In Text Mode: All questions and answers are given for reading and answering at your own D.

D. An adolescent with a positive HIV test and admitted for acute cellulitis of the lower leg
pace. You can also copy this exam and make a printout. 48 hours ago.
1. Which individual is at greatest risk for developing hypertension? 8. A client has been newly diagnosed with hypothyroidism and will
A. 45-year-old African American attorney take levothyroxine (Synthroid) 50 mcg/day by mouth. As part of the teaching plan,
B. 60-year-old Asian American shop owner the nurse emphasizes that this medication:
C. 40-year-old Caucasian nurse A. Should be taken in the morning
D. 55-year-old Hispanic teacher
2. A child who ingested 15 maximum strength acetaminophen tablets 45 minutes ago C. Must be stored in a dark container
is seen in the emergency department. Which of these orders should the nurse do
first? 9. A 3-year-old child comes to the pediatric clinic after the sudden onset of findings
A. Gastric lavage PRN that include irritability, thick muffled voice, croaking on inspiration, hot to touch, sit
B. Acetylcysteine (Mucomyst) for age per pharmacy leaning forward, tongue protruding, drooling and suprasternal retractions. What
C. Start an IV Dextrose 5% with 0.33% normal saline to keep vein open should the nurse do first?
D. Activated charcoal per pharmacy A. Prepare the child for X-ray of upper airways
3. Which complication of cardiac catheterization should the nurse monitor for in the
initial 24 hours after the procedure? C. Collect a sputum specimen
A. angina at rest
B. thrombus formation 10. In children suspected to have a diagnosis of diabetes, which one of the following
C. dizziness complaints would be most likely to prompt parents to take their school-age child for
D. falling blood pressure evaluation?
4. A client is admitted to the emergency room with renal calculi and is complaining of A. Polyphagia
moderate to severe flank pain and nausea B. Dehydration
Fahrenheit. The priority nursing goal for this client is: C. Bedwetting
A. Maintain fluid and electrolyte balance D. Weight loss
B. Control nausea 11. A client comes to the clinic for treatment of recurrent pelvic inflammatory
C. Manage pain disease. The nurse recognizes that this condition most frequently follows which type
D. Prevent urinary tract infection of infection?
5. What would the nurse expect to see while assessing the growth of children during A. Trichomoniasis
their school age years? B. Chlamydia
A. Decreasing amounts of body fat and muscle mass C. Staphylococcus
B. Little change in body appearance from year to year D. Streptococcus
C. Progressive height increase of 4 inches each year 12. An RN who usually works in a spinal rehabilitation unit is floated to the
D. Yearly weight gain of about 5.5 pounds per year emergency department. Which of these clients should the charge nurse assign to this
6. At a community health fair, the blood pressure of a 62-year-old client is 160/96 RN?
A. A middle-
should tell the client to
A. go get a blood pressure check within the next 48 to 72 hours I quit drinking
B. check blood pressure again in two (2) months
C. see the healthcare provider immediately C. An adolescent who has been on pain medications terminal cancer with an initial
D. visit the health care provider within one (1) week for a BP check assessment finding pupils and a relaxed respiratory rate of 10,
7. The hospital has sounded the call for a disaster drill on the evening shift. Which of
these clients would the nurse put first on the list to be discharged in order to make a walking into the emergency room.
room available for a new admission? 13. When teaching a client with coronary artery disease about nutrition, the nurse
A. A middle-aged client with a history of being ventilator dependent for over seven (7) should emphasize
years and admitted with bacterial pneumonia five days ago. A. Eating three (3) balanced meals a day
B. A young adult with diabetes mellitus Type 2 for over ten (10) years and admitted B. Adding complex carbohydrates
with antibiotic-induced diarrhea 24 hours ago. C. Avoiding very heavy meals
C. An elderly client with a history of hypertension, hypercholesterolemia, and lupus, and D. Limiting sodium to 7 gms per day
was admitted with Stevens-Johnson syndrome that morning.
14. Which of these findings indicate that a pump to deliver a basal rate of 10 ml per A. A 2-month-old infant with a history of rolling off the bed and has bulging fontanels with
hour plus PRN for pain breakthrough for morphine drip is not working? crying
A. The client complains of discomfort at the IV insertion site B. A teenager who got a singed beard while camping
C. An elderly client with complaints of frequent liquid brown colored stools
C. The level of drug is 100 ml at 8 AM and is 80 ml at noon D. A middle-aged client with intermittent pain behind the right scapula
D. The level of the drug is 100 ml at 8 AM and is 50 ml at noon 22. While planning care for a toddler, the nurse teaches the parents about the
15. The nurse is speaking at a community meeting about personal responsibility expected developmental changes for this age. Which statement by the mother shows
for health promotion. A participant asks about chiropractic treatment for illnesses.

A. Electrical energy fields

B. Spinal column manipulation
C. Mind-body balance
D. Exercise of joints 23. The nurse is preparing to administer an enteral feeding to a client via a
16. The nurse is performing a neurological assessment on a client post right CVA. nasogastric feeding tube. The most important action of the nurse is
Which finding, if observed by the nurse, would warrant immediate attention? A. Verify correct placement of the tube
A. Decrease in level of consciousness B. Check that the feeding solution matches the dietary order
B. Loss of bladder control C. Aspirate abdominal contents to determine the amount of last feeding remaining in
C. Altered sensation to stimuli stomach
D. Emotional ability D. Ensure that feeding solution is at room temperature
17. A child who has recently been diagnosed with cystic fibrosis is in a pediatric 24. The nurse is caring for a client with a serum potassium level of 3.5 mEq/L. The
clinic where a nurse is performing an assessment. Which later finding of this disease client is placed on a cardiac monitor and receives 40 mEq KCL in 1000 ml of 5%
would the nurse not expect to see at this time? dextrose in water IV. Which of the following EKG patterns indicates to the nurse that
A. Positive sweat test the infusions should be discontinued?
B. Bulky greasy stools A. Narrowed QRS complex
C. Moist, productive cough
D. Meconium ileus
18. The home health nurse visits a male client to provide wound care and finds the waves
client lethargic and confused. His wife states he fell down the stairs 2 hours ago. The 25. A nurse prepares to care for a 4-year-old newly admitted for rhabdomyosarcoma.
nurse should The nurse should alert the staff to pay more attention to the function of which area of
the body?
B. Send him to the emergency room for evaluation A. All striated muscles
C. Reas B. The cerebellum
C. The kidneys
19. Which of the following should the nurse implement to prepare a client for a KUB D. The leg bones
(Kidney, Ureter, Bladder) radiograph test? 26. The nurse anticipates that for a family who practices Chinese medicine the
A. Client must be NPO before the examination priority goal would be to:
B. Enema to be administered prior to the examination A. Achieve harmony
C. Medicate client with Lasix 20 mg IV 30 minutes prior to the examination B. Maintain a balance of energy
D. No special orders are necessary for this examination C. Respect life
20. The nurse is giving discharge teaching to a client trseven (7) days D. Restore yin and yang
post myocardial infarction. He asks the nurse why he must wait six (6) weeks before 27. During an assessment of a client with cardiomyopathy, the nurse finds that the
having sexual intercourse. What is the best response by the nurse to this question? systolic blood pressure has decreased from 145 to 110 mm Hg and the heart rate has
risen from 72 to 96 beats per minute and the client complains of periodic dizzy
spells. The nurse instructs the client to
C A. Increase fluids that are high in protein
B. Restrict fluids
21. A triage nurse has these four (4) clients arrive in the emergency department C. Force fluids and reassess blood pressure
within 15 minutes. Which client should the triage nurse send back to be seen first? D. Limit fluids to non-caffeine beverages
28. The nurse prepares the client for insertion of a pulmonary artery catheter a miscarriage 10 years ago at 12 weeks gestation. How would the nurse accurately
(Swan-Ganz catheter). The nurse teaches the client that the catheter will be inserted document this information?
to provide information about: A. Gravida 4 para 2
A. Stroke volume B. Gravida 2 para 1
B. Cardiac output C. Gravida 3 para 1
C. Venous pressure D. Gravida 3 para 2
D. Left ventricular functioning 36. The nurse is caring for a client with a venous stasis ulcer. Which nursing
intervention would be most effective in promoting healing?
respirations. After calling for help, the first action the nurse should take is: A. Apply dressing using sterile technique
A. Start a peripheral IV
B. Initiate high-quality chest compressions C. Initiate limb compression therapy
C. Establish an airway D. Begin proteolytic debridement
D. Obtain the crash cart 37. A nurse is to administer meperidine hydrochloride (Demerol) 100
30. A client is receiving digoxin (Lanoxin) 0.25 mg daily. The health care provider mg, atropine sulfate (Atropisol) 0.4 mg, and promethazine hydrochloride
has written a new order to give metoprolol (Lopressor) 25 mg B.I.D. In assessing the (Phenergan) 50 mg IM to a pre-operative client. Which action should the nurse take
client prior to administering the medications, which of the following should the first?
nurse report immediately to the health care provider? A. Raise the side rails on the bed
A. Blood pressure 94/60 B. Place the call bell within reach
B. Heart rate 76 C. Instruct the client to remain in bed
C. Urine output 50 ml/hour D. Have the client empty bladder
D. Respiratory rate 16 38. Which of these statements best describes the characteristics of an effective
31. While assessing a 1-month-old infant, which finding should the nurse report reward-feedback system?
immediately? A. Specific feedback is given as close to the event as possible
A. Abdominal respirations B. Staff is given feedback in equal amounts over time
B. Irregular breathing rate C. Positive statements are to precede a negative statement
C. Inspiratory grunt D. Performance goals should be higher than what is attainable
D. Increased heart rate with crying 39. A client with multiple sclerosis plans to begin an exercise program. In addition to
32. The nurse practicing in a maternity setting recognizes that the postmature fetus discussing the benefits of regular exercise, the nurse should caution the client to
is at risk due to avoid activities which
A. Excessive fetal weight A. Increase the heart rate
B. Low blood sugar levels B. Lead to dehydration
C. Depletion of subcutaneous fat C. Are considered aerobic
D. Progressive placental insufficiency D. May be competitive
33. The nurse is caring for a client who had a total hip replacement four (4) days ago. 40. During the evaluation of the quality of home care for a clie
disease, the priority for the nurse is to reinforce which statement by a family
A. I have bad muscle spasms in my lower leg of the affected extremity. member?
A. At least two (2) full meals a day is eaten.
B. We go to a group discussion every week at our community center.
C. We have safety bars installed in the bathroom and have 24-hour alarms on the doors.
D. The medication is not a problem to have it taken three (3) times a day.
34. A client has been taking furosemide (Lasix) for the past week. The nurse
recognizes which finding may indicate the client is experiencing a negative side
Answers and Rationale
effect from the medication? 1. Answer: A: 45-year-old African American attorney
A. Weight gain of 5 pounds The incidence of hypertension is greater among African Americans than other groups in the
B. Edema of the ankles US. The incidence among the Hispanic population is rising.
C. Gastric irritability 2. Answer: A: Gastric lavage PRN
D. Decreased appetite Removing as much of the drug as possible is the first step in treatment for this drug
35. A client who is pregnant comes to the clinic for a first visit. The nurse gathers overdose. This is best done by gastric lavage. The next drug to give would be activated
data about her obstetric history, which includes 3-year-old twins at home and charcoal, then mucomyst and lastly the IV fluids.
3. Answer: B: thrombus formation The theory underlying chiropractic is that interference with transmission of mental
Thrombus formation in the coronary arteries is a potential problem in the initial 24 hours impulses between the brain and body organs produces diseases. Such interference is
after a cardiac catheterization. A falling BP occurs along with hemorrhage of the insertion caused by misalignment of the vertebrae. Manipulation reduces the subluxation.
site which is associated with the first 12 hours after the procedure. 16. Answer: A: Decrease in level of consciousness
4. Answer: C: Manage pain A further decrease in the level of consciousness would be indicative of a further
progression of the CVA.
5. Answer: D: Yearly weight gain of about 5.5 pounds per year 17. Answer: C: Moist, productive cough Option c is a later sign.
School age children gain about 5.5 pounds each year and increase about 2 inches in height. Noisy respirations and a dry non-productive cough are commonly the first of the
6. Answer: A: go get a blood pressure check within the next 48 to 72 hours respiratory signs to appear in a newly diagnosed client with cystic fibrosis (CF). The other
The blood pressure reading is moderately high with the need to have it rechecked in a few options are the earliest findings. CF is an inherited (genetic) condition affecting the cells
for complications that produce mucus, sweat, saliva and digestive juices. Normally, these secretions are thin
such as stroke. However, immediate check by the provider of care is not warranted. and slippery, but in CF, a defective gene causes the secretions to become thick and sticky.
Waiting 2 months or a week for follow-up is too long. Instead of acting as a lubricant, the secretions plug up tubes, ducts, and passageways,
7. Answer: A: A middle-aged client with a history of being ventilator dependent for especially in the pancreas and lungs. Respiratory failure is the most dangerous
over 7 years and admitted with bacterial pneumonia five days ago consequence of CF.
The best candidate for discharge is one who has had a chronic condition and is most 18. Answer: B: Send him to the emergency room for evaluation
familiar with their care. This client in option A is most likely stable and could continue This client requires immediate evaluation. A delay in treatment could result in further
medication therapy at home. deterioration and harm. Home care nurses must prioritize interventions based on
8. Answer: A: Should be taken in the morning
Thyroid supplement should be taken in the morning to minimize the side effects 19. Answer: D: No special orders are necessary for this examination
of insomnia No special preparation is necessary for this examination.

These findings suggest a medical emergency and may be due to epiglottitis. Any child with
an acute onset of an inflammatory response in the mouth and throat should receive There is a risk of cardiac rupture at the point of the myocardial infarction for about six (6)
immediate attention in a facility equipped to perform intubation or a tracheostomy in the weeks. Scar tissue should form about that time. Waiting until the client can tolerate
event of further or complete obstruction. climbing stairs is the usual advice given by healthcare providers.
10. Answer: C: Bedwetting 21. Answer: B: A teenager who got signed beard while camping
In children, fatigue and bed wetting are the chief complaints that prompt parents to take This client is in the greatest danger with a potential of respiratory distress. Any client with
their child for evaluation. Bedwetting in a school-age child is readily detected by the singed facial hair has been exposed to heat or fire in close range that could have caused
parents. serious damage to the interior of the lungs. Note that the interior lining of the lungs have
11. Answer: B: Chlamydia no nerve fibers so the client will not be aware of swelling.
Chlamydial infections are one of the most frequent causes of salpingitis or pelvic
inflammatory disease. Erikson describes the stage of the toddler as being the time when there is normally an
12. Answer: C: An adolescent who has been on pain medications for increase in autonomy. The child needs to use motor skills to explore the environment.
terminal cancer with an initial assessment finding of pinpoint pupils and a relaxed 23. Answer: A: Verify correct placement of the tube
respiratory rate of 10 Proper placement of the tube prevents aspiration.
Nurses who are floated to other units should be assigned to a client who has minimal 24. Answer: C: Tall peaked T waves
anticipated immediate complications of their problem. The client in option C exhibits A tall peaked T wave is a sign of hyperkalemia. The healthcare provider should be notified
opioid toxicity with the pinpoint pupils and has the least risk of complications to occur in regarding discontinuing the medication.
the near future. 25. Answer: A: All striated muscles
13. Answer: C: Avoiding very heavy meals originates in
Eating large, heavy meals can pull blood away from the heart for digestion and is striated (skeletal) muscles and can be found anywhere in the body. The clue is in the
dangerous for the client with coronary artery disease.
14. Answer: C: The level of drug is 100 mL at 8 AM and is 80 mL at noon 26. Answer: D: Restore yin and yang
The minimal dose of 10 mL per hour which would be 40 mL given in a four (4) hour period. For followers of Chinese medicine, health is maintained through the balance between the
Only 60 mL should be left at noon. The pump is not functioning when more than expected forces of yin and yang.
medicine is left in the container. 27. Answer: C: Force fluids and reassess blood pressure
15. Answer: B: Spinal column manipulation
Postural hypotension, a decrease in systolic blood pressure of more than 15 mmHg and an Feedback is most useful when given immediately. Positive behavior is strengthened
increase in heart rate of more than 15 percent usually accompanied by dizziness indicate through immediate feedback, and it is easier to modify problem behaviors if the standards
volume depletion, inadequate vasoconstrictor mechanisms, and autonomic insufficiency. are clearly understood.
28. Answer: D. Left ventricular functioning 39. Answer: B: Lead to dehydration
The catheter is placed in the pulmonary artery. Information regarding left ventricular The client must take in adequate fluids before and during exercise periods.
function is obtained when the catheter balloon is inflated. 40. Answer: C: We have safety bars installed in the bathroom and have 24-hour
29. Answer: B. Initiate high-quality chest compressions alarms on the doors.
As per new guidelines, the American Heart Association recommends beginning CPR with Ensuring safety of the client with increasing memory loss is a priority of home care. Note
chest compression (rather than checking for the airway first). Start CPR with 30 chest all options are correct statements. However, safety is most important to reinforce.
compressions before checking the airway and giving rescue breaths. Starting with chest In Text Mode: All questions and answers are given for reading and answering at your own
compressions first applies to adults, children, and infants needing CPR, but not pace. You can also copy this exam and make a printout.
newborns. CPR can keep oxygenated blood flowing to the brain and other vital organs until 1. A nurse medication during shift change. Which of the
more definitive medical treatment can restore a normal heart rhythm. following medications would be contraindicated if the patient were pregnant? Select
30. Answer: A: Blood pressure 94/60 all that apply:
Both medications decrease the heart rate. Metoprolol affects blood pressure. Therefore, the A. Warfarin (Coumadin)
heart rate and blood pressure must be within normal range (HR 60-100; systolic BP over B. Finasteride (Propecia, Proscar)
100) in order to safely administer both medications. C. Celecoxib (Celebrex)
31. Answer: C: Inspiratory grunt D. Clonidine (Catapres)
Inspiratory grunting is abnormal and may be a sign of respiratory distress in this infant. E. Transdermal nicotine (Habitrol)
32. Answer: D: Progressive placental insufficiency F. Clofazimine(Lamprene)
The placenta functions less efficiently as the pregnancy continues beyond 42 weeks.
