naproxen. The nurse teaches the client to report which most important symptom to the healthcare provider?
a. Drowsiness in the morning
b. Fatigue at bedtime
c. Headache in the evening
d. Stomach pain in the afternoon
149. The nurse teaches a client diagnosed with epilepsy about the disease and its management. Which statement is made by the client, indicates a need for further teaching?
a. “I may experience slurred speech from the medications.”
b. “Epilepsy is not a form of mental illness.”
c. “I will take my medications when I have seizures.”
d. “There is no reason to limit my activities.”
150. The client diagnosed with depression reports the nurse, “I’m too tired to take a shower. Please don’t bother with me today.” Which action, if taken by the nurse, is most appropriate?
a. Returning two hours to encourage the client to take a shower b. Assist the client to meet hygiene needs that day
c. Suggest that the client follow unit rules and take a shower
d. Document “Morning care refused. Client stated, ‘I’m too tired,'” and allow the client to continue resting
151. The nurse understands that the initial nursing action taken for a prolapse of the umbilical cord is effective if which observation is made?
a. The fetal heart rate (FHR) is maintained at 150
b. There is no bleeding from the vagina
c. The fetal heart rate (SHR) decreases with the onset of the contraction
d. The mother’s vital signs are stable
152. A four month old infant has stop breathing. Which action does the nurse take?
a. Covers the infants nose and mouth with the nurses mouth
b. Uses the palm of the nurses hand to compress the sternum rhythmically
c. Palpate the carotid artery pulse with one finger
d. Hyperextends the infants neck to provide an open airway
153. The nurse cares for the client newly diagnosed with type I diabetes. The client receives intermediate acting insulin 20 units every morning. The client ask the nurse, “Why can’t I take an ‘insulin pill’ like my grandparent does?” Which action by the nurse is best?
a. Explain to the client the difference between insulin and oral hypoglycemic agents
b. Assess the clients blood glucose level since the insulin was ordered
c. Tell the client that if sweets are avoided, the client may not have to take insulin
d. Assure the client that it is too early to answer that question
154. The nurse cares for the client after he traditional cholecystectomy. The T-tube drains 300 mL of greenish brown fluid. Which action does the nurse taken initially?
a. Milks the T-tube to encourage additional drainage
b. Clamps the T-tube to prevent further fluid loss
c. Irrigates the T-tube to assess for patency
d. Documents the description of the drainage from the T-tube
155. The client tells the nurse, “I have been menstruating constantly for one year.” It is most important for the nurse to ask the client which question?
a. “What is the duration of your normal menstrual cycle?”
b. “What is your health history?”
c. “How many pads do you use in one hour?”
d. “What does your menstrual flow look like?”
156. The nurse cares for the client diagnosed with the ménière’s disease. Which signs and symptoms does the nurse expect the client to exhibit?
a. Discharge from the ear, pain, and conductive deafness
b. Severe headache, enlargement lymph nodes, and chills c. Vertigo, tinnitus, and neurosensory hearing loss
d. Fever, ear noises, and headache
157. The nurse cares for the client diagnosed with Alzheimer’s disease. The client wanders from room to room. Which action does the nurse take?
a. Places the client in a geri-chair with a lapboard to complete a puzzle
b. Attaches a picture of the clients family to the door of the clients room
c. Writes the clients room number on a piece of paper and puts it in the pocket of the clients trousers
d. Sits the client in a chair by the nurses station, and applies a soft best restraint
158. Which principle best guides the nurse working with pregnant adolescents?
a. Involving the father of the baby will ease the pregnant adolescents adjustment to pregnancy and parenthood
b. Pear relationships will determine to a great extent how the adolescent coats with pregnancy and parenthood c. Physical and emotional immaturity places the pregnant adolescent and infinite risk
d. Adolescent pregnancy helps the teenager with the development task of establishing her unique identity
159. The nurse cares for the client displaying symptoms of a panic attack. Suddenly the client says to the nurse, “Get out of here, and leave me alone.” The nurse takes which action?
