1.

A client is in the hospital with wrist restraints applied to keep

the patient from pulling out their urinary catheter. While assessing the
patient, which observation by the nurse indicates that the person who
placed the wrist restraints on the client failed to follow safety
guidelines?
a. A quick-release knot was used to secure the restraint.
b. Order for restraints is re-ordered by the physician every 24
hours.
c. The documentation identifies the restraint is released every 2
hours.
d. The restraint is secured to the side rail of the bed.

2. The nurse notes a fire in a client’s room. The nurse’s first priority
is to:

a. Report the fire.

b. Remove that client from the room.
c. Contain the fire.
d. Extinguish the fire.

3. When doing a home hazard appraisal of an 83 year-old client, the

nurse is concerned for the client’s safety when the following is
assessed:
a. Throw rug in the entry way to wipe feet.
b. Night light in hallway and bathroom.
c. Water heater temperature set at 150 degrees F.
d. Raised toilet seat with arms.

4. The physician asks the nurse if they feel a patient needs

restraints. The nurse indicates that alternatives have been utilized.
What behaviors would indicate that the alternatives are working?
a. The patient continues to get up from the chair at the nurses’
station.
b. The patient apologizes for being “such a bother”.
c. The patient intently works on a jig-saw puzzle.
d. The sitter leaves the patient alone while they go to lunch.

5. The nurse is providing information regarding safety and

accidental poisoning to a grandmother who will be taking custody of a
1-year-old grandchild. Which of the following comments would indicate
that the grandmother needs further instruction?
a. “The number for poison control is 800-222-1222.”
b. “Never induce vomiting if my grandchild drinks bleach.”
c. “I should call 911 if my grandchild loses consciousness.”
d. “If my grandchild eats a plant, I should provide syrup of ipecac.”

6. The charge nurse identifies a safety concern when observing the

LPN:

a. Place an insulin syringe in the sharps container.

b. Place a tongue blade in the mouth of a seizing patient.
c. Mark the knee a patient is to have replaced in surgery.
d. Apply nonskid footwear on a client prior to walking them.

7. An elderly patient presents to the hospital with a history of falls,

confusion, and a stroke. The nurse determines that the patient is at
risk for falls. Which of the following interventions is most appropriate
for the nurse to take? (SELECT ALL THAT APPLY)
a. Place the patient in restraints.
b. Lock beds and wheelchairs when transferring.
c. Move them to a room closer to the nurses station.
d. Silence fall alert alarm upon request of the family.

8. The nurse is caring for a client who has streptococcal

pneumonia. Which of the following infection control precautions should
the nurse implement?
a. Request dietary to provide disposable utensils on the client’s
meal tray.
b. Wear a surgical mask when obtaining the client’s vital signs.
c. Place the client in a private, negative air pressure room.
d. Do not allow visitors to enter the client’s room.

9. A client was prescribed an antibiotic and is to take one tablet

twice a day. When teaching the client about proper antibiotic use, the
nurses’ teaching includes:
a. The antibiotic will destroy any microorganism that invades your
body.
b. Take the antibiotic as directed, until it is all gone.
c. If you miss your morning dose, take two tablets at the next
dosing time.
d. If your partner shows the same symptoms, give them a tablet to
see if it helps.

10. The nurse is caring for a client with multiple open wounds due to
burns. Based on this information, the nurse identifies the following
nursing diagnosis:
a. Risk for infection related to impaired inflammatory response.
b. Risk for infection related to imbalanced nutrition
c. Risk for infection related to impaired skin integrity
d. Risk for infection related to isolation

11. When caring for a 20-year old client on droplet isolation

precautions, the nurse is concerned that the client may experience
psychological implications of isolation when the client states:
a. “When the nurses wear a mask, I cannot read their lips.”
b. “I like walking in the halls, but I won’t, I feel dirty.”
c. “I’ll watch my favorite show to keep me entertained.”
d. “I am sleeping about 8 hours during the night.”

12. The nurse is caring for a patient on Contact Precautions. Which

of the following actions would be appropriate to prevent the spread of
the disease?
a. Wear a gown, gloves, face mask, and goggles for interactions
with the patient.
b. Use a dedicated blood pressure cuff that stays in the room and
used for that patient only.
c. Place the patient in a room with negative airflow.
d. Transport the patient quickly when going to the radiology
department.
13. The nurse is caring for a patient who has cultured positive for
Clostridium Difficile. Which of the following nursing actions would be
appropriate given this organism?
a. Instruct assistive personnel to use soap and water rather than
hand sanitizer to clean hands.
b. Place the patient on droplet precautions.
c. Wear an N95 respirator when entering the patient room.
d. Teach the patient cough etiquette.

14. The nurse knows that the following client is at greatest risk for
infection:

a. A 16-year old with a broken bone that poked through the skin.
b. An 80-year old taking ibuprofen daily for arthritis.
c. A 2-year old who attends day care 4 times a week.
d. A 40-year old who smokes cigarettes.

15. The client asks the nurse, “What is a HAI?” The nurses’ best
response is:
a. “An infection of the blood from IV drug abuse.”
b. “An infection anywhere in the body due to low T-cells.”
c. “An infection from delivery of health care in a health care
facility.”
d. “An infection due to physicians overuse of antibiotics for viral
infections.”

16. The nurse is planning care for a client diagnosed with active
Tuberculosis Disease, and includes the following transmission-based
precaution in the plan of care:
a. Droplet precautions
b. Standard precautions
c. Airborne precautions
d. Contact precautions

17. The nurse is not following infection prevention and control

measures when they:
a. Wear artificial nails while working in the ICU.
b. Do not share urine-measuring containers among patients.
c. Encourage a client who is immobile to cough and deep breathe
every 2 hours.
d. Wipes around the wound edge first and then cleans outward
away from the wound.

18. To break the chain of infection in the transmission phase, the

nurse teaches the patient to:
a. Take their temperature twice a day.
b. Monitor excretions and secretions.
c. Eat a well-balanced diet.
d. Use condoms during intercourse.

19. The nurse is concerned that a patient diagnosed with a localized

infection of the elbow has progressed to a systemic infection when the
following data is collected. (Select all that apply).
a. Redness at the elbow
b. Malaise
c. Nausea and vomiting
d. Anorexia
e. Edema at the elbow

20. A nurse is caring for a patient in the nursing home who has
difficulty swallowing. Which potential problem associated with
dysphagia has the greatest influence on the plan of care?
a. Anorexia
b. Aspiration
c. Self-care deficit
d. Inadequate intake

21. A nurse is caring for a confused patient. Which should the nurse
do to prevent this patient from falling?
a. Encourage the patient to use handrails
b. Place the patient near the nurses’ station
c. Explain how to use the call light
d. Maintain close supervision

22. A nurse is assessing a patient being admitted to the unit. Which

is the most important information that puts the patient at risk for
physical injury?
a. Weakness experienced from before the admission.
b. Medication that causes diarrhea.
c. Two recent falls at home.
d. The use of glasses.