Immediate and long-term effects may be related to hypoxia. the patient has photosensitive reactions to medications. Which of the following
inutes and I think I drugs is associated with photosensitive reactions? Select all that apply:
A. Ciprofloxacin (Cipro)
The nurse would be concerned about all of these comments. However, the most life- B. Sulfonamide
threatening is option B. Clients who have had hip or knee surgery are at greatest risk for C. Norfloxacin (Noroxin)
development of postoperative pulmonary embolism. Sudden dyspnea and tachycardia are D. Sulfamethoxazole and Trimethoprim (Bactrim)
classic findings of pulmonary embolism. Muscle spasms do not require immediate E. Isotretinoin (Accutane)
attention. Option C may indicate a urinary tract infection. And option D requires further F. Nitro-Dur patch
investigation and is not life-threatening. 3. A patient tells you that her urine is starting to look discolored. If you believe this
34. Answer: D: Decreased appetite n does
Lasix causes a loss of potassium if a supplement is not taken. Signs and symptoms of not cause urine discoloration?
hypokalemia include anorexia, fatigue, nausea, decreased GI motility, muscle weakness, A. Sulfasalazine
dysrhythmias. B. Levodopa
35. Answer: C: Gravida 3 para 1 C. Phenolphthalein
Gravida is the number of pregnancies and Parity is the number of pregnancies that reach D. Aspirin
viability (not the number of fetuses). Thus, for this woman, she is now pregnant, had 2 4. You are responsible
prior pregnancies, and 1 viable birth (twins). following drug, if found inside the fridge, should be removed?
nutritional status A. Nadolol (Corgard)
The goal of clinical management in a client with venous stasis ulcers is to promote healing. B. Opened (in-use) Humulin N injection
This only can be accomplished with proper nutrition. The other answers are correct, but C. Urokinase (Kinlytic)
without proper nutrition, the other interventions would be of little help. D. Epoetin alfa IV (Epogen)
37. Answer: D: Have the client empty bladder 5. A 34-year-old female has recently been diagnosed with an autoimmune disease.
The first step in the process is to have the client void prior to administering the pre- She has also recently discovered that she is pregnant. Which of the following is the
operative medication. The other actions follow this initial step in this sequence: D, C, A and only immunoglobulin that will provide protection to the fetus in the womb?
then B. A. IgA
38. Answer: A: Specific feedback is given as close to the event as possible B. IgD
C. IgE
D. IgG
6. A second-year nursing student has just suffered a needlestick while working with C. Continuously update the patient on the social environment.
a patient that is positive for AIDS. Which of the following is the most significant D. Provide a secure environment for the patient.
action that nursing student should take? 14. A patient is getting discharged from a skilled nursing facility (SNF). The patient
A. Immediately see a social worker. has a history of severe COPD and PVD. The patient is primarily concerned about his
B. Start prophylactic AZT treatment. ability to breathe easily. Which of the following would be the best instruction for this
C. Start prophylactic Pentamidine treatment. patient?
D. Seek counseling. A. Deep breathing techniques to increase oxygen levels.
7. A thirty-five-year-old male has been an insulin-dependent diabetic for five years B. Cough regularly and deeply to clear airway passages.
and now is unable to urinate. Which of the following would you most likely suspect? C. Cough following bronchodilator utilization.
A. Atherosclerosis D. Decrease CO2 levels by increased oxygen take output during meals.
B. Diabetic nephropathy 15. A nurse is caring for an infant that has recently been diagnosed with a congenital
C. Autonomic neuropathy heart defect. Which of the following clinical signs would most likely be present?
D. Somatic neuropathy A. Slow pulse rate
8. You are taking the history of a 14-year-old girl who has a (BMI) of 18. The girl B. Weight gain
reports inability to eat, induced vomiting and severe constipation. Which of the C. Decreased systolic pressure
following would you most likely suspect? D. Irregular WBC lab values
A. Multiple sclerosis
B. Anorexia nervosa will be assigned to care for the child at shift change. Which of the following
C. Bulimia nervosa
D. Systemic sclerosis A. Simian crease
9. A 24-year-old female is admitted to the ER for confusion. This patient has a history B. Brachycephaly
of a myeloma diagnosis, constipation, intense abdominal pain, and polyuria. Based C. Oily skin
on the presenting signs and symptoms, which of the following would you most likely D. Hypotonicity
suspect? 17. A client with myocardial infarction is receiving tissue plasminogen activator,
A. Diverticulosis alteplase (Activase, tPA). While on the therapy, the nurse plans to prioritize which of
B. Hypercalcemia the following?
C. Hypocalcemia A. Observe for neurological changes.
D. Irritable bowel syndrome B. Monitor for any signs of renal failure.
10. Rhogam is most often used to treat____ mothers that have a ____ infant. C. Check the food diary.
A. RH positive, RH positive D. Observe for signs of bleeding.
B. RH positive, RH negative
C. RH negative, RH positive acid. What type of food
D. RH negative, RH negative A. Green vegetables and liver
11. A new mother has some questions about phenylketonuria (PKU). Which of the B. Yellow vegetables and red meat
following statements made by a nurse is not correct regarding PKU? C. Carrots
A. A Guthrie test can check the necessary lab values. D. Milk
B. The urine has a high concentration of phenylpyruvic acid 19. A nurse is putting together a presentation on meningitis. Which of the following
C. Mental deficits are often present with PKU. microorganisms has not been linked to meningitis in humans?
D. The effects of PKU are reversible. A. S. pneumoniae
12. A patient has taken an overdose of aspirin. Which of the following should a nurse B. H. influenzae
most closely monitor for during acute management of this patient? C. N. meningitidis
A. Onset of pulmonary edema D. Cl. difficile
B. Metabolic alkalosis 20. A nurse is administering blood to a patient who has a low hemoglobin count. The
C. Respiratory alkalosis s.
s A. The life span of RBC is 45 days.
13. A 50-year-old blind and deaf patient have been admitted to your floor. As the B. The life span of RBC is 60 days.
charge nurse, your primary responsibility for this patient is? C. The life span of RBC is 90 days.
D. The life span of RBC is 120 days.
B. Communicate with your supervisor your patient safety concerns.
21. A 65-year-old man has been admitted to the hospital for spinal stenosis surgery.
When should the discharge training and planning begin for this patient? you not expect to see with this patient if this condition were acute?
A. Following surgery A. Vomiting
B. Upon admit B. Extreme Thirst
C. Within 48 hours of discharge C. Weight gain
D. Preoperative discussion D. Acetone breath smell
22. A 5-year-old child and has been recently admitted to the hospital. According to meningitis. Which of the following would
Erik psychosocial development stages, the child is in which stage? you not expect to see with this patient if this condition were acute?
A. Trust vs. mistrust A. Increased appetite
B. Initiative vs. guilt B. Vomiting
C. Autonomy vs. shame and doubt C. Fever
D. Intimacy vs. isolation D. Poor tolerance of light
23. A toddler is 26 months old and has been recently admitted to the hospital.
According to Erikson, which of the following stages is the toddler in? conjunctivitis. Which of the following microorganisms is related to this condition?
A. Trust vs. mistrust A. Yersinia pestis
B. Initiative vs. guilt B. Helicobacter pylori
C. Autonomy vs. shame and doubt C. Vibrio cholerae
D. Intimacy vs. isolation D. Haemophilus aegyptius
24. A young adult is 20 years old and has been recently admitted to the hospital.
According to Erikson, which of the following stages is the adult in? Lyme disease. Which of the following microorganisms is related to this condition?
A. Trust vs. mistrust A. Borrelia burgdorferi
B. Initiative vs. guilt B. Streptococcus pyogenes
C. Autonomy vs. shame C. Bacillus anthracis
D. Intimacy vs. isolation D. Enterococcus faecalis
25. A nurse is making rounds taking vital signs. Which of the following vital signs is 33. A fragile 87-year-old female has recently been admitted to the hospital with
abnormal? increased confusion and falls over last two (2) weeks. She is also noted to have a mild
A. 11-year-old male: 90 BPM, 22 RPM, 100/70 mmHg left hemiparesis. Which of the following tests is most likely to be performed?
B. 13-year-old female: 105 BPM, 22 RPM, 105/50 mmHg A. FBC (full blood count)
C. 5-year-old male: 102 BPM, 24 RPM, 90/65 mmHg B. ECG (electrocardiogram)
D. 6-year-old female: 100 BPM, 26 RPM, 90/70 mmHg C. Thyroid function tests
D. CT scan
is dealing with an anxiety disorder. Which of the following medications would the 34. An 84-year-old male has been losing mobility and gaining weight over the last
patient most likely be taking? two (2) months. The patient also has the heater running in his house 24 hours a day,
A. Amitriptyline (Elavil) even on warm days. Which of the following tests is most likely to be performed?
B. Calcitonin A. FBC (full blood count)
C. Pergolide mesylate (Permax) B. ECG (electrocardiogram)
D. Verapamil (Calan) C. Thyroid function tests
27. Which of the following conditions would a nurse not administer erythromycin? D. CT scan
A. Campylobacteriosis infection 35. A 20-year-old female attending college is found unconscious in her dorm room.
She has a fever and a noticeable rash. She has just been admitted to the hospital.
C. Pneumonia Which of the following tests is most likely to be performed first?
D. Multiple Sclerosis A. Blood sugar check
hyperkalemia. Which of the following B. CT scan
would you not expect to see with this patient if this condition were acute? C. Blood cultures
A. Decreased HR D. Arterial blood gases
B. Paresthesias 36. A 28-year-old male has been found wandering around in a confused pattern. The
C. Muscle weakness of the extremities male is sweaty and pale. Which of the following tests is most likely to be performed
D. Migraines first?
A. Blood sugar check Photosensitivity is an extreme sensitivity to ultraviolet (UV) rays from the sun and other
B. CT scan light sources. A type of photosensitivity called Phototoxic reactions are caused when
C. Blood cultures medications in the body interact with UV rays from the sun. Antiinfectives are the most
D. Arterial blood gases common cause of this type of reaction.
37. A m 3. Answer: D. Aspirin
following factors is the most important aspect of toilet training? Aspirin is not known to cause discoloration of the urine.
A. The age of the child Option A: Sulfasalazine may discolor the urine or skin to an orange-yellow color.
Option B: Levodopa may discolor the urine, saliva, or sweat to a dark brown color.
C. The overall mental and physical abilities of the child. Option C: Phenolphthalein can discolor the urine to a red color.
D. Frequent attempts with positive reinforcement. 4. Answer: A. Corgard
38. A parent calls the pediatric clinic and is frantic about the bottle of cleaning fluid Nadolol (Corgard) is stored at room temperature between 59 to 86 ºF (15 and 30 ºC) away
her child drank 20 minutes. Which of the following is the most important instruction from heat, moisture, and light. Do not store in the bathroom and keep bottle tightly closed.
the nurse can give the parent? Option B: Humulin N injection if unopened (not in use) is stored in the fridge and
A. This too shall pass. is used until the expiration date, or stored at room temperature and used within
B. Take the child immediately to the ER 31 days. If opened (in-use), store the vial in a refrigerator or at room temperature
C. Contact the Poison Control Center quickly and use within 31 days. Store the injection pen at room temperature (do not
D. Give the child syrup of ipecac refrigerate) and use within 14 days. Keep it in its original container protected from
39. A nurse is administering a shot of Vitamin K to a 30 day-old infant. Which of the heat and light. Do not draw insulin from a vial into a syringe until you are ready to
following target areas is the most appropriate? give an injection. Do not freeze insulin or store it near the cooling element in a
A. Gluteus maximus refrigerator. Throw away any insulin that has been frozen.
B. Gluteus minimus Option C: Urokinase (Kinlytic) is refrigerated at 2 8°C.
C. Vastus lateralis Option D: Epoetin alfa IV (Epogen) vials should be stored at 2°C to 8°C (36°F to
D. Vastus medialis 46°F); Do not freeze. Do not shake. Protect from light.
40. A nurse has just started her rounds delivering medication. A new patient on her 5. Answer: D. IgG
rounds is a 4-year-old boy who is non-verbal. This child does not have on any IgG is the only immunoglobulin that can cross the placental barrier.
identification. What should the nurse do? Option A: IgA antibodies protect body surfaces that are exposed to outside foreign
A. Contact the provider substances.
B. Ask the child to write their name on paper. Option B: IgD antibodies are found in small amounts in the tissues that line the
C. Ask a coworker about the identification of the child. belly or chest.
Option C: IgE antibodies cause the body to react against foreign substances such
Answers and Rationale as pollen, spores, animal dander.
6. Answer: B. Start prophylactic AZT treatment
1. Answers: A, and B. Azidothymidine (AZT) treatment is the most critical intervention. It is an antiretroviral
Option A: Warfarin (Coumadin). Has a pregnancy category X and associated medication used to prevent and treat HIV/AIDS by reducing the replication of the virus.
with central nervous system defects, spontaneous abortion, stillbirth, prematurity, Options A and D: Other interventions mentioned are to be done later.
hemorrhage, and ocular defects when given anytime during pregnancy and a fetal Option C: Pentamidine is an antimicrobial medication given to prevent and treat
warfarin syndrome when given during the first trimester. pneumocystis pneumonia
Option B: Finasteride (Propecia, Proscar). Also has a pregnancy category X 7. Answer: C. Autonomic neuropathy
which has a high risk of causing permanent damage to the fetus. Autonomic neuropathy (also known as Diabetic Autonomic Neuropathy) affects the
Option C: Celecoxib (Celebrex). Large doses cause birth defects in rabbits; not autonomic nerves, which control the bladder, intestinal tract, and genitals, among other
known if the effect on people is the same. organs. Paralysis of the bladder is a common symptom of this type of neuropathy.
Option D: Clonidine (Catapres). Crosses the placenta but no adverse fetal effects Option A: Atherosclerosis, or hardening of the arteries, is a condition in which
have been observed. plaque builds up inside the arteries. Plaque is made of cholesterol, fatty
Option E: Transdermal nicotine (Habitrol). Nicotine replacement products have substances, cellular waste products, calcium and fibrin (a clotting material in the
been assigned to pregnancy category C (nicotine gum) and category D blood).
(transdermal patches, inhalers, and spray nicotine products). Option B: Diabetic nephropathy (DN) is typically defined by macroalbuminuria
Option F: Clofazimine (Lamprene). Clofazimine has been assigned to pregnancy that is, a urinary albumin excretion of more than 300 mg in a 24-hour collection
category C. or macroalbuminuria and abnormal renal function as represented by an
2. Answers: A, B, C, D, and E. abnormality in serum creatinine, calculated creatinine clearance, or
 glomerular filtration rate (GFR). Clinically, diabetic nephropathy is characterized Early symptoms of aspirin poisoning also include tinnitus, hyperventilation,
by a progressive increase in proteinuria and decline in GFR, hypertension, and a vomiting, dehydration, and fever. Late signs include drowsiness, bizarre behavior,
high risk of cardiovascular morbidity and mortality. unsteady walking, and coma. Abnormal breathing caused by aspirin poisoning is
Option D: Somatic neuropathy affects the whole body and presents with diverse usually rapid and deep.
clinical pictures, most common is the development of diabetic foot followed by Pulmonary edema may be related to an increase in permeability within the
diabetic ulceration and possible amputation.
8. Answer: B. Anorexia nervosa renal and pulmonary tissues. The alteration in renal tubule permeability may lead
All of the clinical signs and symptoms point to a condition of anorexia nervosa. The key to a change in colloid osmotic pressure and thus facilitate pulmonary edema
feature of anorexia nervosa is self-imposed starvation, resulting from a distorted body (via Medscape).
image and an intense, irrational fear of gaining weight, even when the patient is emaciated. 13. Answer: D. Provide a secure environment for the patient.
Anorexia nervosa may include refusal to eat accompanied by compulsive exercising, self- T
induced vomiting, or laxative or diuretic abuse. 14. Answer: C. Cough following bronchodilator utilization
Option A: Multiple sclerosis (MS) is a demyelinating disease in which the The bronchodilator will allow a more productive cough.
insulating covers of the nerve cells in the brain and spinal cord are damaged. 15. Answer: B. Weight gain
Option C: On the other hand, bulimia nervosa features binge eating followed by a Weight gain due to fluid accumulation is associated with heart failure and congenital
feeling of guilt, humiliation, and self-deprecation. These feelings cause the patient heart defects.
to engage in self-induced vomiting, use of laxatives or diuretics. 16. Answer: C. Oily skin
Option D: Systemic sclerosis or systemic scleroderma is an autoimmune disease The skin would be dry and not oily.
of the connective tissue. 17. Answer: D. Observe for signs of bleeding.
9. Answer: B. Hypercalcemia Bleeding is the priority concern for a client taking thrombolytic medication.
Hypercalcemia can cause polyuria, severe abdominal pain, and confusion. Options A and B: Are monitored but are not the primary concern.
Option A: Diverticulosis is a condition that develops when pouches (diverticula) Option C: is not related to the use of medication.
form in the wall of the large intestine 18. Answer: A. Green vegetables and liver
Option C: Hypocalcemia is low calcium levels in the blood; it is asymptomatic in Green vegetables and liver are a great source of folic acid.
mild forms but can cause paresthesia, tetany, muscle cramps, and carpopedal 19. Answer: D. Cl. difficile
spasms in severe hypocalcemia. Cl. difficile has not been linked to meningitis.