a. Decreases environmental stimuli and remains with the client
b. Gently reminded the client that the nurse is there to help
c. Helps the client explore what is making the client anxious
d. Leave the room to allow the client to gain control of the clients behavior
160. The nurse plans care for an 18 month old child Buck’s extension traction. Which action is most important for the nurse to perform?
a. Provide appropriate toys for the client
b. Use aseptic technique when caring for the leg in traction
c. Put all joints through a full range of motion every 4 hours d. Complete thorough skincare every 2 hours
161. The nurse cares for the client in active labor. Fetal heart rate (FHR) is 150. After the apex of the contraction, the fetal heart rate drops to 125. When the contraction is completed, the fetal heart rate is 130. The nurse understands these rate changes indicate which condition?
a. This indicates a late deceleration
b. This indicates poor baseline variability
c. This indicates a variable deceleration
d. This is within normal limits
162. The nurse teaches the client diagnosed with osteoporosis about dietary adjustments. Which menu, if selected by the client, indicate to the nurse the teaching was effective?
a. Baked chicken, potato, vanilla pudding, and apple juice
b. Macaroni and cheese, broccoli, cherry pie, and coffee c. Peanut butter and jelly sandwich, apple, and milk
d. Broiled salmon, corn, custard, and tea
163. The nurse conducts a class about eating disorders at the junior high school. The nurse mentions which common characteristics of people who are at risk for anorexia nervosa?
a. Distorted body image
b. Poor academic achievement
c. History of aberrant social behaviors
d. Disregard for parental expectations
164. The nurse assesses the client five hours after a right total knee arthroplasty. Which observation, it’s made by the nurse, requires intervention?
a. The continuous passive motion (CPM) device extends the clients right leg 10°
b. The client bends the left leg and pushes down to position itself on a fracture bedpan
c. The Hemovac drain contain 75 mL of serosanguineous fluid
d. The continuous passive motion (CPM) Device flexes the clients right leg 90°
165. Which is the best school for a 50-year-old client diagnosed with chronic bronchitis?
a. Client will walk one fourth of a mile three times a week within three weeks
b. Client will use the treadmill and will stop when client becomes shorter breath c. Client will increase physical activity according to clients tolerance
d. Client will resume gardening daily during clear weather
166. The nurse teaches the client about and arteriovenous fistula in the right arm of the client prior to discharge. Which information about care of the fistula does the nurse include?
a. Have the blood pressure checked once a week b. Place the fingers over the fistula once a day
c. Avoid raising the right arm above head
d. Where an ace bandage around the right arm for several days
167. The healthcare provider orders activity therapy for the depressed client. The clients partner asks the nurse, “How will this help my partner?” Which statement, if made by the nurse, is best?
a. “Activity therapy permits insight into the problems causing depression.”
b. “Activity therapy increases exposure to other depressed clients.”
c. “Activity therapy promotes socialization and increases self-esteem.”
d. “Activity therapy channel self-destruction impulses to more acceptable behaviors
168. The nurse explains to a client why the healthcare provider has prescribed nitroglycerin. Which statement, it’s made by the client to the nurse, demonstrates that the teaching was successful?
a. “The medication will prevent extra heartbeats.”
b. “The medication will slow my heart rate.”
c. “The medication will control my blood pressure.” d. “The medication will reduce my hearts workload.”