23. A home health nurse is performing a home assessment for safety.

Which of the following comments by the patient would indicate a need
for further education?
a. “I will schedule an appointment with a chimney inspector next
week.”
b. “Daylight savings is the time to change batteries on the carbon
monoxide detector.”
c. “If I feel dizzy when using the heater, I need to have it
inspected.”
d. “When it is cold outside in the winter, I can warm my car up in
the garage.”

24. Which client is at highest risk for a pressure injury?

a. The client with decreased level of consciousness.

b. The client exercises every other day.
c. The client is 55 years of age and eats 2/3 of their meal.
d. The client weighs 125lb and is 5’4” and smokes.

25. The nurse is collaborating with the dietitian about a patient with
a stage III pressure injury. After the collaboration, the nurse orders a
meal plan that includes increased
a. Fat.
b. Carbohydrates.
c. Protein.
d. Vitamin E.

26. The nurse notes a mixture of clear and blood-tinged drainage

from a surgical wound. The nurse will document this as:
a. Serous drainage
b. Serosanguineous drainage
c. Sanguineous drainage
d. Purulent drainage
27. Which of these findings in a post-operative patient should the
nurse associate with dehiscence?
a. Report by the patient that something has “given way” at the
incision.
b. Protrusion of visceral organs through a wound opening.
c. Chronic drainage of fluid through the incision site.
d. Drainage that is odorous and purulent coming out of the
incision.

28. While admitting an elderly gentleman from a nursing home, the

nurse notes a shallow, open ulcer without slough on the right heel of
the patient (Extends to the dermal/epidermal layer only). This pressure
injury would be staged as stage
a. I
b. II
c. III
d. IV

29. The nurse is evaluating whether a patient’s turning schedule was

effective in preventing the formation of pressure ulcers. Which finding
indicates success of the turning schedule?
a. Staff documentation of turning the patient every 2 hours.
b. Absence of skin breakdown.
c. Presence of redness only on the heels of the patient.
d. Patient’s eating 100% of all meals.

30. The components of the Braden Scale that are assessed by the
nurse to predict a client’s risk for pressure injury includes all of the
following (CHOOSE ALL THAT APPLY):
a. Usual food intake pattern.
b. Degree to which skin is exposed to moisture.
c. Ability to respond to pressure-related discomfort.
d. Staging of a pressure ulcer.
e. Friction and sheer.
31. While performing a moist dressing change, the nurse (CHOOSE
ALL THAT APPLY):
a. Removes the old packing when it is dry.
b. Dries the periwound with gauze.
c. Packs the wound with saline moistened gauze.
d. Changes the dressing every 7 days, unless saturated.

32. A homeless adult patient presents to the emergency department.

The nurse obtains the following vital signs: temperature 94.8° F, blood
pressure 100/56, apical pulse 56, respiratory rate 12. Which of the vital
signs should be addressed immediately?
a. Temperature.
b. Blood Pressure.
c. Apical Pulse.
d. Respiratory rate.

33. The nurse is caring for an elderly patient admitted with nausea,
vomiting, and diarrhea. Upon completing the health history, which
priority concern would require collaboration with social services to
address the patient’s health care needs?
a. The electricity was turned off 2 days ago
b. The water comes from the county water supply.
c. A son and family recently moved into the home.
d. The home is not furnished with a microwave oven.

34. The nurse is preparing a patient for surgery. The nurse explains
that the reason for writing in indelible ink on the surgical site the word
“correct” is to:
a. Distinguish the correct surgical site.
b. Label the correct patient.
c. Comply with the surgeon’s preference.
d. Adhere to the correct regulatory standard.

35. The nurse is caring for a patient who was involved in an

automobile accident 2 weeks ago. The patient sustained a head injury
and is unconscious. The nurse is able to identify that the major
element involved in the development of a decubitus ulcer is
a. Pressure.
b. Resistance.
c. Stress.
d. Weight.

36. The nurse is caring for a patient who has experienced a

laparoscopic appendectomy. The nurse recalls that this type of wound
heals by
a. Tertiary intention.
b. Secondary intention.
c. Partial-thickness repair.
d. Primary intention.

37. The nurse is caring for a patient in the burn unit. The nurse
recalls that this type of wound heals by
a. Tertiary intention.
b. Secondary intention.
c. Partial-thickness repair.
d. Primary intention

38. A nurse is preparing to administer erythromycin estolate 500 mg

po every 8 hours. It is only available in erythromycin suspension 250
mg/ ml. How many ml’s does she administer per dose?
a. 1 ml.
b. 2 ml.
c. 3 ml.
d. 4 ml.

39. A patient has developed a decubitus ulcer. What laboratory data

would be important to gather?
a. Serum albumin
b. Creatine kinase
c. Vitamin E
d. Potassium

40. The nurse is individualizing Mr. Wu’s plan of care by writing a

plan for his nursing diagnosis of anxiety. Why does the nurse need to
write goals/outcomes on the plan of care? Because outcomes
describe:
a. Desirable changes in the patient’s health status.
b. Specific patient responses to medical interventions.
c. Specific nursing behaviors to improve a patient’s health.
d. Criteria to evaluate the appropriateness of a nursing diagnosis.

41. Which nursing intervention is considered an independent

intervention?

a. Administering 1 liter of dextrose 5% in normal saline solution at

100 mL/hour.
b. Encouraging the postoperative client to perform coughing and
deep breathing exercises.
c. Explaining his diet to the client; then communicating the
teaching with the dietitian.
d. Administering morphine sulfate 2 mg IV to the client with
postoperative pain.

42. The nurse caring for a client formulates outcomes based on the
understanding that the outcomes should be which of the following?
a. General in scope
b. Abstract in nature
c. No bounds on time
d. Measurable

43. The nurse is assessing the client’s abdominal wound and notices
a yellow-green purulent wound drainage. The nurse recognizes that
the drainage is an example of:
a. A judgment
b. An inference
c. Objective data
d. Subjective data

44. The client will have a soft formed bowel movement by 9/30/13.
What part of the nursing process is this?
a. An assessment
b. An intervention
c. An outcome
d. An evaluation

45. During the diagnosis phase of the nursing process the nurse:

a. Conducts research
b. Synthesizes data and identifies patterns
c. Develops nursing activities
d. Chooses the best diagnosis according to the medical diagnosis

46. A new intervention was added to the care plan by the doctor:
Mechanical soft diet. This is an example of what type of
intervention?
a. Independent
b. Patient initiated
c. Dependent
d. Collaborative

47. A licensed nurse is to administer/monitor oxygen at 2 liter/min

nasal continuously. In the nursing process what area would this fall
under?
a. Assessment
b. Evaluation
c. Intervention
d. Revision

48. The nurse assesses a client, obtaining information from the

primary source. The nurse has gathered the information from which
of the following?
a. Client’s spouse
b. Client
c. Medical records
d. Primary care physician

49. Which of the following instructions is most important for the

nurse to include when teaching a mother of a 3-year-old about
protecting her child against accidental poisoning?
a. Store medications on countertops out of the child’s reach
b. Purchase medication in child-resistant containers
c. Take medications in front of the child, and explain that they are
for adults only
d. Never leave the child unattended around medications or cleaning
solutions

50. A nurse has seen several patients at a community health

center. Which of the following patients would be most at risk for
developing an infection?
a. An infant who just received first immunizations
b. An adolescent who had a basketball physical
c. An older adult with several chronic illnesses
d. A middle-aged adult with joint pain and stiffness

1. To decrease the effects of immobility on the cardiovascular

system, the nurse includes the following in the plan of care:
a. Teach the patient to rise slowly when going from a
supine to a vertical position.
b. Teach the patient to keep legs in the dependent
position when sitting.
c. Teach the patient to do the valsalva maneuver when
moving up in bed.
d. Teach the patient to hold breath and strain when
having a bowel movement.