Option D: Irritable bowel syndrome is a widespread condition involving recurrent 20. Answer: D. The life span of RBC is 120 days.
abdominal pain and diarrhea or constipation, often associated with Red blood cells have a lifespan of 120 in the body.
stress, depression, anxiety, or previous intestinal infection. 21. Answer: B. Upon admit
10. Answer: C. RH negative, RH positive Discharge education begins upon admission.
Rhogam prevents the production of anti-RH antibodies in the mother that has a Rh-positive 22. Answer: B. Initiative vs. guilt
fetus. Initiative vs. guilt- 3-6 years old
11. Answer: D. The effects of PKU are reversible. 23. Answer: C. Autonomy vs. shame
Phenylketonuria (PKU) is an inherited disorder that increases the levels of phenylalanine Autonomy vs Shame and doubt is at 12-18 months old
(a building block of proteins) in the blood. If PKU is not treated, phenylalanine can build up 24. Answer: D. Intimacy vs. isolation
to harmful levels in the body, causing intellectual disability and other serious health Intimacy vs. isolation- 18-35 years old
problems. The signs and symptoms of PKU vary from mild to severe. The most severe form 25. Answer: B. 13-year-old female: 105 BPM, 22 RPM, 105/50 mmHg
of this disorder is known as classic PKU. Infants with classic PKU appear normal until they HR and Respirations are slightly increased. BP is down.
are a few months old. Without treatment, these children develop a permanent intellectual 26. Answer: A. Elavil
disability. Seizures, delayed development, behavioral problems, and psychiatric disorders Amitriptyline (Elavil) is a tricyclic antidepressant and used to treat symptoms of
are also common. Untreated individuals may have a musty or mouse-like odor as a side depression.
effect of excess phenylalanine in the body. Children with classic PKU tend to have lighter Option B: Calcitonin is used to treat osteoporosis in women who have been
skin and hair than unaffected family members and are also likely to have skin disorders in menopause.
such as eczema. The effects of PKU stay with the infant throughout their life (via Genetic Option C: Pergolide mesylate (Permax) is used in the treatment of
Home Reference). disease.
12. Answer: A. Onset of pulmonary edema Option D: Verapamil (Calan) is a calcium channel blocker.
Aspirin overdose can lead to metabolic acidosis and cause pulmonary edema 27. Answer: D. Multiple Sclerosis
development. Erythromycin is used to treat conditions A-C.
28. Answer: D. Migraines
Answer choices A-C were symptoms of acute hyperkalemia. foods. The nurse enters the room to find the patient confused and shaky. Which of
29. Answer: C. Weight gain
Weight loss would be expected. A. Anesthesia reaction.
30. Answer: A. Increased appetite B. Hyperglycemia.
Loss of appetite would be expected. C. Hypoglycemia.
31. Answer: D. Haemophilus aegyptius D. Diabetic ketoacidosis.
Option A: is linked to Plague 4. A nurse assigned to the emergency department evaluates a patient who
Option B: is linked to peptic ulcers underwent fiberoptic colonoscopy 18 hours previously. The patient reports
Option C: is linked to Cholera. increasing abdominal pain, fever, and chills. Which of the following conditions poses
32. Answer: A. Borrelia burgdorferi the most immediate concern?
Option B: is linked to Rheumatic fever A. Bowel perforation.
Option C: is linked to Anthrax B. Viral Gastroenteritis.
Option D: is linked to Endocarditis. C. Colon cancer.
33. Answer: D. CT scan D. Diverticulitis.
A CT scan would be performed for further investigation of the hemiparesis. 5. A patient is admitted to the same day surgery unit for liver biopsy. Which of the
34. Answer: C. Thyroid function tests following laboratory tests assesses coagulation?
Weight gain and poor temperature tolerance indicate something may be wrong with the A. Partial thromboplastin time.
thyroid function. B. Prothrombin time.
35. Answer: C. Blood cultures C. Platelet count.
Blood cultures would be performed to investigate the fever and rash symptoms. D. Hemoglobin
36. Answer: A. Blood sugar check 6. A nurse is assessing a clinic patient with a diagnosis of hepatitis A. Which of the
With a history of diabetes, the first response should be to check blood sugar levels. following is the most likely route of transmission?
37. Answer: C. The overall mental and physical abilities of the child. A. Sexual contact with an infected partner.
Age is not the greatest factor in potty training. The overall mental and physical abilities of B. Contaminated food.
the child are the most important factor. C. Blood transfusion.
38. Answer: C. Contact the Poison Control Center quickly D. Illegal drug use.
The poison control center will have an exact plan of action for this child. 7. A leukemia patient has a relative who wants to donate blood for transfusion.
39. Answer: C. Vastus lateralis Which of the following donor medical conditions would prevent this?
Vastus lateralis is the most appropriate location. A. A history of hepatitis C five years previously.
40. Answer: D. Ask the father who is in B. Cholecystitis requiring cholecystectomy one year previously.
C. Asymptomatic diverticulosis.
not withhold the medication from the child after identification.
n Text Mode: All questions and answers are given for reading and answering at your pace. 8. A physician has diagnosed acute gastritis in a clinic patient. Which of the following
You can also copy this exam and make a printout. medications would be contraindicated for this patient?
1. A patient is admitted to the hospital with a diagnosis of primary A. Naproxen sodium (Naprosyn).
hyperparathyroidism. A nurse B. Calcium carbonate.
of the following changes in laboratory findings? C. Clarithromycin (Biaxin).
A. Elevated serum calcium. D. Furosemide (Lasix).
B. Low serum parathyroid hormone (PTH). 9. The nurse is conducting nutrition counseling for a patient with cholecystitis.
C. Elevated serum vitamin D. Which of the following information is important to communicate?
D. Low urine calcium. A. The patient must maintain a low-calorie diet.
B. The patient must maintain a high protein/low carbohydrate diet.
of the following diet modifications is NOT recommended? C. The patient should limit sweets and sugary drinks.
A. A diet high in grains. D. The patient should limit fatty foods.
B. A diet with adequate caloric intake. 10. A patient admitted to the hospital with myocardial infarction develops severe
C. A high protein diet. pulmonary edema. Which of the following symptoms should the nurse expect the
D. A restricted sodium diet. patient to exhibit?
3. A patient with a history of diabetes mellitus is on the second post-operative day A. Slow, deep respirations.
following cholecystectomy. She has complained of nausea B. Stridor.
C. Bradycardia. A. Small blue-white spots are visible on the oral mucosa.
D. Air hunger. B. The rash begins on the trunk and spreads outward.
11. A nurse caring for several patients on the cardiac unit is told that one is C. There is low-grade fever.
scheduled for implantation of an automatic internal cardioverter-defibrillator. -on-a-rose-
Which of the following patients is most likely to have this procedure? 18. A child is seen in the emergency department for scarlet fever. Which of the
A. A patient admitted for myocardial infarction without cardiac muscle damage. following descriptions of scarlet fever is NOT correct?
B. A post-operative coronary bypass patient, recovering on schedule. A. Scarlet fever is caused by infection with group A Streptococcus bacteria.
C. A patient with a history of ventricular tachycardia and syncopal episodes.
D. A patient with a history of atrial tachycardia and fatigue. C. Petechiae occur on the soft palate.
12. A patient is scheduled for a magnetic resonance imaging (MRI) scan for D. The pharynx is red and swollen.
suspected lung cancer. Which of the following is a contraindication to the study for 19. A child weighing 30 kg arrives at the clinic with diffuse itching as the result of
this patient? an allergic reaction to an insect bite. Diphenhydramine (Benadryl) 25 mg 3 times a
A. The patient is allergic to shellfish. day is prescribed. The correct pediatric dose is 5 mg/kg/day. Which of the following
B. The patient has a pacemaker. best describes the prescribed drug dose?
C. The patient suffers from claustrophobia. A. It is the correct dose.
D. The patient takes anti-psychotic medication. B. The dose is too low.
13. A nurse calls a physician with the concern that a patient has developed C. The dose is too high.
a pulmonary embolism. Which of the following symptoms has the nurse most likely D. The dose should be increased or decreased, depending on the symptoms.
observed? 20. The mother of a 2-month-old infant brings the child to the clinic for a well-baby
A. The patient is somnolent with decreased response to the family. check. She is concerned because she feels only one testis in the scrotal sac. Which of
B. The patient suddenly complains of chest pain and shortness of breath. the following statements about the undescended testis is the most accurate?
C. The patient has developed a wet cough and the nurse hears crackles on auscultation of A. Normally, the testes are descended by birth.
the lungs. B. The infant will likely require surgical intervention.
D. The patient has a fever, chills, and loss of appetite. C. The infant probably has with only one testis.
14. A patient comes to the emergency department with abdominal pain. Work-up D. Normally, the testes descend by one year of age.
reveals the presence of a rapidly enlarging abdominal aortic aneurysm. Which of the 21. A child is admitted to the hospital with a diagnosis of Wilms tumor, stage II.
following actions should the nurse expect? Which of the following statements most accurately describes this stage?
A. The patient will be admitted to the medicine unit for observation and medication. A. The tumor is less than 3 cm. in size and requires no chemotherapy.
B. The patient will be admitted to the day surgery unit for sclerotherapy. B. The tumor did not extend beyond the kidney and was completely resected.
C. The patient will be admitted to the surgical unit and resection will be scheduled. C. The tumor extended beyond the kidney but was completely resected.
D. The patient will be discharged home to follow-up with his cardiologist in 24 hours. D. The tumor has spread into the abdominal cavity and cannot be resected.
15. A patient with leukemia is receiving chemotherapy that is known to depress 22. A teen patient is admitted to the hospital by his physician who suspects a
bone marrow. A CBC (complete blood count) reveals a platelet count of diagnosis of acute glomerulonephritis. Which of the following findings is consistent
25,000/microliter. Which of the following actions related specifically to the platelet with this diagnosis? Note: More than one answer may be correct.
count should be included in the nursing care plan? A. Urine specific gravity of 1.040.
A. Monitor for fever every 4 hours. B. Urine output of 350 ml in 24 hours.
B. Require visitors to wear respiratory masks and protective clothing. -
C. Consider transfusion of packed red blood cells. D. Generalized edema.
D. Check for signs of bleeding, including examination of urine and stool for blood. 23. Which of the following conditions most commonly causes acute
16. A nurse in the emergency department is observing a 4-year-old child for signs of glomerulonephritis?
increased intracranial pressure after a fall from a bicycle, resulting in head trauma. A. A congenital condition leading to renal dysfunction.
Which of the following signs or symptoms would be cause for concern? B. Prior infection with group A Streptococcus within the past 10-14 days.
A. Bulging anterior fontanel. C. Viral infection of the glomeruli.
B. Repeated vomiting. D. Nephrotic syndrome.
C. Signs of sleepiness at 10 PM. 24. An infant with hydrocele is seen in the clinic for a follow-up visit at 1 month of
D. Inability to read short words from a distance of 18 inches. age. The scrotum is smaller than it was at birth, but fluid is still visible on
17. A nonimmunized child appears at the clinic with a visible rash. Which of the illumination. Which of the following actions is the physician likely to recommend?
following observations indicates the child may have rubeola (measles)? A. Massaging the groin area twice a day until the fluid is gone.
B. Referral to a surgeon for repair.
C. No treatment is necessary; the fluid is reabsorbing normally. C. Expansion of the clot.
D. Keeping the infant in a flat, supine position until the fluid is gone. D. Resolution of the clot.
25. A nurse is caring for a patient with peripheral vascular disease (PVD). The 32. An infant is brought to the clinic by his mother, who has noticed that he holds his
patient complains of burning and tingling of the hands and feet and cannot head in an unusual position and always faces to one side. Which of the following is
tolerate touch of any kind. Which of the following is the most likely explanation for the most likely explanation?
these symptoms? A. Torticollis, with shortening of the sternocleidomastoid muscle.
A. Inadequate tissue perfusion leading to nerve damage. B. Craniosynostosis, with premature closure of the cranial sutures.
B. Fluid overload leading to compression of nerve tissue. C. Plagiocephaly, with flattening of one side of the head.
C. Sensation distortion due to psychiatric disturbance. D. Hydrocephalus, with increased head size.
D. Inflammation of the skin on the hands and feet.
26. A patient in the cardiac unit is concerned about the risk factors associated with participate in sports due to a diagnosis of Osgood-Schlatter disease. Which of the
atherosclerosis. Which of the following are hereditary risk factors for developing following statements about the disease is correct?
atherosclerosis? A. The condition was ca
A. Family history of heart disease. B. The student will most likely require surgical intervention.
B. Overweight. C. The student experiences pain in the inferior aspect of the knee.
C. Smoking. D. The student is trying to avoid participation in physical education.
D. Age. 34. The clinic nurse asks a 13-year-old female to bend forward at the waist with
27. Claudication is a well-known effect of peripheral vascular disease. Which of the arms hanging freely. Which of the following assessments is the nurse most likely
following facts about claudication is correct? Select all that apply: conducting?
A. It results when oxygen demand is greater than oxygen supply. A. Spinal flexibility.
B. It is characterized by pain that often occurs during rest. B. Leg length disparity.
C. It is a result of tissue hypoxia. C. Hypostatic blood pressure.
D. It is characterized by cramping and weakness. D. Scoliosis.
28. A nurse is providing discharge information to a patient with peripheral vascular 35. A clinic nurse interviews a parent who is suspected of abusing her child. Which of
disease. Which of the following information should be included in instructions? the following characteristics is the nurse LEAST likely to find in an abusing parent?
A. Walk barefoot whenever possible. A. Low self-esteem.
B. Use a heating pad to keep feet warm. B. Unemployment.
C. Avoid crossing the legs. C. Self-blame for the injury to the child.
D. Use antibacterial ointment to treat skin lesions at risk of infection. D. Single status.
36. A nurse is assigned to the pediatric rheumatology clinic and is assessing a child
complains of cold and stiffness in the fingers. Which of the following descriptions is who has just been diagnosed with juvenile idiopathic arthritis. Which of the
most likely to fit the patient? following statements about the disease is most accurate?
A. An adolescent male. A. The child has a poor chance of recovery without joint deformity.
B. An elderly woman. B. Most children progress to adult rheumatoid arthritis.
C. A young woman. C. Nonsteroidal anti-inflammatory drugs are the first choice in treatment.
D. An elderly man. D. Physical activity should be minimized.
30. A 23-year-old patient in the 27th week of pregnancy has been hospitalized on 37. A child is admitted to the hospital several days after stepping on a sharp object
complete bed rest for 6 days. She experiences sudden shortness of breath, that punctured her athletic shoe and entered the flesh of her foot. The physician is
accompanied by chest pain. Which of the following conditions is the most likely concerned about osteomyelitis and has ordered parenteral antibiotics. Which of the
cause of her symptoms? following actions is done immediately before the antibiotic is started?
A. Myocardial infarction due to a history of atherosclerosis. A. The admission orders are written.
B. Pulmonary embolism due to deep vein thrombosis (DVT). B. A blood culture is drawn.
C. Anxiety C. A complete blood count with differential is drawn.
D. Congestive heart failure due to fluid overload. D. The parents arrive.
31. Thrombolytic therapy is frequently used in the treatment of suspected stroke. 38. A two-year-old child has sustained an injury to the leg and refuses to walk. The
Which of the following is a significant complication associated with thrombolytic nurse in the emergency department documents swelling of the lower affected leg.
therapy? Which of the following does the nu
A. Air embolus. A. Possible fracture of the tibia.
B. Cerebral hemorrhage. B. Bruising of the gastrocnemius muscle.
C. Possible fracture of the radius. Option D: Diverticulitis may cause pain, fever, and chills, but is far less serious
D. No anatomic injury, the child wants his mother to carry him. than perforation and peritonitis.
39. A toddler has recently been diagnosed with cerebral palsy. Which of the 5. Answers: A, B, and C.
following information should the nurse provide to the parents? Note: More than one Prothrombin time, partial thromboplastin time, and platelet count are all included in
answer may be correct. coagulation studies.
A. Regular developmental screening is important to avoid secondary developmental delays. Option D: The hemoglobin level, though important information prior to an
B. Cerebral palsy is caused by injury to the upper motor neurons and results in motor invasive procedure like liver biopsy, does not assess coagulation.
dysfunction, as well as possible ocular and speech difficulties. 6. Answer: B. Contaminated food.
C. Developmental milestones may be slightly delayed but usually will require no additional Hepatitis A is the only type that is transmitted by the fecal-oral route through
intervention. contaminated food.
D. Parent support groups are helpful for sharing strategies and managing health care Options A, C, and D: Hepatitis B, C, and D are transmitted through infected bodily
issues. fluids.
7. Answer: A. A history of hepatitis C five years previously.
parents are receiving genetic counseling prior to planning another pregnancy. Which Hepatitis C is a viral infection transmitted through bodily fluids, such as blood, causing
of the following statements includes the most accurate information? inflammation of the liver. Patients with hepatitis C may not donate blood for transfusion
-linked recessive disorder, so daughters have a 50% chance of being due to the high risk of infection in the recipient. Cholecystitis (gallbladder disease),
carriers and sons a 50% chance of developing the disease. diverticulosis, and
-linked recessive disorder, so both daughters and sons have a 50% 8. Answer: A. Naproxen sodium (Naprosyn).
chance of developing the disease. Naproxen sodium is a nonsteroidal anti-inflammatory drug that can cause inflammation of
C. Each child has a 1 in 4 (25%) chance of developing the disorder. the upper GI tract. For this reason, it is contraindicated in a patient with gastritis.
D. Sons only have a 1 in 4 (25%) chance of developing the disorder. Option B: Calcium carbonate is used as an antacid for the relief of indigestion and
is not contraindicated.