169. The healthcare provider asks the nurse to obtain a urine sample from a client with an indwelling catheter. To obtain the urine specimen, which action does the nurse take first?
a. Removes 10 mL from the drainage bag
b. Clamps the catheter to being above the porthole
c. Indeed the drainage bag and collects the next 10 mL from the bag
d. Clamps the catheter to being below the porthole
170. A prominent member of society is hospitalized with a diagnosis of urinary tract calculi. People are calling and asking about the clients condition. Which action does the nurse take?
a. Provide them with the name of the clients healthcare provider b. Suggest that they speak to a family member
c. Offers a time when they can speak directly to the client
d. Informs them that the client is doing as well as can be expected
171. A client receives digoxin 0.25 mg and furosemide 40mg once a day. Which action does the nurse take?
a. Increase the fluid intake to 3000 mL per day b. Increased oral intake of potassium rich foods
c. Administers the digoxin with food
d. Gives the digoxin in the morning and the furosemide at night
172. The nurse cares for the client diagnosed with chronic obstructive pulmonary disease (COPD). Which priority does the nurse rank at highest?
a. Offer the client small, frequent feedings
b. Encourage the client to play cards with other clients
c. Involve the client in a support group for people with a chronic disease
d. Allow the client to make choices regarding care
173. The school age client receives prednisone. It is most important for the nurse to assess which information while the client receives this medication?
a. The clients pulse rate
b. The clients blood glucose
c. The clients blood pressure
d. The client’s daily weight
174. The client diagnosed with rheumatoid arthritis receives a nursing diagnosis of “Activity intolerance related to fatigue.” Which intervention it does the nurse include?
a. Increase the number of activities the client performs each day
b. Perform activities of daily living for the client
c. Ask the clients family member to provide most of the clients care d. Provide rest periods for the client between activities
175. The school nurse talks with a group of college students too will be traveling to an underdeveloped country on a field trip. The students expressed concerns about contracting hepatitis during the trip. Which statement, if may by student to the nurse, indicates that further teaching is necessary?
a. “I shouldn’t eat any soups or drink iced beverages while I’m gone.”
b. “I should drink only bottled water while we are traveling.”
c. “I should only eat vegetables during the trip that have been cooked.” d. “I shouldn’t need any food I am unfamiliar with until I return.”
176. The RN observes the nursing student insert a urinary catheter in a preschool age child. Which action, if observed by the nurse, requires an intervention?
a. Nursing student spreads the labia minora in an anterior direction
b. The nursing student select a #10 french catheter
c. The nursing student wipes around the circumference of the labia using a sterile cotton ball
d. The nursing student inserts to catheter one inch into the urethra
177. The nurse cares for the client displaying confusion and agitation. As a nurse tries to admit the client to the unit, the client becomes more belligerent and agitated. The nurse takes which action?
a. Call the security guard, and asks the client to calm down
b. Obtained an order for an antipsychotic medication that has sedation as a side effect
c. Explains the unit rules, and asks the client to respect them
d. Approach is the client in a nonthreatening manner, and reduces environmental stimuli
178. The client is they’ve reported victim of an assault. The police told the nurse they found the client is oriented, agitated, and wandering in a parking lot. Upon arrival in the emergency department (ED), the nurse observes that the client is calm and quiet. The nurse concludes the client’s change in behavior is a result of which reason?
a. The client feels relieved to be in a hospital setting
b. The client is withdrawing into a catatonic state
c. Enough time has passed for the client to calm down d. At this time the client is in a state of denial
179. The nurse cares for the client diagnosed with a right hip fracture being treated with bucks traction using a foam boot. The nurse observes and LPN/LVN replaced the phone boot after morning care. Which observation, it’s made by the nurse, requires an intervention?
a. The LPN/LVN places the clients heal well within the heel of the boot
b. The LPN/LVN tapes the knot securing the weight to the rope
c. The LPN/LVN secures a Velcro strap over the malleolus
d. The LPN/LVN attaches a weight to the spreader or footplate
180. The nurse teaches a client diagnosed with tuberculosis (TB) prior to discharge. Which statement, if made by the client to the nurse, indicates the teaching is effective?
a. “I should keep taking my pills until the bottle is empty.”
b. “If I cough or sneeze, I should cover my mouth with a disposable tissue.”
c. “I will have to wear a mask when I leave my house for next month.”
“I can’t be around my grandchildren for several wee
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