2. Patients who are on bedrest or otherwise immobile are at

risk for:
a. Pneumonia
b. Diarrhea
c. Increased urinary output
d. Improved circulation

3. The nurse is assessing the way the patient walks. The

manner of walking is known as the patient’s
a. Activity tolerance.
b. Body alignment
c. Range of motion.
d. Gait.

4. The nurse positions an unconscious client who is drooling

in the following position:
a. Supine
b. Orthopneic (tripod)
 c. Sim’s
d. High Fowler’s

5. The nurse is observing a CNA working with a client who is

using crutches. The nurse knows to intervene when they see:
a. The crutches are about two inches below the axillae.
b. The arms are almost extended when leaning on palms
on hand bars.
c. The client places both crutches in hand on affected
side and holds on to handrail with hand on unaffected
side.
d. The client goes up the stairs leading with the crutches
and affected leg, followed by the unaffected leg.

6. The nurse identifies the problem of Activity Intolerance for

a client after collecting the following data: (CHOOSE ALL
THAT APPLY)
a. Has to stop and rest in the middle of showering.
b. BP prior to walking 110/56, and 116/62 immediately
after walking.
c. Client reports shortness of breath while ambulating to
bathroom.
d. Client carries on an unlabored conversation while
dressing and combing hair.
7. While caring for a patient with known, insomnia, the nurse
asks the patient the following question to determine if they
are currently having problems with insomnia:
a. Have you recently fallen asleep while having a
conversation with another person?
b. Has your spouse told you that you are still sleep
walking during the night?
c. Have you had any problems with falling asleep,
staying asleep or early morning waking lately?
d. Has your spouse told you that you stop breathing
during the night for periods of time?

8. The nurse teaches a middle aged adult that the following

will promote sleep:
a. Exercise one hour prior to going to bed.
 b. Keep the bedroom comfortably cool.
c. Watch TV in bed; turn the sleep timer on 30 minutes.
d. Consume an alcoholic beverage right before bed.

9. When the nurse is assessing short term memory, an

appropriate question to ask an 80 year-old client is:
a. “Can you tell me what high school you went to?”
b. “What year was your first son born?”
c. “What did you have for supper last night?”
d. “Where did you go last month on vacation?”

10. The nurse suspects the client has a visual problem

when the following data is collected:
a. Strong body odor
b. Excessive use of salt
c. No reaction to loud noise
d. Over-reaching for an object

11. The nurse assesses that the client is immobile, blind,

and does not participate in any social activities. The nurse is
primarily concerned that the patient is at risk for:
a. Presbycusis
b. Dementia
c. Delirium
d. Sensory deprivation

12. The nurse identifies that the client is hard of hearing

and includes all of the following in the plan of care (SELECT
ALL THAT APPLY):
a. Move into a position where the client can see you
when talking to them.
b. Turn down TV when talking with the client.
c. Use visible facial expressions while talking with the
client.
d. Shout into the client’s good ear.
13. The nurse implements the following interventions for
the resident who is manifesting sensory overload (SELECT ALL
THAT APPLY):
a. Turns the lights on brightly so the patient can see
what is going on around them.
b. Provides a private room and limits visitors.
c. Allows for uninterrupted periods of sleep and rest.
d. Encourages social interaction with other residents.

14. A 48 year-old client with glaucoma wants to know how

frequently they should get their eyes checked. The nurses’
best response is:
a. “twice a year.”
b. “every 1-2 years.”
c. “every 3 years.”
d. “every 3-5 years.”

15. The nurse assesses that the client is unable to name

common objects or express simple ideas in words. The nurse
documents that the client has:
a. Macular degeneration
b. Stroked
c. Confusion
d. Expressive aphasia

16. The nurse includes the following question when

assessing the auditory sense:
a. “When did you last visit an eye doctor?”
b. “Do you experience any dizziness or vertigo?”
c. “Do you have any numbness or tingling in your
extremities?”
d. “Do you have difficulty perceiving the position of parts
of your body?”

17. Acute confusion with a cause is the definition of:

a. Delirium
b. Dementia
c. Alzheimer’s
d. Somnolence
18. To provide tactile stimulation for an unconscious
client, the nurse implements the following intervention:
a. Encourages client to chew food thoroughly.
b. Sprays favorite cologne on client.
c. Brushes and combs client’s hair.
d. Pulls shades to reduce outdoor light.

19. An adolescent tells the nurse, “I have difficulty

awaking in the morning for school because I am up late doing
homework. I am cranky to my little sister, I fall asleep
sometimes in class, and I have to drink about 4 Mountain Dew
a day to stay awake.” The nurse identifies that the adolescent
is describing symptoms of:
a. Parasomnia
b. Narcolepsy
c. Sleep deprivation
d. Hypersomnia

20. The patient asks the nurse what narcolepsy means.

The nurses best response is:
a. “Things a person does in their sleep that interferes
with their sleep.”
b. “When medical conditions, such as a stroke, causes a
person to excessively sleep in the daytime.”
c. “When a person suddenly has this overwhelming
sleepiness and they fall asleep during the day.”
d. “When a person has periodic cessation of breathing
during their sleep.”

21. The nurse implements the following to prevent

problems with the integumentary system for a patient who is
immobile:
a. Turn every 2 hours.
b. Incentive spirometry every 2 hours.
c. Increase fiber to 25 grams per day.
d. Encourage the patient to do crossword puzzles.

22. The nurse is not using good body mechanics when

they:
 a. Pivot on balls of feet when boosting patient up in
bed.
b. Uses a ceiling lift for lifting a patient who is paralyzed
out of bed to chair.
c. Lifts a child out of bed weighing 30 pounds and places
them in a wheelchair.
d. Bends at waist to lift a box off of the floor to place it
on a chair.

23. A nursing student is completing an assessment on an

80-year-old patient who is alert and oriented. The patient’s
daughter is present in the room. Which of the following actions
made by the nursing student requires the nursing professor to
intervene?
a. The nursing student is making eye contact with the
patient.
b. The nursing student is speaking only to the patient’s
daughter.
c. The nursing student nods periodically while the
patient is speaking.
d. The nursing student leans forward while talking with
the patient.

24. The nurse and patient take action to meet health-

related goals. The nurse is in which phase of the helping
relationship?
a. Pre-interaction
b. Orientation
c. Working
d. Termination

25. A patient was admitted 2 days ago with pneumonia

and a history of angina. The patient is now having chest pain
with a pulse rate of 108. Using SBAR, which piece of data will
the nurse use for B?
 a. Having chest pain.
b. Pulse rate of 108.
c. History of angina.
d. Oxygen is needed.