Answers and Rationale Option C: Clarithromycin is an antibacterial often used for the treatment
1. Answer: A. Elevated serum calcium. of Helicobacter pylori in gastritis.
The parathyroid glands regulate the calcium level in the blood. In hyperparathyroidism, the Option D: Furosemide is a loop diuretic and is NOT contraindicated in a patient
serum calcium level will be elevated. with gastritis.
Option B: Parathyroid hormone levels may be high or normal but not low. 9. Answer: D. The patient should limit fatty foods.
Option C: The body will lower the level of vitamin D in an attempt to lower Cholecystitis, inflammation of the gallbladder, is most commonly caused by the presence
calcium. of gallstones, which may block bile (necessary for fat absorption) from entering the
Option D: Urine calcium may be elevated, with calcium spilling over from elevated intestines. Patients should decrease dietary fat by limiting foods like fatty meats, fried
serum levels. This may cause renal stones. foods, and creamy desserts to avoid irritation of the gallbladder.
2. Answer: D. A restricted sodium diet. 10. Answer: D. Air hunger.
Patients with pulmonary edema experience air hunger, anxiety, and agitation.
loss. Adequate caloric intake is recommended with a diet high in protein and complex Options A and C: Respiration is fast and shallow and heart rate increases.
carbohydrates, including grains. Option B: Stridor is noisy breathing caused by laryngeal swelling or spasm and is
3. Answer: C. Hypoglycemia. not associated with pulmonary edema.
A post-operative diabetic patient who is unable to eat is likely to be suffering from 11. Answer: C. A patient with a history of ventricular tachycardia and syncopal
hypoglycemia. Confusion and shakiness are common symptoms. episodes.
Option A: An anesthesia reaction would not occur on the second postoperative An automatic internal cardioverter-defibrillator delivers an electric shock to the heart to
day. terminate episodes of ventricular tachycardia and ventricular fibrillation. This is necessary
Options B and D: Hyperglycemia and ketoacidosis do not cause confusion and for a patient with significant ventricular symptoms, such as tachycardia resulting in
shakiness. syncope.
4. Answer: A. Bowel perforation Option A: A patient with myocardial infarction that resolved with no permanent
Bowel perforation is the most serious complication of fiberoptic colonoscopy. Important cardiac damage would not be a candidate.
signs include progressive abdominal pain, fever, chills, and tachycardia, which indicate Option B: A patient recovering well from coronary bypass would not need the
advancing peritonitis. device.
Options B and C: Viral gastroenteritis and colon cancer do not cause these Option D: Atrial tachycardia is less serious and is treated conservatively with
symptoms. medication and cardioversion as a last resort.
12. Answer: B. The patient has a pacemaker.
The implanted pacemaker will interfere with the magnetic fields of the MRI scanner and 20. Answer: D. Normally, the testes descend by one year of age.
may be deactivated by them. Normally, the testes descend by one year of age. In young infants, it is common for the
Option A: Shellfish/iodine allergy is not a contraindication because the contrast testes to retract into the inguinal canal when the environment is cold or the cremasteric
used in MRI scanning is not iodine-based. reflex is stimulated. The exam should be done in a warm room with warm hands. It is most
Options C and D: Open MRI scanners and anti-anxiety medications are available likely that both testes are present and will descend by a year. If not, a full assessment will
for patients with claustrophobia. Psychiatric medication is not a contraindication determine the appropriate treatment.
to MRI scanning. 21. Answer: C. The tumor extended beyond the kidney but was completely resected.
13. Answer: B. The patient suddenly complains of chest pain and shortness of breath. The staging of is confirmed at surgery as follows: Stage I, the tumor is limited
Typical symptoms of pulmonary embolism include chest pain, shortness of breath, and to the kidney and completely resected; stage II, the tumor extends beyond the kidney but is
severe anxiety. The physician should be notified immediately. completely resected; stage III, residual nonhematogenous tumor is confined to the
Options A and C: A patient with pulmonary embolism will not be sleepy or have a abdomen; stage IV, hematogenous metastasis has occurred with spread beyond the
cough with crackles on the exam. abdomen; and stage V, bilateral renal involvement is present at diagnosis.
Option D: A patient with fever, chills, and loss of appetite may be 22. Answers: A, B, and C
developing pneumonia. Acute glomerulonephritis is characterized by high urine specific gravity related to oliguria
14. Answer: C. The patient will be admitted to the surgical unit and resection will be as -
scheduled. Option D: There is periorbital edema, but generalized edema is seen in nephrotic
A rapidly enlarging abdominal aortic aneurysm is at significant risk of rupture and should syndrome, not acute glomerulonephritis.
be resected as soon as possible. No other appropriate treatment options currently exist. 23. Answer: B. Prior infection with group A Streptococcus within the past 10-14 days.
15. Answer: D. Check for signs of bleeding, including examination of urine and stool Acute glomerulonephritis is most commonly caused by the immune response to a prior
for blood. upper respiratory infection with group A Streptococcus. Glomerular inflammation occurs
A platelet count of 25,000/microliter is severely thrombocytopenic and should prompt the about 10-14 days after the infection, resulting in scant, dark urine and retention of body
initiation of bleeding precautions, including monitoring urine and stool for evidence of fluid. Periorbital edema and hypertension are common signs at diagnosis.
bleeding. 24. Answer: C. No treatment is necessary; the fluid is reabsorbing normally.
Options A and B: Monitoring for fever and requiring protective clothing are A hydrocele is a collection of fluid in the scrotum that results from a patent tunica vaginalis.
indicated to prevent infection if white blood cells are decreased. Illumination of the scrotum with a pocket light demonstrates the clear fluid. In most cases,
Option C: Transfusion of red cells is indicated for severe anemia. the fluid reabsorbs within the first few months of life and no treatment is necessary.
16. Answer: B. Repeated vomiting. Options A and D: Massaging the area or placing the infant in a supine position
Increased pressure caused by bleeding or swelling within the skull can damage delicate would have no effect.
brain tissue and may become life-threatening. Repeated vomiting can be an early sign of Option B: Surgery is not indicated.
pressure as the vomiting center within the medulla is stimulated. 25. Answer: A. Inadequate tissue perfusion leading to nerve damage.
Option A: The anterior fontanel is closed in a 4-year-old child. Patients with the peripheral vascular disease often sustain nerve damage as a result of
Option C: Evidence of sleepiness at 10 PM is normal for a four-year-old. inadequate tissue perfusion.
Option D: The average 4-year-old child cannot read yet, so this too is normal. Option B: Fluid overload is not characteristic of PVD.
17. Answer: A. Small blue-white spots are visible on the oral mucosa. Option C: There is nothing to indicate a psychiatric disturbance in the patient.
-white spots visible on the oral mucosa and are characteristic Option D: Skin changes in PVD are secondary to decreased tissue perfusion rather
of measles infection. than primary inflammation.
Option B: The body rash typically begins on the face and travels downward. 26. Answer: A. Family history of heart disease.
Option C: High fever is often present. A family history of heart disease is an inherited risk factor that is not subject to lifestyle
Option D: change. Having a first-degree relative with heart disease has been shown to significantly
in varicella (chickenpox). increase risk.
18. Answer: C. Petechiae occur on the soft palate. Options B and C: Overweight and smoking are risk factors that are subject to
Petechiae on the soft palate are characteristic of rubella infection. lifestyle change and can reduce risk significantly.
Options A, B, and D are characteristic of scarlet fever, a result of group A Option D: Advancing age increases the risk of atherosclerosis but is not a
Streptococcus infection. hereditary factor.
19. Answer: B. The dose is too low. 27. Answers: A, C, and D.
This child weighs 30 kg, and the pediatric dose of diphenhydramine is 5 mg/kg/day (5 X 30 Claudication describes the pain experienced by a patient with a peripheral vascular disease
= 150/day). Therefore, the correct dose is 150 mg/day. Divided into 3 doses per day, the when oxygen demand in the leg muscles exceeds the oxygen supply. The tissue becomes
child should receive 50 mg 3 times a day rather than 25 mg 3 times a day. Dosage should hypoxic, causing cramping, weakness, and discomfort.
not be titrated based on symptoms without consulting a physician.
 Option B: This most often occurs during activity when demand increases in Option D: Continued participation will worsen the condition and the symptoms.
muscle tissue. 34. Answer: D. Scoliosis.
28. Answer: C. Avoid crossing the legs. A check for scoliosis, a lateral deviation of the spine, is an important part of the routine
Patients with peripheral vascular disease should avoid crossing the legs because this can adolescent exam. It is assessed by having the teen bend at the waist with arms dangling,
impede blood flow. while observing for lateral curvature and uneven rib level. Scoliosis is more common in
Option A: Walking barefoot is not advised, as foot protection is important to avoid female adolescents.
trauma that may lead to serious infection. Options A, B, and C are not part of the routine adolescent exam.
Option B: Heating pads can cause injury, which can also increase the risk of 35. Answer: C. Self-blame for the injury to the child.
infection. The profile of a parent at risk of abusive behavior includes a tendency to blame the child or
Option D: Skin lesions at risk for infection should be examined and treated by a others for the injury sustained.
physician. Options A, B, and D: These parents also have a high incidence of low self-esteem,
29. Answer: C. A young woman. unemployment, unstable financial situation, and single status.
36. Answer: C. Nonsteroidal anti-inflammatory drugs are the first choice in
rheumatologic disorders, such as lupus and rheumatoid arthritis. treatment.
30. Answer: B. Pulmonary embolism due to deep vein thrombosis (DVT). Nonsteroidal anti-inflammatory drugs are important first line treatment for juvenile
In a hospitalized patient on prolonged bed rest, the most likely cause of sudden onset idiopathic arthritis (formerly known as juvenile rheumatoid arthritis). NSAIDs require 3-4
shortness of breath and chest pain is pulmonary embolism. Pregnancy and prolonged weeks for the therapeutic anti-inflammatory effects to be realized.
inactivity both increase the risk of clot formation in the deep veins of the legs. These clots Options A and B: Half of children with the disorder recover without joint
can then break loose and travel to the lungs. deformity and about a third will continue with symptoms into adulthood.
Options A and D: Myocardial infarction and atherosclerosis are unlikely in a 27- Option D: Physical activity is an integral part of therapy.
year-old woman, as is congestive heart failure due to fluid overload. 37. Answer: B. A blood culture is drawn.
Option C: There is no reason to suspect an anxiety disorder in this patient. Though Antibiotics must be started after the blood culture is drawn, as they may interfere with the
anxiety is a possible cause of her symptoms, the seriousness of pulmonary identification of the causative organism.
embolism demands that it be considered first. Option C: The blood count will reveal the presence of infection but does not help
31. Answer: B. Cerebral hemorrhage. identify an organism or guide antibiotic treatment.
Cerebral hemorrhage is a significant risk when treating a stroke victim with thrombolytic Option D: Parental presence is important for the adjustment of the child but not
therapy intended to dissolve a suspected clot. The success of the treatment demands that it for the administration of medication.
be instituted as soon as possible, often before the cause of stroke has been determined. Air 38. Answer: A. Possible fracture of the tibia.
embolus is not a concern. Thrombolytic therapy does not lead to
Option A: Air embolus is not a concern. Option B: Toddlers will often continue to walk on a muscle that is bruised or
Options C and D: Thrombolytic therapy does not lead to the expansion of the clot, strained.
but to resolution, which is the intended effect. Option C: The radius is found in the lower arm and is not relevant to this question.
32. Answer: A. Torticollis, with shortening of the sternocleidomastoid muscle. Option D: Toddlers rarely feign injury to be carried, and swelling indicates a
In torticollis, the sternocleidomastoid muscle is contracted, limiting the range of motion of physical injury.
the neck and causing the chin to point to the opposing side. 39. Answers: A, B, and D.
Option B: In craniosynostosis one of the cranial sutures, often the sagittal, closes Delayed developmental milestones are characteristic of cerebral palsy, so regular screening
prematurely, causing the head to grow in an abnormal shape. and intervention is essential. Because of injury to upper motor neurons, children may have
Option C: Plagiocephaly refers to the flattening of one side of the head, caused by ocular and speech difficulties. Parent support groups help families to share and cope.
the infant being placed supine in the same position over time. Physical therapy and other interventions can minimize the extent of the delay in
Option D: Hydrocephalus is caused by a build-up of cerebrospinal fluid in the developmental milestones.
brain resulting in large head size. 40. Answer: A. -linked recessive disorder, so daughters have a
33. Answer: C. The student experiences pain in the inferior aspect of the knee. 50% chance of being carriers and sons a 50% chance of developing the disease.
Osgood-Schlatter disease occurs in adolescents in rapid growth phase when the The recessive Duchenne gene is located on one of the two X chromosomes of a female
infrapatellar ligament of the quadriceps muscle pulls on the tibial tubercle, causing pain carrier. If her son receives the X bearing the gene he will be affected. Thus, there is a 50%
and swelling in the inferior aspect of the knee. Osgood-Schlatter disease is commonly chance of a son being affected. Daughters are not affected, but 50% are carriers because
caused by activities that require repeated use of the quadriceps, including track and soccer. they inherit one copy of the defective gene from the mother. The other X chromosome
Option A: Swimming is not a likely cause. comes from the father, who cannot be a carrier.
Option B: The condition is usually self-limited, responding to ice, rest, and In Text Mode: All questions and answers are given for reading and answering at your own
analgesics. pace. You can also copy this exam and make a print out.
1. The primary reason for rapid continuous rewarming of the area affected A. Have a Protime done monthly
by frostbite is to: B. Eat more fruits and vegetables
A. Lessen the amount of cellular damage C. Drink more liquids
B. Prevent the formation of blisters D. Avoid crowds
C. Promote movement 9. The nurse is assisting the physician with removal of a central venous catheter. To
D. Prevent pain and discomfort facilitate removal, the nurse should instruct the client to:
2. A client recently started on hemodialysis wants to know how the dialysis will take A. Perform the Valsalva maneuver as the catheter is advanced
the place of his kidneys. The nurse that B. Turn his head to the left side and hyperextend the neck
hemodialysis works by: C. Take slow, deep breaths as the catheter is removed
A. Passing water through a dialyzing membrane D. Turn his head to the right while maintaining a sniffing position
B. Eliminating plasma proteins from the blood 10. A client has an order for streptokinase. Before administering the medication, the
C. Lowering the pH by removing nonvolatile acids nurse should assess the client for:
D. Filtering waste through a dialyzing membrane A. Allergies to pineapples and bananas
3. During a home visit, a client with AIDS tells the nurse that he has been exposed B. A history of streptococcal infections
to measles. Which action by the nurse is most appropriate? C. Prior therapy with phenytoin
A. Administer an antibiotic D. A history of alcohol abuse
B. Contact the physician for an order for immune globulin 11. The nurse is providing discharge teaching for the client with leukemia. The client
C. Administer an antiviral should be told to avoid:
D. Tell the client that he should remain in isolation for 2 weeks A. Using oil- or cream-based soaps
4. A client hospitalized with MRSA (methicillin-resistant staph aureus) is placed on B. Flossing between the teeth
contact precautions. Which statement is true regarding precautions for infections C. The intake of salt
spread by contact? D. Using an electric razor
A. The client should be placed in a room with negative pressure. 12. The nurse is changing the ties of the client with a tracheotomy. The safest method
B. Infection requires close contact; therefore, the door may remain open. of changing the tracheotomy ties is to:
C. Transmission is highly likely, so the client should wear a mask at all times. A. Apply the new tie before removing the old one.
D. Infection requires skin-to-skin contact and is prevented by hand washing, gloves, and a B. Have a helper present.
gown. C. Hold the tracheotomy with the nondominant hand while removing the old tie.
5. A client who is admitted with an above-the-knee amputation tells the nurse that D. Ask the doctor to suture the tracheostomy in place.
his foot hurts and itches. Which response by the nurse indicates an understanding of 13. The nurse is monitoring a client following a lung resection. The hourly output
phantom limb pain? from the chest tube was 300mL. The nurse should give priority to:
A. Turning the client to the left side
nervous system interruptions. I will get you some B. Milking the tube to ensure patency
pain medication C. Slowing the intravenous infusion
D. Notifying the physician
surgery 14. The infant is admitted to the unit with tetralogy of falot. The nurse would
6. A client with cancer of the pancreas has undergone a Whipple procedure. The anticipate an order for which medication?
nurse is aware that during the Whipple procedure, the doctor will remove the: A. Digoxin
A. Head of the pancreas B. Epinephrine
B. Proximal third section of the small intestines C. Aminophylline
C. Stomach and duodenum D. Atropine
D. Esophagus and jejunum -breast exam. The nurse is aware
7. The physician has ordered a minimal-bacteria diet for a client with neutropenia. that most malignant breast masses occur in the Tail of Spence. On the diagram
The client should be taught to AVOID eating: below, select where the Tail of Spence is.
A. Packed fruits
B. Salt
C. Fresh raw pepper
D. Ketchup
8. A client is discharged home with a prescription for Coumadin (sodium warfarin).
The client should be instructed to:
 A. Atrial flutter
B. A sinus rhythm
C. Ventricular tachycardia
16. The toddler is admitted with a cardiac anomaly. The nurse is aware that the D. Atrial fibrillation
infant with a ventricular septal defect will: 20. A client with clotting disorder has an order to continue Lovenox (enoxaparin)
A. Tire easily injections after discharge. The nurse should teach the client that Lovenox injections
B. Grow normally should:
C. Need more calories A. Be injected into the deltoid muscle
D. Be more susceptible to viral infections B. Be injected into the abdomen
17. The nurse is monitoring a client with a history of stillborn infants. The nurse is C. Aspirate after the injection
aware that a nonstress test can be ordered for this client to: D. Clear the air from the syringe before injections
A. Determine lung maturity 21. The nurse has a preop order to administer Valium (diazepam) 10mg and
B. Measure the fetal activity Phenergan (promethazine) 25mg. The correct method of administering these
C. Show the effect of contractions on fetal heart rate medications is to:
D. Measure the wellbeing of the fetus A. Administer the medications together in one syringe
18. The nurse is evaluating the client who was admitted 8 hours ago for induction B. Administer the medication separately
of labor. The following graph is noted on the monitor. Which action should be taken C. Administer the Valium, wait 5 minutes, and then inject the Phenergan
first by the nurse? D. Question the order because they cannot be given at the same time
22. A client with frequent urinary tract infections asks the nurse how she can
prevent the reoccurrence. The nurse should teach the client to:
A. Douche after intercourse
B. Void every 3 hours
C. Obtain a urinalysis monthly
D. Wipe from back to front after voiding
23. Which task should be assigned to the nursing assistant?
A. Placing the client in seclusion
B. Emptying the Foley catheter of the preeclamptic client
C. Feeding the client with dementia
D. Ambulating the client with a fractured hip
24. The client has recently returned from having a thyroidectomy. The nurse should
keep which of the following at the bedside?
A. A tracheotomy set
B. A padded tongue blade
A. Instruct the client to push C. An endotracheal tube
B. Perform a vaginal exam D. An airway
C. Turn off the Pitocin infusion 25. The physician has ordered a histoplasmosis test for the elderly client. The nurse
D. Place the client in a semi- is aware that histoplasmosis is transmitted to humans by:
19. The nurse notes the following on the ECG monitor. The nurse would evaluate A. Cats
the cardiac arrhythmia as: B. Dogs
C. Turtles
D. Birds

89%?
A. Administer morphine. 34. A patient infected with human immunodeficiency virus (HIV) begins zidovudine
B. Administer oxygen. therapy. Which of the following statements best describes this
C. Administer sublingual nitroglycerin. A. It destroys the outer wall of the virus and kills it.
D. Obtain an electrocardiogram (ECC) B. It interferes with viral replication.
27. Which of the following signs and symptoms usually signifies rapid expansion and C. It stimulates the immune system.
impending rupture of an abdominal aortic aneurysm? D. It promotes excretion of viral antibodies.
A. Abdominal pain. 35. A 20-year-old patient is being treated for pneumonia. He has a
B. Absent pedal pulses. persistent cough and complains of severe pain on coughing. What could you tell him
C. Chest pain. to help him reduce his discomfort?
D. Lower back pain.
28. In which of the following types of cardiomyopathy does cardiac output remain
normal?
A. Dilated.
B. Hypertrophic. 36. A 19-year-old patient comes to the ED with acute asthma. His respiratory rate is
C. Obliterative. 44 breaths/minute, and he appears to be in acute respiratory distress. Which of the
D. Restrictive. following actions should you take first?
29. Which of the following interventions should be your first priority when treating a A. Take a full medical history.
patient experiencing chest pain while walking? B. Give a bronchodilator by nebulizer.
A. Have the patient sit down. C. Apply a cardiac monitor to the patient.
B. Get the patient back to bed. D. Provide emotional support for the patient.
C. Obtain an ECG. 37. A firefighter who was involved in extinguishing a house fire is being treated for
D. Administer sublingual nitroglycerin. smoke inhalation. He develops severe hypoxia 48 hours after the incident, requiring
30. Which of the following positions would best aid breathing for a patient with acute intubation and mechanical ventilation. Which of the following conditions has he
pulmonary edema? most likely developed?
A. Lying flat in bed. A. Acute respiratory distress syndrome (ARDS).
B. Left side-lying position. B. Atelectasis.
C. Bronchitis.
D. Semi- D. Pneumonia.
31. A pregnant woman arrives at the emergency department (ED) with abruptio 38. Which of the following measures best determines that a patient who had
placentae for which of the following blood a pneumothorax no longer needs a chest tube?
dyscrasias? A. You see a lot of drainage from the chest tube.
A. Thrombocytopenia. B. Arterial blood gas (ABG) levels are normal.
B. Idiopathic thrombocytopenic purpura (ITP). C. The chest X-ray continues to show the lung is 35% deflated.
C. Disseminated intravascular coagulation (DIC). D. The water- no suction is applied.
D. Heparin-associated thrombosis and thrombocytopenia (HATT). 39. Which of the following nursing interventions should you use to prevent footdrop
32. A 16-year-old patient involved in a motor vehicle accident arrives in the ED and contractures in a patient recovering from a subdural hematoma?
A. High-top sneakers.
his pelvis and legs. Which of the following parenteral fluids is the best choice for his B. Low-dose heparin therapy.
current condition? C. Physical therapy consultation.
A. Fresh frozen plasma. D. Sequential compressive device.
B. 0.9% sodium chloride solution. 40. Which of the following signs of increased intracranial pressure (ICP) would
C. Lac appear first after head trauma?
D. Packed red blood cells. A. Bradycardia.
B. Large amounts of very dilute urine.
Which of the following conditions or actions do they suppress? C. Restlessness and confusion.
A. Cushing syndrome. D. Widened pulse pressure.
B. Pain receptors. 41. When giving intravenous (I.V.) phenytoin, which of the following methods should
C. Immune response. you use?
D. Neural transmission.
A. Use an in-line filter. A. Albumin.
B. Withhold other anticonvulsants. B. D5W.
C. Mix the drug with saline solution only.
D. Flush the I.V. catheter with dextrose solution. D. 0.9% sodium chloride solution with 2 mEq of potassium per 100 ml.
42. After surgical repair of a hip, which of the following positions is best for the 50. Which of the following techniques is correct for obtaining a wound culture
specimen from a surgical site?
A. Abduction. A. Thoroughly irrigate the wound before collecting the specimen.
B. Adduction. B. Use a sterile swab and wipe the crusty area around the outside of the wound.
C. Prone. C. Gently roll a sterile swab from the center of the wound outward to collect drainage.
D. Subluxated. D. Use a sterile swab to collect drainage from the dressing.
43. Which of the following factors should be the primary focus of nursing
management in a patient with acute pancreatitis?
Answers and Rationale
A. Nutrition management. 1. Answer: A. Lessen the amount of cellular damage
B. Fluid and electrolyte balance. Rapid continuous rewarming of a frostbite primarily lessens cellular damage. It does not
C. Management of hypoglycemia. prevent
D. Pain control. Options B, C, and D: It does not prevent the formation of blisters. It does promote
44. After a liver biopsy, place the patient in which of the following positions? movement, but this is not the primary reason for rapid rewarming. It might
A. Left side-lying, with the bed flat. increase pain for a short period of time as the feeling comes back into the
B. Right side-lying, with the bed flat. extremity.
C. Left side-lying, with the bed in semi- position. 2. Answer: D. Filtering waste through a dialyzing membrane
D. Right side-lying, with the bed in semi- Hemodialysis works by using a dialyzing membrane to filter waste that has accumulated in
45. Which of the following potentially serious complications could occur with the blood.
therapy for hypothyroidism? Options A, B, and C: It does not pass water through a dialyzing membrane nor
A. Acute hemolytic reaction. does it eliminate plasma proteins or lower the pH.
B. Angina or cardiac arrhythmia. 3. Answer: B. Contact the physician for an order for immune globulin
C. Retinopathy. The client who is immunosuppressed and is exposed to measles should be treated with
D. Thrombocytopenia. medications to boost his immunity to the virus.
46. Adequate fluid replacement and vasopressin replacement are objectives of Options A, C, and D: An antibiotic or antiviral will not protect the client and it is
therapy for which of the following disease processes? too late to place the client in isolation.
A. Diabetes mellitus. 4. Answer: D. Infection requires skin-to-skin contact and is prevented by hand
B. Diabetes insipidus. washing, gloves, and a gown.
C. Diabetic ketoacidosis. The client with MRSA should be placed in isolation. Gloves, a gown, and a mask should be
D. Syndrome of inappropriate antidiuretic hormone secretion (SIADH). used when caring for the client and hand washing is very important.
47. Patients with Type 1 diabetes mellitus may require which of the following Options A and B: The door should remain closed, but a negative-pressure room is
changes to their daily routine during periods of infection? not necessary. MRSA is spread by contact with blood or body fluid or by touching
A. No changes. the skin of the client.
B. Less insulin. Option C: It is cultured from the nasal passages of the client, so the client should
C. More insulin. be instructed to cover his nose and mouth when he sneezes or coughs. It is not
D. Oral diabetic agents. necessary for the client to wear the mask at all times; the nurse should wear the
48. On a follow-up visit after having a vaginal hysterectomy, a 32-year-old patient mask.
has a decreased hematocrit level. Which of the following complications does this 5. Answer: B.
suggest?
A. Hematoma. Pain related to phantom limb syndrome is due to peripheral nervous system interruption.
B. Hypovolemia. Option A is incorrect because phantom limb pain can last several months or
C. Infection. indefinitely.
D. Pulmonary embolus (PE). Option C is incorrect because it is not psychological.
49. A patient has partial-thickness burns to both legs and portions of his trunk. Option D: It is also not due to infections.
Which of the following I.V. fluids is given first? 6. Answer: A. Head of the pancreas
During a Whipple procedure the head of the pancreas, which is a part of the stomach, the The toddler with a ventricular septal defect will tire easily. He will not grow normally but
jejunum, and a portion of the stomach are removed and anastomosed. will not need more calories. He will be susceptible to bacterial infection, but he will be no
7. Answer: C. Fresh raw pepper more susceptible to viral infections than other children.
Fresh raw or whole pepper are not allowed unless thoroughly cooked in food. 17. Answer: B. Measure the fetal activity
Option A: Canned fruits are allowed since they are processed and pasteurized. A nonstress test determines periodic movement of the fetus.
Options B and D: Salt, ketchup, and sugar are allowed. Options A, C, and D: Non-stress test does not determine lung maturity, show
8. Answer: A. Have a Protime done monthly contractions, or measure neurological well-being.
Coumadin is an anticoagulant. One of the tests for bleeding time is a Protime. This test 18. Answer: C. Turn off the Pitocin infusion
should be done monthly. The monitor indicates variable decelerations caused by cord compression. If Pitocin is
Option B: Eating more fruits and vegetables is not necessary, and dark-green infusing, the nurse should turn off the Pitocin. Instructing the client to push is incorrect
vegetables contain vitamin K, which increases clotting. because pushing could increase the decelerations and because the client is 8cm dilated,
Options C and D: Drinking more liquids and avoiding crowds is not necessary. making answer A incorrect. Performing a vaginal exam should be done after turning off the
9. Answer: A. Perform the Valsalva maneuver as the catheter is advanced Pitocin, and placing the client in a semi-
The client who is having a central venous catheter removed should be told to hold his situation; therefore, answers B and D are incorrect.
breath and bear down. This prevents air from entering the line. 19. Answer: C. Ventricular tachycardia
10. Answer: B. A history of streptococcal infections The graph indicates ventricular tachycardia. The answers in A, B, and D are not noted on
Clients with a history of streptococcal infections could have antibodies that render the the ECG strip.
streptokinase ineffective. 20. Answer: B. Be injected into the abdomen
Options A, C, and D: There is no reason to assess the client for allergies to Option A: Lovenox injections should be given in the abdomen, not in the deltoid
pineapples or bananas, there is no correlation to the use of phenytoin and muscle.
streptokinase, and a history of alcohol abuse is also not a factor in the order for Options C and D: The client should not aspirate after the injection or clear the air
streptokinase. from the syringe before injection.
11. Answer: B. Flossing between the teeth 21. Answer: B. Administer the medication separately
The client who is immune-suppressed and has bone marrow suppression should be taught Option A: Valium is not given in the same syringe with other medications.
not to floss his teeth because platelets are decreased. Using oils and cream-based soaps Option C: it is not necessary to wait to inject the second medication. Valium is an
Options A, C, and D: Using oils and cream-based soaps is allowed, as is eating salt antianxiety medication, and Phenergan is used as an antiemetic.
and using an electric razor. Option D: These medications can be given to the same client.
12. Answer: A. Apply the new tie before removing the old one. 22. Answer: B. Void every 3 hours
The best method and safest way to change the ties of a tracheotomy is to apply the new Voiding every 3 hours prevents stagnant urine from collecting in the bladder, where
ones before removing the old ones. bacteria can grow.
Option B: Having a helper is good, but the helper might not prevent the client Options A and C: Douching is not recommended and obtaining a urinalysis
from coughing out the tracheotomy. monthly is not necessary.
Option C: Hold the tracheotomy with the nondominant hand while removing the Option D: The client should practice wiping from front to back after voiding and
old tie is not the best way to prevent the client from coughing out the tracheotomy. bowel movements.
Option D: Asking the doctor to suture the tracheotomy in place is not appropriate. 23. Answer: C. Feeding the client with dementia
13. Answer: D. Notifying the physician Of these clients, the one who should be assigned to the care of the nursing assistant is the
The output of 300 mL is indicative of hemorrhage and should be reported immediately. client with dementia.
Option A: Turning the client to the left side does nothing to help the client. Option A: Only an RN or the physician can place the client in seclusion.
Options B and C: Milking the tube is done only with an order and will not help in Option B: The nurse should empty the Foley catheter of the preeclamptic client
this situation, and slowing the intravenous infusion is not an appropriate action. because the client is unstable.
14. Answer: A. Digoxin Option D: A nurse or physical therapist should ambulate the client with a
The infant with Tetralogy of Fallot involves four heart defects: A large ventricular septal fractured hip.
defect (VSD), Pulmonary stenosis, Right ventricular hypertrophy and, An overriding aorta. 24. Answer: A. A tracheotomy set
He will be treated with digoxin to slow and strengthen the heart. The client who has recently had a thyroidectomy is at risk for tracheal edema.
Options B, C, and D: Epinephrine, aminophylline, and atropine will speed the Option B: padded tongue blade is used for seizures and not for the client with
heart rate and are not used in this client. tracheal edema.
15. Answer: A. Options C and D: If the client experiences tracheal edema, the endotracheal tube
The Tail of Spence is located in the upper outer quadrant of the breast. or airway will not correct the problem.
16. Answer: A. Tire easily 25. Answer: D. Birds
Histoplasmosis is a fungus carried by birds. It is not transmitted to humans by cats, dogs, or Zidovudine inhibits DNA synthesis in HIV, thus interfering with viral replication. The drug
turtles.
26. Answer: B. Administer oxygen. excretion.
Administering supplemental oxygen to the patient is the first priority. Administer oxygen 35. Answer: D.
to increase SpO2 to greater than 90% to help prevent further cardiac damage. Showing this patient how to splint his chest wall will help decrease discomfort when
Options A and C: Sublingual nitroglycerin and morphine are commonly coughing.
administered after oxygen. Option A: Holding in his coughs will only increase his pain.
27. Answer: D. Lower back pain. Option B: Placing the head of the bed flat may increase the frequency of his cough
Lower back pain results from expansion of an aneurysm. The expansion applies pressure and his work of breathing.
in the abdomen, and the pain is referred to the lower back. Option C: Increasing fluid intake will help thin the secretions, making it easier for
Option A: Abdominal pain is the most common symptom resulting from impaired him to clear them.
circulation. 36. Answer: B. Give a bronchodilator by nebulizer.
Option B: Absent pedal pulses are a sign of no circulation and would occur after a The patient having an acute asthma attack needs more oxygen delivered to his lungs and
ruptured aneurysm or in peripheral vascular disease. body. Nebulized bronchodilators open airways and increase the amount of oxygen
Option C: Chest pain usually is associated with coronary artery or pulmonary delivered.
disease. Options A and D: Important but not a priority as of the moment; emotional
28. Answer: B. Hypertrophic support can help calm the patient but can be done after medical intervention.
he size of the Option C:
ventricle remains relatively unchanged. old unless he has a medical history of cardiac problems.
Options A, C, and D: Dilated cardiomyopathy, obliterative cardiomyopathy, and 37. Answer: A. Acute respiratory distress syndrome (ARDS).
restrictive cardiomyopathy all decrease cardiac output.
29. Answer: A. Have the patient sit down. typically associated with smoke inhalation.
The initial priority is to decrease oxygen consumption by sitting the patient down. 38. Answer: D. The water-
Options B, C, and D: Administer sublingual nitroglycerin as you simultaneously -expanded and is
expected to stay that way. One indication of reexpansion is the cessation of fluctuation in
30. Answer: C. High Fo the water-
Lying flat and side- Option A: Drainage should be minimal before the chest tube is removed.
Option B:
31. Answer: C. Disseminated intravascular coagulation (DIC). Option C: The chest X-ray should show that the lung is re-expanded.
Abruptio placentae is a cause of DIC because it activates the clotting cascade after 39. Answer: A. High-top sneakers.
hemorrhage. High-top sneakers are used to prevent foot drop and contractures in patients with
Option A: Thrombocytopenia results from decreased production of platelets. neurologic conditions.
Option B: Option C: A consult with physical therapy is important to prevent foot drop, but
Option D: t heparin and, as a result, you can use high-top sneakers independently.
40. Answer: C. Restlessness and confusion.
32. Answer: D. Packed red blood cells. The earliest sign of increased ICP is a change in mental status.
In a trauma situation, the first blood product given is unmatched (O negative) packed red Option A: Bradycardia and widened pulse pressure occur later.
blood cells. Option B: The patient may void a lot of very dilute urine if his posterior pituitary
Option A: Fresh frozen plasma often is used to replace clotting factors. is damaged.