26. Hello Dr. Smith, this is Barb from the med-surg unit
calling. I’m caring for Mr. Green in room 221. I am calling
about his pain control. Mr. Green is a 23 year old who had a
surgical repair of a fracture ankle 1 day ago. He has had
minimal pain control since surgery. He has an order for
Morphine 1-2 mg every 4 hours for pain less than 5 and
Morphine 3 mg every 4 hours for pain over 5. He is not allergic
to any medications. This is the first time he has had any type
of surgery. Mr. Green rates his pain 9/10 with the quality
being sharp and radiating to his mid-calf area. He is hesitant
to ambulate. His pedal pulses are equal and strong. His
surgical site is clean and dry. His vital signs are stable. What
part of the SBAR report was omitted?

a. S
b. B
c. A
d. R

27. The nurse completes an Incident Report after a

patient falls while getting out of bed unassisted. What is the
main purpose of this report?

a. Ensure that all parties have an opportunity to

document what happened.
b. Help established who is responsible for the incident.
c. Make data available for quality-control analysis.
d. Document the incident on the patient’s chart.

28. The nurse knows that the purpose of using SBAR is to

provide a structured method for:
a. Communicating during hand-offs
 b. Documenting assessments
c. Completing incident reports
d. Providing patient teaching

29. The nurse is discussing DAR format charting with a

graduate nurse. The graduate nurse demonstrates
understanding when they document that they applied a cool
washcloth to the patients forehead under this area:
a. D
b. A
c. R
d. Focus Area

30. After providing care, a nurse charts in the patient’s

record. Which entry is an appropriate entry to document?
a. Appears restless when sitting in chair.
b. Drank adequate amounts of water.
c. Apparently not sleeping well, yawn frequently.
d. Skin is pale and cool.

31. The nurse is trying to get a patient to cough and deep

breathe. The nurse is using therapeutic communication when
they state:
a. “If you don’t cough and deep breathe you will end up
with pneumonia.”
b. “It’s up to you if you want to cough and deep breathe,
I can’t make you.”
c. “Your incision might hurt when you cough, but you
must do this.”
d. “To help prevent pneumonia, it is important to cough
and deep breathe.”

32. The nurse charts the following in the subjective area

of SOAP charting? (Select all that apply)
a. States, “I feel extremely happy to be going home.”
b. Wound is reddened and warm, and draining clear
fluid.
c. States, “I am really scared about surgery tomorrow.”
 d. Patient is pacing the floor while awaiting test
results.
e. Oral temperature is 99.5 degrees Fahrenheit.

33. The nurse includes all the following in the shift report.
(Select all that Apply)
a. Patients name and date of birth
b. Patient is currently having nausea.
c. Patient received anti-nausea medication 1 hour ago.
d. Patient had an appendectomy 5 years ago.
e. Patient had an abdominal X-Ray yesterday showing no
obstruction

34. Family members who provide full time care for a

dependent family member with dementia are reporting
exhaustion and burn out. Which approach, by the nurse, is in
the best interest of the patient?
a. Ask the patient what they would like to do
b. Have the family caregivers discuss it among
themselves
c. Inform the family that the patient should go to a
nursing care facility
d. Assist the family to arrange a family conference
involving social services and appropriate resources

35. The provider ordered warfarin (Coumadin) 10 mg po

once a day on the even days of the month and 15 mg on the
odd days of the month. The 10 mg tablets are scored. How
many tablets should the nurse administer on the 5th day of the
month?
a. 0 tabs
b. 1 tab
c. 1.5 tabs
d. 2 tabs

36. Which of the following patients requires a co-signature

for a valid consent for surgery?
a. 15-year-old mother whose infant requires exploratory
surgery.
 b. 40-year-old resident in a home for developmentally
disabled adults
c. 90-year-old adult who wants more information about
the risks for surgery.
d. 50-year-old unconscious trauma victim who needs
insertion of a chest tube.

37. A newly hired experienced nurse is preparing to

change a patient’s abdominal dressing and hasn’t done it
before at this hospital. Which action by the nurse is best?
a. Ask another nurse to do it so the correct method can
be viewed.
b. Check the policy and procedure manual for the
agency’s method.
c. Change the dressing using the method taught in
nursing school.
d. Ask the patient how the dressing change has been
recently done.

38. The patient tells the nurse that she is afraid to speak
up regarding her desire to end care for fear of upsetting her
husband and children. Which principle in the nursing code of
ethics ensures that the nurse will promote the patient’s
cause?
a. Responsibility
b. Advocacy.
c. Confidentiality
d. Accountability

39. The patient’s son requests to view the documentation

in his mother’s medical record. What is the nurse’s best
response to this request?
a. I’ll be happy to get that for you.”
b. “You will have to talk to the physician about that.”
c. “You will need your mother’s permission.”
d. “You are not allowed to see it.”

40. While preparing client assignments for the oncoming

shift for an RN and a LPN, the charge nurse knows that the
following patient should not be assigned to the LPN:
 a. Patient with a wound needing a dressing change.
b. Patient currently having chest pain requiring
nitroglycerin.
c. Patient who had their knee replaced two days ago.
d. Patient with left-sided weakness from a stroke
receiving rehabilitative therapy.

41. A nurse moves from Seattle, Washington to Boston,

Massachusetts and begins working in a hospital. The most
important thing for the nurse to consider when beginning work
in a new state is:
a. Massachusetts nurse practice act.
b. If this hospital in Boston has Magnet Status.
c. Clinical ladder of mobility in the new hospital.
d. Requirement for continuing education units in
Massachusetts.

42. A single mother who is unemployed and does not have

health insurance brought her child into the emergency room
after falling from a tree. The child needs surgery for a broken
arm. The mother inquires about health insurance plans that
can help her pay for healthcare. To best help the family, the
case manager provides her an application for:
a. Medicare
b. Long-term care insurance
c. Medicaid
d. Private Health Insurance (e.g.: Blue Shield)

43. When obtaining a client signature on a consent form

for surgery, the nurse knows that the nurses’ role in informed
consent includes (CHOOSE ALL THAT APPLY):
a. Witnessing the client’s signature
b. Assuring the client is not coerced
c. Explaining the surgical procedure
d. Explaining the risks of the surgery

44. The nurse is unsure about compatibility of two

medications. The best person for the nurse to consult is the:
a. Physician
 b. Pharmacist
c. Case Manager
d. Charge Nurse

45. The nurse is caring for a 79-year old patient in need of

heart surgery. When the nurse goes to obtain the patient’s
signature on the surgical consent form, the patient states, “I
have decided not to have the heart surgery.” The nurse
respects the patient’s right to choose, thereby honoring this
moral principle:
a. Justice
b. Nonmaleficence
c. Beneficence
d. Autonomy

46. According to the Wisconsin State Practice Act, based

on religious or moral precepts the nurse:
a. May refuse to care for a patient who had an abortion.
b. May refuse to care for a patient who is homosexual
and has AIDS.
c. May refuse to assist with a tubal ligation or
vasectomy.
d. May refuse to assist families in providing food and
fluids to the dying patient.

47. Which timed entry will require follow-up by the nurse

manager?