Options B and C: 41. Answer: C. Mix the drug with saline solution only.
increase volume and blood pressure, but too much of these crystalloids will dilute Phenytoin is compatible only with saline solutions.
the blood and -carrying capacity. Options A and B: -
33. Answer: C. Immune response. line filter.
Corticosteroids suppress eosinophils, lymphocytes, and natural-killer cells, inhibiting the Option D: Dextrose causes an insoluble precipitate to form.
natural inflammatory process in an infected or injured part of the body. This helps resolve 42. Answer: A. Abduction
inflammation, stabilizes lysosomal membranes, decreases capillary permeability, and After surgical repair of the hip, keep the legs and hips abducted to stabilize the prosthesis
depresses phagocytosis of tissues by white blood cells, thus blocking the release of more in the acetabulum.
inflammatory materials. Excessive corticosteroid therapy can lead to . 43. Answer: B. Fluid and electrolyte balance.
34. Answer: B. It interferes with viral replication.
Acute pancreatitis is commonly associated with fluid isolation and accumulation in the Option A: Irrigating the wound washes away drainage, debris, and many of the
bowel secondary to ileus or peripancreatic edema. Fluid and electrolyte loss colonizing or infecting microorganisms.
from vomiting is a major concern. Therefore, your priority is to manage hypovolemia and Option B: The outside of the wound and the dressing may be colonized with
restore electrolyte balance.
Options A & D: Pain control and nutrition also are important, but not priority. could give inaccurate results.
Option C: Patients are at risk for hyperglycemia, not hypoglycemia. In Text Mode: All questions and answers are given for reading and answering at your own
44. Answer: B. Right side-lying, with the bed flat. pace. You can also copy this exam and make a print out.
Positioning the patient on his right side with the bed flat will splint the biopsy site and 1. A nurse is administering IV furosemide to a patient admitted with congestive heart
minimize bleeding. failure. After the infusion, which of the following symptoms is NOT expected?
site or internally. A. Increased urinary output.
45. Answer: B. Angina or cardiac arrhythmia. B. Decreased edema.
Precipitation of angina or cardiac arrhythmia is a potentially serious complication C. Decreased pain.
of hypothyroidism treatment. D. Decreased blood pressure.
Option A: Acute hemolytic reaction is a complication of blood transfusions. 2. There are a number of risk factors associated with coronary artery disease. Which
Option C: Retinopathy typically is a complication of diabetes mellitus. of the following is a modifiable risk factor?
Option D: hypothyroidism. A. Obesity.
46. Answer: B. Diabetes insipidus. B. Heredity.
Maintaining adequate fluid and replacing vasopressin are the main objectives in treating C. Gender.
diabetes insipidus. D. Age.
Option A: Diabetes is a chronic condition associated with abnormally high levels 3. Tissue plasminogen activator (t-PA) is considered for treatment of a patient who
of sugar (glucose) in the blood. Insulin produced by the pancreas lowers blood arrives in the emergency department following onset of symptoms of myocardial
glucose. infarction. Which of the following is a contraindication for treatment with t-PA?
Option C: Diabetic ketoacidosis is a result of severe insulin insufficiency. A. Worsening chest pain that began earlier in the evening.
Option D: An excess of antidiuretic hormone leads to SIADH, causing the patient B. History of cerebral hemorrhage.
to retain fluid. C. History of prior myocardial infarction.
47. Answer: C. More insulin. D. Hypertension.
During periods of infection or illness, patients with Type 1 diabetes may need even more 4. Following myocardial infarction, a hospitalized patient is encouraged to practice
insulin to compensate for increased blood glucose levels. frequent leg exercises and ambulate in the hallway as directed by his physician.
48. Answer: A. Hematoma. Which of the following choices reflects the purpose of exercise for this patient?
A decreased hematocrit level is a sign of hematoma, a delayed complication of abdominal A. Increases fitness and prevents future heart attacks.
and vaginal hysterectomy. B. Prevents bedsores.
Option B: Symptoms of hypovolemia include increased hematocrit and C. Prevents DVT (deep vein thrombosis).
hemoglobin values. D. Prevent constipations.
Option C: Infection manifests with fever and high WBC count. 5. A patient arrives in the emergency department with symptoms of myocardial
Option D: Symptoms of a PE include dyspnea, chest pain, cough, hemoptysis, infarction, progressing to cardiogenic shock. Which of the following symptoms
restlessness, and signs of shock. should the nurse expect the patient to exhibit with cardiogenic shock?
49. Answer: C. A. Hypertension.
sis, both of B. Bradycardia.
which commonly occur following a burn. C. Bounding pulse.
Option A: Albumin is used as adjunct therapy, not primary fluid replacement. D. Confusion.
Option B: 6. A patient with a history of congestive heart failure arrives at the clinic
can cause pseudodiabetes. complaining of dyspnea. Which of the following actions is the first the nurse should
Option D: The patient is hyperkalemic from the potassium shift from the perform?
intracellular space to the plasma, so potassium would be detrimental. A. Ask the patient to lie down on the exam table.
50. Answer: C. Gently roll a sterile swab from the center of the wound outward to B. Draw blood for chemistry panel and arterial blood gas (ABG).
collect drainage. C. Send the patient for a chest x-ray.
Rolling a swab from the center outward is the right way to obtain a culture specimen from D. Check blood pressure.
a wound.
7. A clinic patient has recently been prescribed nitroglycerin for treatment of angina. C. Give aspirin in case of headaches.
He calls the nurse complaining of frequent headaches. Which of the following D. Impose immune precautions.
responses to the patient is correct? 14. A nurse in the emergency department assesses a patient who has been taking
long-term corticosteroids to treat renal disease. Which of the following is a typical
side effect of corticosteroid treatment? Note: More than one answer may be correct.
cause bleeding in the brain A. Hypertension.
B. Cushingoid features.
C. Hyponatremia.
do D. Low serum albumin.
8. A patient received surgery and chemotherapy for colon cancer, completing 15. A nurse is caring for patients in the oncology unit. Which of the following is the
therapy three (3) months previously, and she is now in remission. At a follow-up most important nursing action when caring for a neutropenic patient?
appointment, she complains of fatigue following activity and difficulty with A. Change the disposable mask immediately after use.
concentration at her weekly bridge games. Which of the following explanations could B. Change gloves immediately after use.
account for her symptoms? C. Minimize patient contact.
A. The symptoms may be the result of anemia caused by chemotherapy. D. Minimize conversation with the patient.
B. The patient may be immunosuppressed. 16. A patient is undergoing the induction stage of treatment for leukemia. The nurse
C. The patient may be depressed. teaches family members about infectious precautions. Which of the following
D. The patient may be dehydrated. statements by family members indicates that the family needs more education?
9. A clinic patient has a hemoglobin concentration of 10.8 g/dL and reports sticking A. We will bring in books and magazines for entertainment.
to a strict vegetarian diet. Which of the follow nutritional advice is appropriate? B. We will bring in personal care items for comfort.
A. The diet is providing adequate sources of iron and requires no changes. C. We will bring in fresh flowers to brighten the room.
B. The patient should add meat to her diet; a vegetarian diet is not advised. D. We will bring in family pictures and get well cards.
C. The patient should use iron cookware to prepare foods, such as dark-green, leafy 17. A nurse is caring for a patient with acute lymphoblastic leukemia (ALL). Which of
vegetables and legumes, which are high in iron. the following is the most likely age range of the patient?
D. A cup of coffee or tea should be added to every meal. A. 3-10 years.
10. A hospitalized patient is receiving packed red blood cells (PRBCs) for treatment B. 25-35 years.
of severe anemia. Which of the following is the most accurate statement? C. 45-55 years.
A. Transfusion reaction is most likely immediately after the infusion is completed. D. over 60 years.
B. PRBCs are best infused slowly through a 20g. IV catheter.
C. PRBCs should be flushed with a 5% dextrose solution. disease. Which of the following symptoms is typical of Hodgk
D. A nurse should remain in the room during the first 15 minutes of infusion. A. Painful cervical lymph nodes.
11. A patient who has received chemotherapy for cancer treatment is given an B. Night sweats and fatigue.
injection of Epoetin. Which of the following should reflect the findings in a complete C. Nausea and vomiting.
blood count (CBC) drawn several days later? D. Weight gain.
A. An increase in neutrophil count.
B. An increase in hematocrit.
C. An increase in platelet count. were correct, which of the following cells would the pathologist expect to find?
D. An increase in serum iron. A. Reed-Sternberg cells.
12. A patient is admitted to the hospital with suspected polycythemia vera. Which of B. Lymphoblastic cells.
the following symptoms is consistent with the diagnosis? Select all that applies.
A. Weight loss.
B. Increased clotting time. 20. A patient is about to undergo bone marrow aspiration and biopsy and
C. Hypertension. expresses fear and anxiety about the procedure. Which of the following is the most
D. Headaches. effective nursing response?
13. A nurse is caring for a patient with a platelet count of 20,000/microliter. Which A. Warn the patient to stay very still because the smallest movement will increase her pain.
of the following is an important intervention? B. Encourage the family to stay in the room for the procedure.
A. Observe for evidence of spontaneous bleeding. C. Stay with the patient and focus on slow, deep breathing for relaxation.
B. Limit visitors to family only. D. Delay the procedure to allow the patient to deal with her feelings.
21. A 43-year-old African American male is admitted with sickle cell anemia. The A. Palpate the spleen
nurse plans to assess circulation in the lower extremities every 2 hours. Which of the B. Take the blood pressure
following outcome criteria would the nurse use? C. Examine the feet for petechiae
A. Body temperature of 99°F or less D. Examine the tongue
B. Toes moved in active range of motion 29. An African American female comes to the outpatient clinic. The physician
C. Sensation reported when soles of feet are touched suspects vitamin B12 deficiency anemia. Because jaundice is often a clinical
D. Capillary refill of < 3 seconds manifestation of this type of anemia, what body part would be the best indicator?
22. A 30-year-old male from Haiti is brought to the emergency department in sickle A. Conjunctiva of the eye
cell crisis. What is the best position for this client? B. Soles of the feet
A. Side-lying with knees flexed C. Roof of the mouth
B. Knee-chest D. Shins
30. The nurse is conducting a physical assessment on a client with anemia. Which of
D. Semi- the following clinical manifestations would be most indicative of the anemia?
23. A 25-year-old male is admitted in sickle cell crisis. Which of the following A. BP 146/88
interventions would be of highest priority for this client? B. Respirations 28 shallow
A. Taking hourly blood pressures with mechanical cuff C. Weight gain of 10 pounds in 6 months
B. Encouraging fluid intake of at least 200mL per hour D. Pink complexion
31. The nurse is teaching the client with polycythemia vera about prevention of
D. Administering Tylenol as ordered complications of the disease. Which of the following statements by the client
24. Which of the following foods would the nurse encourage the client in sickle cell indicates a need for further teaching?
crisis to eat?
A. Peaches
B. Cottage cheese
C. Popsicle
D. Lima beans 32. A 33-year-old male is being evaluated for possible acute leukemia. Which of the
25. A newly admitted client has sickle cell crisis. The nurse is planning care based on following would the nurse inquire about as a part of the assessment?
assessment of the client. The client is complaining of severe pain in his feet and A. The client collects stamps as a hobby.
hands. The pulse oximetry is 92. Which of the following interventions would be B. The client recently lost his job as a postal worker.
implemented first? Assume that there are orders for each intervention.
A. Adjust the room temperature
B. Give a bolus of IV fluids 33. An African American client is admitted with acute leukemia. The nurse is
C. Start O2 assessing for signs and symptoms of bleeding. Where is the best site for examining
D. Administer meperidine (Demerol) 75 mg IV push for the presence of petechiae?
26. The nurse is instructing a client with iron-deficiency anemia. Which of the A. The abdomen
following meal plans would the nurse expect the client to select? B. The thorax
A. Roast beef, gelatin salad, green beans, and peach pie C. The earlobes
B. Chicken salad sandwich, coleslaw, French fries, ice cream D. The soles of the feet
C. Egg salad on wheat bread, carrot sticks, lettuce salad, raisin pie 34. A client with acute leukemia is admitted to the oncology unit. Which of the
D. Pork chop, creamed potatoes, corn, and coconut cake following would be most important for the nurse to inquire?
27. Clients with sickle cell anemia are taught to avoid activities that cause hypoxia
and hypoxemia. Which of the following activities would the nurse recommend?
A. A family vacation in the Rocky Mountains
B. Chaperoning the local boys club on a snow-skiing trip
C. Traveling by airplane for business trips 35. Which of the following would be the priority nursing diagnosis for the adult
D. A bus trip to the Museum of Natural History client with acute leukemia?
28. The nurse is conducting an admission assessment of a client with vitamin B12 A. Oral mucous membrane, altered related to chemotherapy
deficiency. Which of the following would the nurse include in the physical B. Risk for injury related to thrombocytopenia
assessment? C. Fatigue related to the disease process
D. Interrupted family processes related to life-threatening illness of a family member
36. A 21-year- A. Glucometer readings as ordered
He is engaged to be married and is to begin a new job upon graduation. Which of the B. Intake/output measurements
following diagnoses would be a priority for this client? C. Sodium and potassium levels monitored
A. Sexual dysfunction related to radiation therapy D. Daily weights
B. Anticipatory grieving related to terminal illness 44. A client had a total thyroidectomy yesterday. The client is complaining of tingling
C. Tissue integrity related to prolonged bed rest around the mouth and in the fingers and toes. What would the next action
D. Fatigue related to chemotherapy be?
A. Obtain a crash cart
response to treatment, the nurse would monitor: B. Check the calcium level
A. Platelet count C. Assess the dressing for drainage
B. White blood cell count D. Assess the blood pressure for hypertension
C. Potassium levels 45. A 32-year-old mother of three is brought to the clinic. Her pulse is 52, there is a
D. Partial prothrombin time (PTT) weight gain of 30 pounds in 4 months, and the client is wearing two sweaters. The
38. The home health nurse is visiting a client with autoimmune thrombocytopenic client is diagnosed with hypothyroidism. Which of the following nursing diagnoses is
of highest priority?
to teach the client and family about: A. Impaired physical mobility related to decreased endurance
A. Bleeding precautions B. Hypothermia r/t decreased metabolic rate
B. Prevention of falls C. Disturbed thought processes r/t interstitial edema
C. Oxygen therapy D. Decreased cardiac output r/t bradycardia
D. Conservation of energy
39. A client with a pituitary tumor has had a transsphenoidal hypophysectomy.
Answers and Rationale
Which of the following interventions would be appropriate for this client? 1. Answer: C. Decreased pain.
A. Place the client in Trendelenburg position for postural drainage Furosemide, a loop diuretic, does not alter pain.
B. Encourage coughing and deep breathing every 2 hours Option A: Furosemide acts on the kidneys to increase urinary output.
C. Elevate the head of the bed 30° Option B: Fluid may move from the periphery, decreasing edema.
D. Encourage the Valsalva maneuver for bowel movements Option D: Fluid load is reduced, lowering blood pressure.
40. The client with a history of diabetes insipidus is admitted with polyuria, 2. Answer: A. Obesity.
polydipsia, and mental confusion. The priority intervention for this client is: Obesity is an important risk factor for coronary artery disease that can be modified by
A. Measure the urinary output improved diet and weight loss.
B. Check the vital signs Options B, C, and D: Family history of coronary artery disease, male gender, and
C. Encourage increased fluid intake advancing age increase risk but cannot be modified.
D. Weigh the client 3. Answer: B. History of cerebral hemorrhage.
41. A client with hemophilia has a nosebleed. Which nursing action is most A history of cerebral hemorrhage is a contraindication to tPA because it may increase the
appropriate to control the bleeding? risk of bleeding. TPA acts by dissolving the clot blocking the coronary artery and works
A. Place the client in a sitting position with the head hyperextended best when administered within 6 hours of onset of symptoms.
B. Pack the nares tightly with gauze to apply pressure to the source of bleeding Option C: Prior MI is not a contraindication to tPA.
C. Pinch the soft lower part of the nose for a minimum of 5 minutes Option D: Patients receiving tPA should be observed for changes in blood
D. Apply ice packs to the forehead and back of the neck pressure, as tPA may cause hypotension.
42. A client has had a unilateral adrenalectomy to remove a tumor. To prevent 4. Answer: C. Prevents DVT (deep vein thrombosis).
complications, the most important measurement in the Exercise is important for all hospitalized patients to prevent deep vein thrombosis.
immediate postoperative period for the nurse to take is: Muscular contraction promotes venous return and prevents hemostasis in the lower
A. Blood pressure extremities.
B. Temperature Options A, B, and D: This exercise is not sufficiently vigorous to increase physical
C. Output fitness, nor is it intended to prevent bedsores or constipation.
D. Specific gravity 5. Answer: D. Confusion.
Cardiogenic shock severely impairs the pumping function of the heart muscle, causing
vomiting for the past 3 days. The client is receiving IV glucocorticoids (Solu-Medrol). diminished blood flow to the organs of the body. This results in diminished brain function
Which of the following interventions would the nurse implement? and confusion, as well as hypotension, tachycardia, and weak pulse. Cardiogenic shock is a
serious complication of myocardial infarction with a high mortality rate.
6. Answer: D. Check blood pressure. experience headaches, dizziness, and visual disturbances. Cardiovascular effects include
A patient with congestive heart failure and dyspnea may have pulmonary edema, which can increased blood pressure and delayed clotting time.
Option A: Weight loss is not a manifestation of polycythemia vera.
first action. 13. Answer: A. Observe for evidence of spontaneous bleeding.
Option A: Lying flat on the exam table would likely worsen the dyspnea, and the Platelet counts under 30,000/microliter may cause spontaneous petechiae and bruising,
patient may not tolerate it. particularly in the extremities. When the count falls below 15,000, spontaneous bleeding
Option B: Blood draws for chemistry and ABG will be required, but not prior to into the brain and internal organs may occur. Headaches may be a sign and should be
the blood pressure assessment. watched for.
7. Answer: C. Options B and D: Thrombocytopenia does not compromise immunity, and there
causes is no reason to limit visitors as long as any physical trauma is prevented.