0800 – Patient states, “Fell out of bed.” Patient found lying by bed
on the floor. Legs equal in length bilaterally with no
distortion, pedal pulses strong, leg strength equal and
strong, no bruising or bleeding. Neuro checks within normal
limits. States, “Did not pass out.” Assisted back to bed. Call
bell within reach. Bed monitor
on--------------------------------------------------------------C. Smith, RN
0810 – Notified primary care provider of patient’s status. New
orders received.
---------------------------------------------------------------------------------------C.
Smith, RN
0815 – Portable x-ray of left hip taken in room. States, “I feel
fine.” C. Smith, RN
0830 – Incident report completed and placed on chart. -----------------
C. Smith, RN

a. 0800
b. 0810
c. 0815
d. 0830

48. The new nurse asks the nurse manager what

organization provides guidance related to ethical care in
nursing. The nurse manager’s best response is:
a. American Nurses Association
b. National League for Nursing
c. State Board of Nursing
d. The Joint Commission

49. A nurse who usually works in the newborn nursery is

assigned to work on a cardiac unit. The nurse feels he/she has
a lack of knowledge regarding the care of the cardiac
patients. The nurse should:
a. Refuse and leave work
b. Ask to work with a nurse from the cardiac unit
c. Quit their job and find a different one
d. Contact the state board of nursing and complain

50. The nurse knows that the following can be delegated

to an unlicensed assistive personnel (UAP):
a. Identifying interventions needed in a plan of care.
b. Evaluating if the patient blood pressure is better after
IV fluids were administered.
c. Obtaining a temperature on a patient who received
acetaminophen 1 hour ago.
 d. Transporting a patient to the cardiac catheterization
lab who is having chest pain.

1. The nurse assesses that the patient has right shoulder pain. The
doctor identified that the patient’s pain is because of their bad
gallbladder. This shoulder pain from the gallbladder source is known
as
a. Radiating pain
b. Threshold pain
c. Tolerance of pain
d. Referred pain

2. The nurse is caring for a patient with pain of a “10” on a 0-10

scale. The nurse has pain medication choices as follows, and chooses
to administer it by the following route:
a. PO (orally)
b. IV (Intravenously)
c. Per Rectum (rectally)
d. IM (intramuscularly)

3. A client who had a right below the knee amputation two days ago
informs the nurse that they have pain in their right great toe. This
type of pain is known as
a. referred pain
b. phantom pain
c. psychogenic pain
d. intractable pain

4. A client with a fractured hip states, “I have pain”. The client is

grimacing and wincing when the nurse helps them turn in bed. The
nurse observes that the client’s pulse is 120 bpm, respirations are
30/minute, and the client is perspiring. The nurse identifies a priority
NANDA nursing diagnosis of
a. acute pain
b. chronic pain
c. decreased cardiac output
d. impaired mobility
5. A four-year-old client has severe abdominal pain. What is the
nurse trying to assess when asking the client’s mother if the child has
had any nausea or vomiting with their pain?
a. associated symptoms
b. aggravating factors
c. effect on activities of daily living
d. alleviating factors

6. The nurse includes the following independent nursing

interventions in the plan of care for a patient with abdominal pain
(CHOOSE ALL THAT APPLY):
a. Administer Percocet 2 tablets PO every 4 hours as needed for
pain.
b. Reposition every two hours.
c. Provide a back massage twice daily and prn.
d. Provide acupressure twice daily and prn.

7. When assessing a patient who has a Morphine PCA, the most

concerning data collected by the nurse is:
a. Nausea.
b. Respirations of 12 per minute.
c. No bowel movement in 4 days.
d. Painful stimuli needed to arouse patient.

8. The RN knows to intervene when they observe the student

nurse:

a. Removing the Lidoderm patch after 12 hours.

b. Cutting the Lidoderm patch and placing ½ on each side of the
lower back.
c. Applying EMLA cream prior to starting an IV on a 3-year-old
child.
d. Applying a heating pad over the anterior shoulder, right over the
fentanyl patch.

9. A patient verbalizes a low pain level of 2 out of 10, but exhibits

extreme facial grimacing while moving around in bed. What is the
nurse’s best action in response to this observation?
a. Proceed to the next patient’s room while making rounds.
b. Offer a massage because the patient stated they did not need
any pain medicine.
c. Ask the patient about the facial grimacing with movement.
d. Administer the pain medication ordered for moderate to severe
pain.

10. After assessing the patient, the nurse identifies the need for
headache relief and administers acetaminophen (Tylenol) 650mg PO
per patient request. What is the nurse’s next BEST action?
a. Eliminate Acute Pain from the nursing care plan.
b. Direct the nursing assistant to evaluate if the patient’s headache
is relieved.
c. Reassess the patient’s pain level in one hour.
d. Inform the patient to notify staff when the headache is relieved.

11. When describing the physiology of pain, the point at which a

stimulus is perceived as painful, is the definition of:
a. Pain tolerance
b. Pain threshold
c. Modulation
d. Somatic Pain

12. The nurse documents the patient’s description of their pain as

“sharp” under:

a. Tolerable level.
b. Pain Scale
c. Aggravating factors
d. Characteristics

13. When assessing the patient, the nurse notes the following which
alerts them to chronic hypoxemia in the patient:
a. Wheezes in the lungs
b. Dullness over the right upper lobe posteriorly
c. Oxygen saturation of 92% on room air
d. Clubbed fingers – distorted angle of nail bed
14. The nurse expects to hear the following when auscultating the
lungs of a person with asthma and narrowed airways:
a. Rhonchi
b. Wheezes
c. Rales
d. Pleural friction rub

15. All of the following are signs of inadequate oxygenation except:

a. Restlessness and apprehension

b. Bradycardia
c. Tachypnea
d. Unexplained fatigue

16. The following intervention assists in expanding the alveoli, thus

preventing atelectasis:
a. Incentive Spirometry
b. Purse-lip breathing
c. Humidifying oxygen
d. Semi-fowler’s position

17. The diagnostic test whereby fluid is aspirated from the pleural
space through the chest wall with a needle is:
a. Bronchoscopy
b. Pulmonary Function Test
c. Arterial Blood Gases
d. Thoracentesis

18. While teaching the patient to do incentive spirometry, the nurse

teaches:

a. To breathe out into the mouth piece.

b. Inhale slowly with even flow.
c. Blow out hard and fast.
d. Breathe out through lips shaped as if they were going to
whistle.

19. The nurse knows that this oxygen administration device has an
adjustable barrel on it that allows the nurse to adjust the FIO2 %:
a. Nasal cannula
b. Simple face mask
c. Partial Rebreather Mask
d. Venturi Mask

20. The nurse positions the patient in the best position that will
promote lung expansion and reduce pressure from the abdomen on the
diaphragm. The nurse places the patient in:
a. Prone position
b. Supine position
c. Semi-Fowler’s position
d. Lateral Recumbant position
21. The nurse notes that the patient has an O2 saturation of 88%.
The nurse’s best first action is to:
a. Notify the physician.
b. Check the patient’s respiratory rate.
c. Auscultate the patient’s lungs.
d. Apply oxygen at 2L/NC

22. The nurse delegates to the CNA the following while caring for a
patient with asthma:

a. Place the HOB in semi-fowler’s position.

b. Teach the patient how to use the incentive spirometer.
c. Ambulate the patient and evaluate if they are tolerating the
activity.
d. Auscultate lung sounds and have patient cough and deep breathe
if you hear crackles.

23. A client takes ½ of a tablet labeled 0.05 mg each day. How

many milligrams will the client take in 7 days?
a. 0.35 mg
b. 0.7 mg
c. 0.175 mg
d. 0.025 mg

24. The nurse documents the blood in the patient’s sputum as:

a. Hemoptysis
b. Hypoxia
c. Orthopnea
d. Dyspnea

25. While preparing client assignments for the oncoming shift for an
RN and a LPN, the charge nurse knows that the following patient
should not be assigned to the LPN:
a. Patient with a wound needing a dressing change.
b. Patient currently having chest pain requiring nitroglycerin.
c. Patient who had their knee replaced two days ago.
d. Patient with left-sided weakness from a stroke receiving
rehabilitative therapy.

26. Which statement by the patient indicates an understanding of

atelectasis?
a. “It is important to do breathing exercises every hour to prevent
atelectasis.”
b. “If I develop atelectasis, I will need a chest tube to drain excess
fluid.”
c. “Atelectasis affects only those with chronic conditions such as
emphysema.”
d. “Hyperventilation will open up my alveoli, preventing
atelectasis.”

27. The nurse assesses that the patient has jaw pain. The doctor
identified that the patient is having a heart attack. The jaw pain is
known as
a. Radiating pain
b. Threshold pain
c. Tolerance of pain
d. Referred Pain

28. A 24-year-old Asian woman is in labor and refuses to receive any

sort of anesthesia medication. Which alternative treatment is best for
this patient?
a. Relaxation and guided imagery
b. Transcutaneous electrical nerve stimulation (TENS)
c. Herbal supplements with analgesic effects
d. Pudendal block
29. Which of the following statements made by the patient indicates
to the nurse that teaching on a patient-controlled analgesia (PCA)
device has been effective?
a. “This is the only pain medication I will need to be on.”
b. I can administer the pain medication as frequently as I need to.”
c. “I feel less anxiety about the possibility of overdosing.”
d. “I will need the nurse to notify me when it is time for another
dose.”

30. The nurse working in the hospital informs a female patient of

another ethnicity that they can make decisions for their own health
care, and that the husband has no right in telling her what to do. The
nurse says, “That’s the American way; the best way.” The nurse is
portraying:
a. Assimilation
b. Ethnocentrism
c. Socialization
d. Acculturation

31. A client of Hispanic origin is screaming in pain constantly. The

nurse states to the doctor, “All Hispanics are so dramatic.” The nurse
is guilty of
a. Stereotyping
b. Discrimination
c. Ethnocentrism
d. Prejudice

32. A client of Hmong descent is requesting the Shaman to perform a

spiritual ritual prior to their surgery. A culturally sensitive nurse
would:
a. Tell the client that in modern healthcare there is no need for a
Shaman.
b. Tell the client that these rituals are not part of the preoperative
preparation.
c. Provide the space and privacy for the Shaman to perform the
ritual.
d. Offer the hospital chaplain to come pray with the client.
33. Which of the following is an inappropriate practice guideline
when using an interpreter?
a. Use an interpreter of the same gender.
b. Address the questions to the interpreter, and the interpreter will
address the client.
c. Ask the interpreter to communicate to the client without
omissions, or adding or distorting the content.
d. Ask the interpreter not to use metaphors or slang terms when
communicating the information to the client.

34. The nurse is caring for a client who is of Native American decent.
The nurse is unfamiliar with the client’s Native American culture. The
nurses’ best action is to
a. Read about the Native American culture and implement
interventions based on the values, beliefs, and practices you read
about.
b. Politely and respectfully seek information from the client
regarding their cultural values, beliefs, and practices.
c. Care for them like you would any client and if they do not bring
up anything you must be providing culturally appropriate care.
d. Ask a co-worker who is of Native American culture and go by
what they tell you are the best ways to provide care for this client.

35. Identify which of the following is an example of a western culture

of health and caring.
a. Client with cancer seeks the services of a priest to remove the
cause.
b. Client with epilepsy seeks the services of a neurologist.
c. Client with aches and pains receives cupping remedy.
d. Client with vomiting takes herbs provided by Shaman.

36. While communicating with a client who speaks limited English, it

would be inappropriate for the nurse to:
a. Avoid use of slang words.
b. Augment spoken words with gestures or pictures.
c. Speak slowly and in a normal tone of voice.
d. Interpret nodding to mean the client understands.

37. A client who is of Asian descent requests hot foods. A culturally

competent nurse will bring the client foods that are
a. hot in temperature.
b. spicy in taste.
c. identified by the client as hot.
d. hot or cold teas or soups.

38. When planning care for a client of a different culture, the nurse
includes all the following in the plan of care (CHOOSE ALL THAT
APPLY)
a. Discover how deeply the client identifies with their traditional
heritage.
b. Change the client’s beliefs if they do not coincide with scientific
medicine.
c. Incorporate treatments that the client feels are meaningful and
are not harmful.
d. Explain why certain cultural practices are harmful, and try to
identify alternatives cooperatively with the client.

39. Which of the following explains why it is important to have the

correct etiology for a nursing diagnosis? The etiology:
a. Is the cause of the problem
b. Cannot always be observed
c. Directs nursing care
d. Is an inference

40. Which of the following nursing diagnosis have the highest

priority?

a. Spiritual distress
b. Stress incontinence
c. Anxiety
d. Ineffective breathing patterns

41. A patient comes to the emergency department complaining of

severe chest pain. The nurse asks the patient questions and takes
his vital signs. Which step of the nursing process is the nurse
demonstrating?
a. Assessing
b. Diagnosing
c. Planning
d. Implementing

42. A nurse is reviewing the health history and physical assessment

findings for a patient who is having respiratory problems. Of the
following data collected, what data from the health history would be a
cue to a nursing diagnosis for his problem?
a. “I often have diarrhea after I eat spicy foods.”
b. “My skin is so dry I just can’t keep from scratching it.”
c. “I get out of breath when I walk a few steps.”
d. “I just feel so bad about myself these days.”
43. The nurse is caring for a client who emigrated from Puerto Rico.
She can best care for this patient by learning about the:
a. Practices of the patient’s ethnic group
b. Patient’s individual cultural beliefs
c. Values of her own culture
d. Spanish-speaking community

44. When your client complains of an increase in pain it could be a

sign of which of the following?
a. It is often a sign of addiction to analgesics
b. It is a normal component of aging
c. Inadequate pain management and/or sign of developing
complications
d. Caregiver has a better idea of the pain being experienced by the
client
45. A nurse is assessing a patient admitted with sudden onset of
severe back pain of unknown origin. Which statement would be most
effective for the nurse to use to elicit further information from this
patient about his pain?
a. “Does the pain medication you’re taking relieve the pain?”
b. “Can you point to where the pain is worst?”
c. “Tell me how you are feeling right now.”
d. “Changing positions makes your pain worse, right?”