Nitroglycerin is a potent vasodilator and often produces unwanted effects such as Option C: Aspirin disables platelets and should never be used in the presence of
headache, dizziness, and hypotension. Patients should be counseled, and the dose titrated, thrombocytopenia.
to minimize these effects. In spite of the side effects, nitroglycerin is effective at reducing 14. Answers: A, B, and D.
myocardial oxygen consumption and increasing blood flow. Side effects of corticosteroids include weight gain, fluid retention with hypertension,
Option A: The patient should not stop the medication. Cushingoid features, a low serum albumin, and suppressed inflammatory response.
Option B: Nitroglycerine does not cause bleeding in the brain. Patients are encouraged to eat a diet high in protein, vitamins, and minerals and low in
8. Answer: A. The symptoms may be the result of anemia caused by chemotherapy. sodium.
Three months after surgery and chemotherapy the patient is likely to be feeling the after- Option C: Corticosteroids cause hypernatremia and not hyponatremia.
effects, which often includes anemia because of bone-marrow suppression. 15. Answer: B. Change gloves immediately after use.
Option B: There is no evidence that the patient is immunosuppressed, and fatigue The neutropenic patient is at risk of infection. Changing gloves immediately after use
is not a typical symptom of immunosuppression. protects patients from contamination with organisms picked up on hospital surfaces. This
Options C and D: The information given does not indicate contamination can have serious consequences for an immunocompromised patient.
that depression or dehydration is a cause of her symptoms. Option A: Changing the respiratory mask is desirable, but not nearly as urgent as
9. Answer: C. The patient should use iron cookware to prepare foods, such as dark changing gloves.
green, leafy vegetables and legumes, which are high in iron. Options C and D: Minimizing contact and conversation are not necessary and may
Normal hemoglobin values range from 11.5-15.0. This vegetarian patient is mildly anemic.
When food is prepared in iron cookware its iron content is increased. 16. Answer: C. We will bring in fresh flowers to brighten the room.
Option A: In addition, dark green leafy vegetables, such as spinach and kale, and During induction chemotherapy, the leukemia patient is severely immunocompromised
legumes are high in iron. and at risk of serious infection. Fresh flowers, fruit, and plants can carry microbes and
Option B: Mild anemia does not require that animal sources of iron be added to should be avoided.
the diet. Many non-animal sources are available. Options A, B, and D: Books, pictures, and other personal items can be cleaned
Option D: Coffee and tea increase gastrointestinal activity and inhibit absorption with antimicrobials before being brought into the room to minimize the risk of
of iron. contamination.
10. Answer: D. A nurse should remain in the room during the first 15 minutes of 17. Answer: A. 3-10 years.
infusion. The peak incidence of ALL is at 4 years (range 3-10). It is uncommon after the mid-teen
Transfusion reaction is most likely during the first 15 minutes of infusion, and a nurse years. The peak incidence of chronic myelogenous leukemia (CML) is 45-55 years. The peak
should be present during this period. incidence of acute myelogenous leukemia (AML) occurs at 60 years. Two-thirds of cases of
Option B: PRBCs should be infused through a 19g or larger IV catheter to avoid chronic lymphocytic leukemia (CLL) occur after 60 years.
slow flow, which can cause clotting. 18. Answer: B. Night sweats and fatigue.
Option C: PRBCs must be flushed with 0.45% normal saline solution. sweats, fatigue, weakness, and tachycardia.
Other intravenous solutions will hemolyze the cells. Option A: The disease is characterized by painless, enlarged cervical lymph nodes.
11. Answer: B. An increase in hematocrit. Option C:
Epoetin is a form of erythropoietin, which stimulates the production of red blood cells, Option D: Weight loss occurs early in the disease.
causing an increase in hematocrit. Epoetin is given to patients who are anemic, often as a 19. Answer: A. Reed-Sternberg cells.
result of chemotherapy treatment. -Sternberg cells are found on
Options A, C, and D: Epoetin has no effect on neutrophils, platelets, or serum iron. pathologic examination of the excised lymph node.
12. Answers: B, C, and D. Option B: Lymphoblasts are immature cells found in the bone marrow of patients
Polycythemia vera is a condition in which the bone marrow produces too many red blood with acute lymphoblastic leukemia.
cells. This causes an increase in hematocrit and viscosity of the blood. Patients can
 Option C: Options A, B, and C: A family vacation in the Rocky Mountains at high altitudes,
disease. cold temperatures, and airplane travel can cause sickling episodes and should be
Option D: cells are myeloblasts found in patients with acute myelogenous avoided.
leukemia. 28. Answer: D. Examine the tongue
20. Answer: C. Stay with the patient and focus on slow, deep breathing for relaxation. The tongue is smooth and beefy red in the client with vitamin B12 deficiency, so examining
Slow, deep breathing is the most effective method of reducing anxiety and stress. It reduces the tongue should be included in the physical assessment. Bleeding,
the level of carbon dioxide in the brain to increase calm and relaxation. Options A, B, and C: Bleeding, splenomegaly, and blood pressure changes do not
Option A: Warning the patient to remain still will likely increase her anxiety. occur.
Option B: Encouraging family members to stay with the patient may make her 29. Answer: C. Roof of the mouth
worry about their anxiety as well as her own. The oral mucosa and hard palate (roof of the mouth) are the best indicators of jaundice in
Option D: Delaying the procedure is unlikely to allay her fears. dark-skinned persons.
21. Answer: D. Capillary refill of < 3 seconds Option A: The conjunctiva can have normal deposits of fat, which give a yellowish
It is important to assess the extremities for blood vessel occlusion in the client with sickle hue.
cell anemia because a change in capillary refill would indicate a change in circulation. Option B: The soles of the feet can be yellow if they are calloused.
Options A, B, and C: Body temperature, motion, and sensation would not give Option D: The shins would be an area of darker pigment.
information regarding peripheral circulation. 30. Answer: B. Respirations 28 shallow
22. Answer: D. Semi- When there are fewer red blood cells, there is less hemoglobin and less oxygen. Therefore,
Placing the client in semi- the client is often short of breath.
Options A, B, and C: Flexion of the hips and knees, which includes the knee-chest Options A, C, and D: The client with anemia is often pale in color, has weight loss,
position, impedes circulation and is not correct positioning for this client. and may be hypotensive.
23. Answer: B. Encouraging fluid intake of at least 200mL per hour 31. Answer: A.
It is important to keep the client in sickle cell crisis hydrated to prevent further sickling of The client with polycythemia vera is at risk for thrombus formation. Hydrating the client
the blood. with at least 3L of fluid per day is important in preventing clot formation, so the statement
Option A: Taking hourly blood pressures with mechanical cuff is incorrect to drink less than 500mL is incorrect.
because a mechanical cuff places too much pressure on the arm. Options B, C, and D: Support hose promotes venous return, the electric razor
Option C: prevents bleeding due to injury, and a diet low in iron is essential to preventing
because it impedes circulation. further red cell formation.
Option D: Administering Tylenol is too mild an analgesic for the client in crisis. 32. Answer: C.
24. Answer: C. Popsicle teenager.
Hydration is important in the client with sickle cell disease to prevent thrombus formation. Radiation treatment for other types of cancer can result in leukemia. Some hobbies and
Popsicles, gelatin, juice, and pudding have high fluid content. occupations involving chemicals are linked to leukemia.
Options A, B, and D do not aid in hydration and are, therefore, incorrect. Option D: he incidence of leukemia is higher in twins than in siblings.
25. Answer: C. Start O2 33. Answer: D. The soles of the feet
The most prominent clinical manifestation of sickle cell crisis is pain. However, the pulse Petechiae are not usually visualized on dark skin. The soles of the feet and palms of the
oximetry indicates that oxygen levels are low; thus, oxygenation takes precedence over hand provide a lighter surface for assessing the client for petechiae.
pain relief. Options A, B, and C: The skin in the abdomen, thorax, and earlobes might be too
Option A: Warm environment reduces pain and minimizes sickling, it would not dark to make an assessment.
be a priority. 34. Answer: B.
Option B: Although hydration is important, it would not require a bolus. The client with leukemia is at risk for infection and has often had recurrent respiratory
Option D: Demerol is acidifying to the blood and increases sickling. infections during the previous 6 months.
26. Answer: C. Egg salad on wheat bread, carrot sticks, lettuce salad, raisin pie Options A, C, and D: Insomnolence, weight loss, and a decrease in alertness also
Egg yolks, wheat bread, carrots, raisins, and green, leafy vegetables are all high in iron, occur in leukemia, but bleeding tendencies and infections are the primary clinical
which is an important mineral for this client. manifestations.
Options A, B, and D: Roast beef, cabbage, and pork chops are also high in iron, but 35. Answer: B. Risk for injury related to thrombocytopenia
the side dishes accompanying these choices are not. The client with acute leukemia has bleeding tendencies due to decreased platelet counts,
27. Answer: D. A bus trip to the Museum of Natural History and any injury would exacerbate the problem.
Taking a trip to the museum is the only answer that does not pose a threat. 36. Answer: A. Sexual dysfunction related to radiation therapy
Radiation therapy often causes sterility in male clients and would be of primary
importance to this client. The psychosocial needs of the client are important to address in
 45. Answer: D. Decreased cardiac output r/t bradycardia
diagnosed early. The decrease in pulse can affect the cardiac output and lead to shock, which would take
37. Answer: A. Platelet count precedence over the other choices.
Clients with autoimmune thrombocytopenic purpura (ATP) have low platelet counts, In Text Mode: All questions and answers are given for reading and answering at your own
making answer A the correct answer. pace. You can also copy this exam and make a print out.
Options B, C, and D: White cell counts, potassium levels, and PTT are not affected 1. The client is having an arteriogram. During the procedure, the client tells the
in ATP.
38. Answer: A. Bleeding precautions allergic reaction. I will get an order for Benadryl
The normal platelet count is 120,000 400, Bleeding occurs in clients with low platelets.
The priority is to prevent and minimize bleeding.
Options B and D are of lesser priority and are incorrect in this instance.
Option C is important, but platelets do not carry oxygen.
39. Answer: C. Elevate the head of the bed 30° 2. The nurse is observing several healthcare workers providing care. Which action
Elevating the head of the bed 30° avoids pressure on the sella turcica and alleviates by the healthcare worker indicates a need for further teaching?
headaches. A, B, and D are incorrect A. The nursing assistant wears gloves while giving the client a bath.
Options A, B, and D: Trendelenburg, Valsalva maneuver, and coughing all B. The nurse wears goggles while drawing blood from the client.
increase the intracranial pressure. C. The doctor washes his hands before examining the client.
40. Answer: B. Check the vital signs
A large amount of fluid loss can cause fluid and electrolyte imbalance that should be 3. The client is having electroconvulsive therapy for treatment of severe depression.
corrected. The loss of electrolytes would be reflected in the vital signs.
Option A: Measuring the urinary output is important, but the stem already says A. The client loses consciousness.
that the client has polyuria. B. The client vomits.
Option C: Encouraging fluid intake will not correct the problem. C. The
Option D: Weighing the client is not necessary at this time. D. The client has a grand mal seizure.
41. Answer: C. Pinch the soft lower part of the nose for a minimum of 5 minutes 4. The 5-year-old is being tested for enterobiasis (pinworms). To collect a specimen
The client should be positioned upright and leaning forward, to prevent aspiration of for assessment of pinworms, the nurse should teach the mother to:
blood. A. Examine the perianal area with a flashlight 2 or 3 hours after the child is asleep
Options A, B, and D: Direct pressure to the nose stops the bleeding, and ice packs B. Scrape the skin with a piece of cardboard and bring it to the clinic
should be applied directly to the nose as well. If a pack is necessary, the nares are C. Obtain a stool specimen in the afternoon
loosely packed. D. Bring a hair sample to the clinic for evaluation
42. Answer: A. Blood pressure 5. The nurse is teaching the mother regarding treatment for enterobiasis. Which
Blood pressure is the best indicator of cardiovascular collapse in the client who has had an instruction should be given regarding the medication?
adrenal gland removed. The remaining gland might have been suppressed due to the tumor A. Treatment is not recommended for children less than 10 years of age.
activity. Temperature would be an indicator of infection, B. The entire family should be treated.
Options B, C, and D: Temperature would be an indicator of infection, decreased C. Medication therapy will continue for 1 year.
output would be a clinical manifestation but would take longer to occur than blood D. Intravenous antibiotic therapy will be ordered.
pressure changes, and specific gravity changes occur with other disorders. 6. The registered nurse is making assignments for the day. Which client should be
43. Answer: A. Glucometer readings as ordered assigned to the pregnant nurse?
IV glucocorticoids raise the glucose levels and often require coverage with insulin. A. The client receiving linear accelerator radiation therapy for lung cancer
Options B, C, and D: Intake/output measurements is not necessary at this time, B. The client with a radium implant for cervical cancer
sodium and potassium levels would be monitored when the client is receiving C. The client who has just been administered soluble brachytherapy for thyroid cancer
mineralocorticoids, and daily weights is unnecessary. D. The client who returned from placement of iridium seeds for prostate cancer
44. Answer: B. Check the calcium level 7. The nurse is planning room assignments for the day. Which client should be
The parathyroid glands are responsible for calcium production and can be damaged during assigned to a private room if only one is available?
a thyroidectomy. The tingling is due to low calcium levels.
Option A: The crash cart would be needed in respiratory distress but would not be B. The client with diabetes
the next action to take. C. The client with acromegaly
Options C and D: Hypertension occurs in thyroid storm and the drainage would D. The client with myxedema
occur in hemorrhage.
8. The nurse caring for a client in the neonatal intensive care unit administers adult- B. The client who is 6 months pregnant with abdominal pain and the client with facial
strength Digitalis to the 3-pound infant. As a result of her actions, the baby suffers lacerations and a broken arm
permanent heart and brain damage. The nurse can be charged with: C. A child whose pupils are fixed and dilated and his parents, and a client with a frontal
A. Negligence head injury
B. Tort D. The client who arrives with a large puncture wound to the abdomen and the client
C. Assault with chest pain
D. Malpractice 16. The nurse is caring for a 6-year-old client admitted with a diagnosis of
9. Which assignment should not be performed by the licensed practical nurse? conjunctivitis. Before administering eye drops, the nurse should recognize that it is
A. Inserting a Foley catheter essential to consider which of the following?
B. Discontinuing a nasogastric tube A. The eye should be cleansed with warm water, removing any exudate, before instilling the
C. Obtaining a sputum specimen eyedrops.
D. Starting a blood transfusion B. The child should be allowed to instill his own eye drops.
10. The client returns to the unit from surgery with a blood pressure of 90/50, pulse C. The mother should be allowed to instill the eyedrops.
132, and respirations 30. Which action by the nurse should receive priority? D. If the eye is clear from any redness or edema, the eyedrops should be held.
A. Continuing to monitor the vital signs 17. The nurse is discussing meal planning with the mother of a 2-year-old toddler.
B. Contacting the physician Which of the following statements, if made by the mother, would require a need for
C. Asking the client how he feels further instruction?
D. Asking the LPN to continue the post-op care
11. Which nurse should be assigned to care for the postpartum client with
preeclampsia? ught hot dogs to grill for his
A. The RN with 2 weeks of experience in postpartum
B. The RN with 3 years of experience in labor and delivery
C. The RN with 10 years of experience in surgery 18. A 2-year-old toddler is admitted to the hospital. Which of the following nursing
D. The RN with 1 year of experience in the neonatal intensive care unit interventions would you expect?
12. Which information should be reported to the state Board of Nursing? A. Ask the parent/guardian to leave the room when assessments are being performed.
A. The facility fails to provide literature in both Spanish and English.
B. The narcotic count has been incorrect on the unit for the past 3 days. the outside should not be brought into the hospital.
C. The client fails to receive an itemized account of his bills and services received during his C. Ask the parent/guardian to room-in with the child.
hospital stay. D. If the child is screaming, tell him this is inappropriate behavior.
D. The nursing assistant assigned to the client with hepatitis fails to feed the client and give 19. Which instruction should be given to the client who is fitted for a behind-the-ear
the bath. hearing aid?
13. The nurse is suspected of charting medication administration that he did not A. Remove the mold and clean every week.
give. After talking to the nurse, the charge nurse should: B. Store the hearing aid in a warm place.
A. Call the Board of Nursing C. Clean the lint from the hearing aid with a toothpick.
B. File a formal reprimand D. Change the batteries weekly.
C. Terminate the nurse 20. A priority nursing diagnosis for a child being admitted from surgery following a
D. Charge the nurse with a tort tonsillectomy is:
14. The A. Body image disturbance
seen first? B. Impaired verbal communication
A. The 78-year-old who had a gastrectomy 3 weeks ago and has a PEG tube C. Risk for aspiration
B. The 5-month-old discharged 1 week ago with pneumonia who is being treated with D. Pain
amoxicillin liquid suspension 21. A client with bacterial pneumonia is admitted to the pediatric unit. What would
C. The 50-year-old with MRSA being treated with Vancomycin via a PICC line the nurse expect the admitting assessment to reveal?