46. A client suffering from chronic obstructive pulmonary disease

complains that it is hard to cough up secretions which are thick and
sticky. The nurse should instruct the client to:
a. Eat small frequent meals to conserve energy
b. Decrease exercise and increase rest periods
c. Increase her fluid intake to thin secretions
d. Take a cough suppressant to decrease coughing

47. A client is having difficulty breathing. During an assessment of

the client, which of the following findings would the nurse expect to
see? Select all that apply
a. Lack of energy
b. Rapid, shallow breathing
c. Rubor of the skin
d. Nasal flaring

48. A nurse is assessing a patient with a respiratory problem. Which

clinical manifestation is most reflective of an early response to
hypoxia?
a. Dysrhythmias
b. Restlessness
c. Cyanosis
d. Apnea

49. A patient has a history of Chronic Obstructive Pulmonary Disease

(COPD). His pulse oximetry is 95%. What other findings would
indicate adequate tissue perfusion and organ oxygenation. Select all
that apply
a. Urine output of 50-60 ml/hr
b. Strong peripheral pulses
c. Clear breath sounds bilaterally
d. Normal muscle strength

50. A provider prescribes ondansetron (Zofran) 6 mg to be

administered via oral suspension to a 12-year-old child 30 minutes
before chemotherapy and then every 8 hours for two more doses. The
medication states that there are 4 mg/5ml. How much oral solution
should the nurse administer per dose? _________________________7.5 ml

1. The nurse plans to monitor the fluid volume status of a

patient with heart failure. Which is the most effective nursing
intervention to monitor the patient?
a. Weigh the patient each morning
b. Ask the patient to record intake and output
c. Measure the blood pressure every 4 hours
d. Assess for edema in lower extremities

2. While assessing serum laboratory values, the nurse notes that the
total calcium is 12.2 mg/dl. In noting this, the nurse would also
expect to assess for which clinical manifestation?

a. The patient is experiencing muscle twitching and tetany.

b. The patient is experiencing hyperactive bowel sounds and
diarrhea.
c. The phosphorus level is less than the normal value.
d. The magnesium level is less than the normal value.

3. When assessing whether a client’s weight is healthy, the nurse

knows that a body mass index of 35 is an indication of:
a. Healthy weight for a person’s height
b. Risk for cardiovascular disease, diabetes, hypertension
c. Underweight for a person’s height
d. Past stroke and muscle atrophy

4. The nurse knows the client needs further teaching regarding a

low sodium diet when they state:
a. “I eat a bologna sandwich every day at lunch.”
b. “I don’t eat those frozen pizzas.”
c. “I eat 2 apples and a banana every day.”
d. “I drink a glass of orange juice in the morning.”

5. The nurse teaches the client taking an iron supplement the

following: (CHOOSE ALL THAT APPLY)
a. Iron may cause constipation.
b. Iron may cause stool to turn green-black.
c. Take iron with milk to increase absorption.
d. Take iron right after evening meal.
6. A client asks the nurse why their Protime/INR keeps decreasing,
and their warfarin dose keeps increasing. When reviewing the client’s
diet, the nurse explains that they may be consuming:
a. Too much whole grain bread
b. Too many hamburgers
c. Too many alcoholic beverages
d. Too much spinach

7. The nurse is caring for a client on a full liquid diet. The nurse
provides the client with the following appropriate foods/beverages:
(CHOOSE ALL THAT APPLY)
a. Ice cream
b. Pureed meats
c. Grape juice
d. Mashed potatoes
e. Coffee

8. The nurse is concerned about a client’s nutrition when evaluating

this lab data:
a. Hgb 14 g/dl
b. WBC 17,000 per cubic millimeter
c. Albumin 2.5 g/dl
d. Transferrin level 350 mg/dl

9. A client asks the nurse, “I don’t like oranges, so what else can I
eat for a good source of vitamin C?” The nurses’ best response is
a. liver
b. green beans
c. red pepper
d. fish

10. The nutrient that provides the main source of energy is

a. Proteins
b. Fats
c. Vitamins
d. Carbohydrates
11. The nurse knows the nursing assistant feeding a client with
dysphagia needs further teaching when the nursing assistant:
a. Encourages the client double swallow.
b. Provides a 30-minute rest period before eating.
c. Encourages the client to tilt their head back when swallowing.
d. Places food on stronger side of the mouth for client with
unilateral weakness.

12. The nurse is adding up how much fluid the client consumed for
the following: ½ of an 8 ounce soda, ¾ of a 4 ounce orange juice, and
all of their 12 ounce coffee.
The nurse documents the fluids consumed as:
a. 19 mL
b. 24 mL
c. 570 mL
d. 720 mL

13. The nurse collects the following data from a client assessment:
fatigued, brittle nails, dry and brittle hair, and spongy and inflamed
tongue. The nurse suspects:
a. Malnutrition
b. Fluid volume deficit
c. Fluid volume overload
d. Abuse

14. The nurse would expect to collect the following data for a client
with the nursing diagnosis of fluid volume excess/overload:
a. Dry mucous membranes
b. Weight loss
c. Weak, thready, rapid pulse
d. Crackles in the lungs

15. The nurse includes the following in the plan of care for a client
with the nursing diagnosis of fluid volume deficit:
a. Restrict fluids
b. Provide mouth care
c. Restrict dietary sodium
d. Administer diuretics
16. The client with fluid volume overload asks the nurse what may
have caused their weight to increase. After reviewing the clients data,
the nurse informs the client:
a. “You are not consuming enough fluids.”
b. “The frequent vomiting over this last week.”
c. “You are consuming foods with too much sodium.”
d. “Exercising is causing you to excessively sweat.”

17. A patient’s lab results indicate a Potassium level of 1.8. The

nurse should be MOST concerned about:
a. Cardiac dysrhythmias
b. Leg cramps
c. Vomiting
d. Diarrhea

18. Your patient has hypocalcemia. Which of the following foods will
you encourage your patient to eat? CHOOSE ALL THAT APPLY
a. Bananas
b. Yogurt
c. Cheese
d. Sardines

19. When a word begins with the prefix inter- , the nurse knows that
this means
a. Within
b. Outside
c. Deficient
d. Between

20. When pressing a finger over the client’s shin, the nurse notes
that the tissue depresses 2mm, but is barely detectable. The nurse will
document this as:
a. 1+ edema
b. 2+ edema
c. 3+ edema
d. 4+ edema

21. The nurse suspects that the following is the cause for the client’s
right arm edema:
a. Low blood pressure
b. High levels of plasma proteins
c. Tissue trauma from a fall
d. Lack of fluid intake

22. The nurse knows that the client at most risk for fluid imbalance
is
a. A 70-year old client with a fractured wrist
b. A middle aged woman who is vomiting
c. An adolescent mowing the lawn on a hot day
d. A 3-month old infant with diarrhea

23. An initial physical examination of the client’s fluid balance is a

focused assessment of the:
a. Gastrointestinal system
b. Musculoskeletal system
c. Skin and mucous membranes
d. Cardiovascular system

24. Plasma proteins help to hold fluid in the vascular space by

exerting:
a. Filtration pressure
b. Colloid osmotic pressure
c. Diffusion pressure
d. Hydrostatic pressure

25. While assessing stool, the nurse notes that it is black/tarry,

sticky, and odorless, and understands that this is normal for:
a. Newborn
b. Child
c. Adult
d. Elderly

26. A female patient asks the nurse, “Why am I constipated?” After

analyzing the data collected, the nurse informs the patient that the
factor contributing to the patient’s constipation is that they are
a. Consuming 22 grams of fiber per day
b. Consuming 750 mL of fluid per day
c. Participating in 30 minutes of aerobic exercise per day
d. Taking the time to evacuate the bowels every morning
27. A patient feels discomfort in his pubic area. He tells the nurse
he has been voiding “only a little bit, about every half hour.” These
are clinical signs of which urinary complication?
a. functional incontinence
b. retention
c. nocturia
d. stress incontinence

28. The production of scant amounts of urine, such as 100 to 500 ml

per day, is referred to as which of the following?
a. anuria
b. oliguria
c. urinary urgency
d. dysuria

29. What will the nurse monitor to detect the most serious potential
problem arising from severe diarrhea?
a. serum electrolyte levels
b. abdominal cramps and pain
c. skin assessment of the rectal area
d. stool color and consistency

30. A patient describes symptoms of urinary stress

incontinence.
Based on this, which nursing intervention would be most
helpful?
a. Encourage use of adult briefs
b. Insert a foley catheter
c. Administer medications to decrease urination
d. Teach Kegel exercises

31. Which of the following nursing interventions would be

implemented for the patient to prevent urinary tract infections?
a. Recommend foods that decrease urine acidity
b. Encourage fluid intake of 500-700 ml per day
c. Instruct the patient to empty their bladder completely
d. Encourage an increase of carbohydrates in their diet
32. The patient is an 80-year-old male who is visiting the clinic
today
for his routine physical examination. The patient’s skin turgor is
fair, but he has been complaining of fatigue and weakness. His
skin is warm and dry, pulse rate is 126 beats per minute, and
sodium level is elevated. Based on the assessment, the
nurse would make which recommendation for the patient?
a. Decrease intake of milk and dairy products
b. Drink more orange juice to enhance vitamin C
c. Eat more protein to increase energy levels
d. Drink more water to avoid dehydration

33. The nurse is working with a patient who has a colostomy.

Which instruction would be included in the plan of care for
this
patient?

a. The stoma bag need only be worn at night

b. A decrease in physical activity may be needed
c. Special skin care is a priority
d. Fluid intake should be limited

34. The nurse is caring for a 19 year old male patient with a
fractured femur whose leg was surgically pinned yesterday. He is now
in traction on complete bed rest. Which of the following is most likely
the cause of the patient’s difficulty with urination?
a. Pain related to the fracture
b. Anxiety about healing
c. Not being able to stand to urinate
d. Poor fluid intake

35. The nurse implements all the following interventions for the
patient experiencing diarrhea (SELECT ALL THAT APPLY)
a. Cleanses rectal/perineal area after each stool
b. Administers daily dose of scheduled lactulose
c. Encourages client to eat bland foods (bananas, white rice,
applesauce, toast)
d. Encourages client to eat yogurt with live, active cultures
36. The nurse knows that all of the following diagnostic and
laboratory tests can provide information related to the patient’s
bowel elimination/gastrointestinal tract (SELECT ALL THAT APPLY)
a. Colonoscopy
b. BUN
c. Barium enema
d. Stool for Guaiac

37. The nurse would anticipate administering the following

medication to a patient immediately following a barium swallow:
a. Kaopectate
b. Pepto-Bismol
c. Milk of Magnesia
d. Metamucil

38. To prevent urinary tract infections, the nurse teaches the female
client to:
a. Take bubble baths
b. Wear tight-fitting pants
c. Wipe perineal area from front to back
d. Decrease fluid intake

39. The nurse includes the following in the plan of care for a client at
risk for constipation:
a. Encourage consumption of fresh fruits and vegetables
b. Teach client to avoid whole grains
c. Limit fluid intake to 1000 mL per day
d. Encourage client to take a laxative every day at bedtime

40. The nurse is observing the nursing assistant caring for a client
with a urinary catheter and knows that further teaching is necessary
when the nursing assistant:
a. Cleanses the catheter from the urinary meatus outward
b. Assures that the catheter tube is secured to the thigh
c. Unwinds any kinks in the drainage tubing
d. Attaches the drainage bag to the side rail on the bed

41. The nurse identifies that all of the following could be causes for
the patient’s urinary incontinence (SELECT ALL THAT APPLY)
a. Delirium
b. Urinary Tract Infection
c. Limited fluid intake
d. Restricted mobility

42. The nurse catheterizes a client after voiding and obtains 250 mL
of clear, amber urine. The nurse will document the urine output
obtained from the catheterization as:
a. Enuresis
b. Residual urine
c. Polyuria
d. Anuria

43. The mother of a child dying of terminal cancer asks God to take
her instead. The nurse identifies that according to Kubler-Ross, the
mother is in this stage of grieving
a. Denial
b. Anger
c. Bargaining
d. Depression

44. A client who just had their right leg amputated yells at the nurse
for opening the window blinds in the room. The nurse’s best response
is
a. Close the blinds and walk out of the room like nothing
happened.
b. Tell the client that opening the blinds will put them in a happier
mood.
c. Tell the client to push the call light when they want the blinds
opened.
d. Allow time to talk with the client to find out what may be
bothering them.

45. The nurse knows that this age group may fantasize that death
can be defied and participate in reckless behaviors:
a. 5 to 9 years
b. 9 to 12 years
c. 12 to 18 years
d. 20 to 45 years
46. A family member asks the nurse what they might see as their
dying mother gets closer to death. The nurse tells the family that they
may see (CHOOSE ALL THAT APPLY):
a. Reddish-blue mottling with a “fishnet” appearance on her feet
and legs and possibly arms.
b. Noisy, rattling breathing.
c. Slow, strong pulse.
d. Elevated blood pressure.
e. Difficulty swallowing.

47. When providing palliative care to an unconscious client, the

nurse includes in the plan of care to (CHOOSE ALL THAT APPLY):
a. Dangle client’s legs when sitting to improve circulation to lower
legs and feet.
b. Provide frequent mouth care to prevent dry mouth.
c. Touch as minimally as possible to prevent overstimulation.
d. Apply liberal amounts of moisturizing creams and lotions to
skin.

48. A client asks the nurse for an advanced directive. The nurse
provides the client with
a. A durable power of attorney for healthcare form.
b. An inquest form.
c. A do not resuscitate form.
d. An autopsy form.

49. The nurse knows to intervene when the CNA positions the body
of a patient who just died as follows:
a. Palms up
b. Supine
c. Eyelids shut
d. Small pillow under head and shoulders

50. All of the following are true regarding Hospice Care (CHOOSE
ALL THAT APPLY):
a. It is provided in only a special care facility.
b. Bereavement follow-up is provided after client’s death.
c. Medical and nursing services are available at all times.
d. It is a philosophy of care.