D. The 30-year-old with an exacerbation of multiple sclerosis being treated with cortisone A. High fever
via a centrally placed venous catheter B. Nonproductive cough
15. The emergency room is flooded with clients injured in a tornado. Which clients C. Rhinitis
can be assigned to share a room in the emergency department during the disaster? D. Vomiting and diarrhea
A. A schizophrenic client having visual and auditory hallucinations and the client with
ulcerative colitis
22. The nurse is caring for a client admitted with epiglottitis. Because of the A. A painless delivery
possibility of complete obstruction of the airway, which of the following should the B. Cervical effacement
nurse have available? C. Infrequent contractions
A. Intravenous access supplies D. Progressive cervical dilation
B. A tracheostomy set 30. A vaginal exam reveals a footling breech presentation. The nurse should take
C. Intravenous fluid administration pump which of the following actions at this time?
D. Supplemental oxygen A. Anticipate the need for a Caesarean section
23. A 25-year- admitted to the unit. What would the B. Apply the fetal heart monitor
nurse expect the admitting assessment to reveal? C. Place the client in Genupectoral position
A. Bradycardia D. Perform an ultrasound exam
B. Decreased appetite 31. A vaginal exam reveals that the cervix is 4cm dilated, with intact membranes and
C. Exophthalmos a fetal heart tone rate of 160 170 bpm. The nurse decides to apply an external fetal
D. Weight gain monitor. The rationale for this implementation is:
24. The nurse is providing dietary instructions to the mother of an 8-year-old child A. The cervix is closed.
diagnosed with celiac disease. Which of the following foods, if selected by the B. The membranes are still intact.
mother, would indicate her understanding of the dietary instructions? C. The fetal heart tones are within normal limits.
A. Ham sandwich on whole-wheat toast D. The contractions are intense enough for insertion of an internal monitor.
B. Spaghetti and meatballs 32. The following are all nursing diagnoses appropriate for a gravida 1 para 0
C. Hamburger with ketchup in labor. Which one would be most appropriate for the primigravida as she
D. Cheese omelet completes the early phase of labor?
25. The nurse is caring for an 80-year-old with chronic bronchitis. Upon the morning A. Impaired gas exchange related to hyperventilation
rounds, the nurse finds an O2 sat of 76%. Which of the following actions should the B. Alteration in placental perfusion related to maternal position
nurse take first? C. Impaired physical mobility related to fetal-monitoring equipment
A. Notify the physician D. Potential fluid volume deficit related to decreased fluid intake
B. Recheck the O2 saturation level in 15 minutes 33. As the client reaches 8 cm dilation, the nurse notes late decelerations on the fetal
C. Apply oxygen by mask monitor. The FHR baseline is 165 175 bpm with variability of 0 2bpm. What is the
D. Assess the pulse most likely explanation of this pattern?
26. A gravida 3 para 0 is admitted to the labor and delivery unit. The doctor A. The baby is asleep.
performs an amniotomy. Which observation would the nurse be expected to make B. The umbilical cord is compressed.
after the amniotomy? C. There is a vagal response.
A. Fetal heart tones 160bpm D. There is uteroplacental insufficiency.
B. A moderate amount of straw-colored fluid 34. The nurse notes variable decelerations on the fetal monitor strip. The most
C. A small amount of greenish fluid appropriate initial action would be to:
D. A small segment of the umbilical cord A. Notify her doctor
27. The client is admitted to the unit. A vaginal exam reveals that she is 2cm dilated. B. Start an IV
Which of the following statements would the nurse expect her to make? C. Reposition the client
D. Readjust the monitor
35. Which of the following is a characteristic of a reassuring fetal heart rate pattern?
A. A fetal heart rate of 170 180 bpm
B. A baseline variability of 25 35 bpm
28. The client is having fetal heart rates of 90 110 bpm during the contractions. The C. Ominous periodic changes
first action the nurse should take is: D. Acceleration of FHR with fetal movements
A. Reposition the monitor 36. The rationale for inserting a French catheter every hour for the client with
B. Turn the client to her left side epidural anesthesia is:
C. Ask the client to ambulate A. The bladder fills more rapidly because of the medication used for the epidural.
D. Prepare the client for delivery B. Her level of consciousness is such that she is in a trancelike state.
29. In evaluating the effectiveness of IV Pitocin for a client with secondary dystocia, C. The sensation of the bladder filling is diminished or lost.
the nurse should expect: D. She is embarrassed to ask for the bedpan that frequently.
37. A client in the family planning clinic asks the nurse about the most likely time for 45. Which of the following
her to conceive. The nurse explains that conception is most likely to occur when: regarding oral contraceptives?
A. Estrogen levels are low. A. Weight gain should be reported to the physician.
B. Luteinizing hormone is high. B. An alternate method of birth control is needed when taking antibiotics.
C. The endometrial lining is thin. C. If the client misses one or more pills, two pills should be taken per day for 1 week.
D. The progesterone level is low. D. Changes in the menstrual flow should be reported to the physician.
38. A client tells the nurse that she plans to use the rhythm method of birth control. 46. The nurse is discussing breastfeeding with a postpartum client. Breastfeeding is
The nurse is aware that the success of the rhythm method depends on the: contraindicated in the postpartum client with:
A. Age of the client A. Diabetes
B. Frequency of intercourse B. Positive HIV
C. Regularity of the menses C. Hypertension
D. Thyroid disease
39. A client with diabetes asks the nurse for advice regarding methods of birth 47. A client is admitted to the labor and delivery unit complaining of vaginal
control. Which method of birth control is most suitable for the client with diabetes?
A. Intrauterine device A. Assess the fetal heart tones
B. Oral contraceptives B. Check for cervical dilation
C. Diaphragm C. Check for firmness of the uterus
D. Contraceptive sponge D. Obtain a detailed history
40. The doctor suspects that the client has an ectopic pregnancy. Which symptom is 48. A client telephones the emergency room stating that she thinks that she is in
consistent with a diagnosis of ectopic pregnancy? labor. The nurse should tell the client that labor has probably begun when:
A. Painless vaginal bleeding A. Her contractions are 2 minutes apart.
B. Abdominal cramping B. She has back pain and a bloody discharge.
C. Throbbing pain in the upper quadrant C. She experiences abdominal pain and frequent urination.
D. Sudden, stabbing pain in the lower quadrant D. Her contractions are 5 minutes apart.
41. The nurse is teaching a pregnant client about nutritional needs during 49. The nurse is teaching a group of prenatal clients about the effects of cigarette
pregnancy. Which menu selection will best meet the nutritional needs of the smoke on fetal development. Which characteristic is associated with babies born to
pregnant client? mothers who smoked during pregnancy?
A. Hamburger pattie, green beans, French fries, and iced tea A. Low birth weight
B. Roast beef sandwich, potato chips, baked beans, and cola B. Large for gestational age
C. Baked chicken, fruit cup, potato salad, coleslaw, yogurt, and iced tea C. Preterm birth, but appropriate size for gestation
D. Fish sandwich, gelatin with fruit, and coffee D. Growth retardation in weight and length
42. The client with hyperemesis gravidarum is at risk for developing: 50. The physician has ordered an injection of RhoGam for the postpartum client
A. Respiratory alkalosis without dehydration whose blood type is A negative but whose baby is O positive. To provide postpartum
B. Metabolic acidosis with dehydration prophylaxis, RhoGam should be administered:
C. Respiratory acidosis without dehydration A. Within 72 hours of delivery
D. Metabolic alkalosis with dehydration B. Within 1 week of delivery
43. A client tells the doctor that she is about 20 weeks pregnant. The most definitive C. Within 2 weeks of delivery
sign of pregnancy is: D. Within 1 month of delivery
A. Elevated human chorionic gonadotropin
B. The presence of fetal heart tones
Answers and Rationale
C. Uterine enlargement 1. Answer: B.
D. Breast enlargement and tenderness It is normal for the client to have a warm sensation when dye is injected.
44. The nurse is caring for a neonate whose mother is diabetic. The nurse will expect Options A, C, and D indicate that the nurse believes that the hot feeling is
the neonate to be: abnormal, so they are incorrect.
A. Hypoglycemic, small for gestational age 2. Answer: D.
B. Hyperglycemic, large for gestational age It is not necessary to wear gloves to take the vital signs of the client. If the client has
C. Hypoglycemic, large for gestational age active infection with methicillin-resistant Staphylococcus aureus, gloves should be worn.
D. Hyperglycemic, small for gestational age Options A, B, and C: The health care workers indicate knowledge of infection
control by their actions.
3. Answer: D. The client has a grand mal seizure. Option A: Continuing to monitor the vital signs can result in deterioration of the
During ECT, the client will have a grand mal seizure. This indicates completion of the
electroconvulsive therapy. Option C: Asking the client how he feels will only provide subjective data.
Options A, B, and C do not indicate that the ECT has been effective. Option D: Assigning an unstable client to an LPN is inappropriate.
4. Answer: A. Examine the perianal area with a flashlight 2 or 3 hours after the child 11. Answer: B. The RN with 3 years of experience in labor and delivery
is asleep The nurse with 3 years of experience in labor and delivery knows the most about possible
Infection with pinworms begins when the eggs are ingested or inhaled. The eggs hatch in complications involving preeclampsia.
the upper intestine and mature in 2 8 weeks. The females then mate and migrate out the Option A: The nurse is a new staff to the unit hence lacking the experience needed.
anus, where they lay up to 17,000 eggs. This causes intense itching. The mother should be Options C and D: These nurses lack sufficient experience with a postpartum
told to use a flashlight to examine the rectal area about 2 3 hours after the child is asleep. client.
Placing clear tape on a tongue blade will allow the eggs to adhere to the tape. The specimen 12. Answer: B. The narcotic count has been incorrect on the unit for the past 3 days.
should then be brought in to be evaluated. The Joint Commission on Accreditation of Hospitals will probably be interested in the
Options B, C, and D: There is no need to scrape the skin, collect a stool specimen, problems in answers A and C. The failure of the nursing assistant to care for the client with
or bring a sample of hair. hepatitis might result in termination but is not of interest to the Joint Commission.
5. Answer: B. The entire family should be treated. 13. Answer: B. File a formal reprimand
Enterobiasis, or pinworms, is treated with Vermox (mebendazole) or Antiminth (pyrantel The next action after discussing the problem with the nurse is to document the incident by
pamoate). The entire family should be treated to ensure that no eggs remain. Because a filing a formal reprimand.
single treatment is usually sufficient, there is usually good compliance. The family should Options A, C, and D: If the behavior continues or if harm has resulted to the client,
then be tested again in 2 weeks to ensure that no eggs remain. the nurse may be terminated and reported to the Board of Nursing, but these are
6. Answer: A. The client receiving linear accelerator radiation therapy for lung not the first actions requested in the stem. A tort is a wrongful act to the client or
cancer his belongings and is not indicated in this instance.
The pregnant nurse should not be assigned to any client with radioactivity present. The 14. Answer: D. The 30-year-old with an exacerbation of multiple sclerosis being
client receiving linear accelerator therapy travels to the radium department for therapy. treated with cortisone via a centrally placed venous catheter
The radiation stays in the department, so the client is not radioactive. These clients are The client at highest risk for complications is the client with multiple sclerosis who is being
radioactive in very small doses, especially upon returning from the procedures. For treated with cortisone via the central line. The others are more stable. MRSA is Methicillin-
approximately 72 hours, the clients should dispose of urine and feces in special containers Resistant Staphylococcus Aureus. Vancomycin is the drug of choice and is given at
and use plastic spoons and forks. scheduled times to maintain blood levels of the drug.
Options B, C, and D: The following clients pose a risk to the pregnant nurse. Options A, B, and C: These clients are more stable and can be seen later.
7. Answer: A. 15. Answer: B. The client who is 6 months pregnant with abdominal pain and the
client with facial lacerations and a broken arm
level of cortisone causes the client to be immunosuppressed. The pregnant client and the client with a broken arm and facial lacerations are the best
Option B: the client with diabetes poses no risk to other clients. choices for placing in the same room.
Option C: The client has an increase in growth hormone and poses no risk to Options A, C, and D: The following group of clients needs to be placed in separate
himself or others. rooms due to the serious nature of their injuries.
Option D: The client has hypothyroidism or myxedema and poses no risk to 16. Answer: A. The eye should be cleansed with warm water, removing any exudate,
others or himself. before instilling the eyedrops.
8. Answer: D. Malpractice Before instilling eye drops, the nurse should cleanse the area with water.
The nurse could be charged with malpractice, which is failing to perform, or performing an Option B: A 6-year-old child is not developmentally ready to instill his own
act that causes harm to the client. Giving the infant an overdose falls into this category. eyedrops.
Option A: Negligence is failing to perform care for the client. a tort is a wrongful Option C: Although the mother of the child can instill the eye drops, the area must
act committed be cleansed before administration.
Option B: A tort is a wrongful act committed on the client or their belongings Option D: Although the eye might appear to be clear, the nurse should instill the
Option C: Assault is a violent physical or verbal attack. eyedrops, as ordered, so answer D is incorrect.
9. Answer: D. Starting a blood transfusion 17. Answer: C. I have bought hot
The licensed practical nurse should not be assigned to begin a blood transfusion.
Options A, B, and C: The licensed practical nurse can insert a Foley catheter, Remember the ABCs (airway, breathing, circulation) when answering this question.
discontinue a nasogastric tube, and collect sputum specimen. trachea and poses a risk
10. Answer: B. Contacting the physician of aspiration.
The vital signs are abnormal and should be reported immediately.
 Options A, B, and D: A white grape juice, grilled cheese sandwich, and ice cream Option D: If the nurse notes the umbilical cord, the client is experiencing a
do not pose a risk of aspiration for a child. prolapsed cord and would need to be reported immediately.
18. Answer: C. Ask the parent/guardian to room-in with the child. 27. Answer: D.
The nurse should encourage rooming-in to promote parent-child attachment. It is okay for Dilation of 2 cm marks the end of the latent phase of labor.
the parents to be in the room for assessment of the child. Option A is a vague answer.
Options A and B: Allowing the child to have items that are familiar to him is Option B indicates the end of the first stage of labor.
allowed and encouraged. Option C indicates the transition phase.
Option D: Telling the child that screaming is inappropriate behavior is not part of 28. Answer: B. Turn the client to her left side
The normal fetal heart rate is 120 160 bpm; 100 110bpm is bradycardia. The first action
19. Answer: B. Store the hearing aid in a warm place. would be to turn the client to the left side and apply oxygen.
The hearing aid should be stored in a warm, dry place. Option A: Repositioning the monitor is not indicated at this time.
Option A: It should be cleaned daily but should not be moldy. Option C: Asking the client to ambulate is not the best action for clients
Option C: A toothpick is inappropriate to use to clean the aid; the toothpick might experiencing bradycardia.
break off in the hearing aid. Option D: There is no data to indicate the need to move the client to the delivery
Option D: Changing the batteries weekly is not necessary. room at this time.
20. Answer: C. Risk for aspiration 29. Answer: D. Progressive cervical dilation
Always remember your ABCs (airway, breathing, circulation) when selecting an answer. The expected effect of Pitocin is cervical dilation.
Option A: does not apply for a child who has undergone a tonsillectomy. Option A: Pitocin causes more intense contractions, which can increase the pain.
Options B and D: Although these nursing diagnoses might be appropriate for this Option B: Cervical effacement is caused by pressure on the presenting part.
child, risk for aspiration should have the highest priority. Option C: Infrequent contractions is opposite the action of Pitocin.
21. Answer: A. High fever 30. Answer: B. Apply the fetal heart monitor
If the child has bacterial pneumonia, a high fever is usually present. Applying a fetal heart monitor is the correct action at this time.
Option B: Bacterial pneumonia usually presents with a productive cough, not a Options A and C: There is no need to prepare for a Caesarean section or to place
nonproductive cough. the client in Genupectoral position (knee-chest).
Options C and D: Rhinitis is often seen with viral pneumonia, and vomiting Option D: There is no need for an ultrasound based on the finding.
and diarrhea are usually not seen with pneumonia. 31. Answer: B. The membranes are still intact.
22. Answer: B. A tracheostomy set The nurse decides to apply an external monitor because the membranes are intact.
For a child with epiglottitis and the possibility of complete obstruction of the airway, Options A, C, and D: The cervix is dilated enough to use an internal monitor, if
emergency tracheostomy equipment should always be kept at the bedside. necessary. An internal monitor can be applied if the client is at 0-station.
Options A, C, and D: Intravenous supplies, fluid, and oxygen will not treat an Contraction intensity has no bearing on the application of the fetal monitor.
obstruction. 32. Answer: D. Potential fluid volume deficit related to decreased fluid intake
23. Answer: C. Exophthalmos Clients admitted in labor are told not to eat during labor, to avoid nausea and vomiting. Ice
Exophthalmos (protrusion of eyeballs) often occurs with hyperthyroidism. chips may be allowed, but this amount of fluid might not be sufficient to prevent fluid
Options A, B, and D: The client with hyperthyroidism will often exhibit volume deficit.
tachycardia, increased appetite, and weight loss. Option A: Impaired gas exchange related to hyperventilation would be indicated
24. Answer: D. Cheese omelet during the transition phase.
The child with celiac disease should be on a gluten-free diet. Options B and C: Impaired physical mobility and fluid volume deficit are not
Options A, B, and C: These food items all contain gluten. correct in relation to the stem.
25. Answer: C. Apply oxygen by mask 33. Answer: D. There is uteroplacental insufficiency.
Remember the ABCs (airway, breathing, circulation) when answering this question. Before This information indicates a late deceleration. This type of deceleration is caused by
notifying the physician or assessing the pulse, oxygen should be applied to increase the uteroplacental lack of oxygen.
oxygen saturation, so answers A and D are incorrect. The normal oxygen saturation for a Option A: Has no relation to the readings.
child is 92% 100%, making answer B incorrect. Option B: Compressed umbilical cord results in a variable deceleration.
26. Answer: B. A moderate amount of straw-colored fluid Option C: A vagal response is indicative of an early deceleration.
An amniotomy is an artificial rupture of membranes and normal amniotic fluid is straw- 34. Answer: C. Reposition the client
colored and odorless. The initial action by the nurse observing a late deceleration should turn the client to the
Options A and C: Fetal heart tones of 160 indicate tachycardia, and greenish fluid side preferably, the left side. Administering oxygen is also indicated.
is indicative of meconium. Option A: Notifying the physician might be necessary but not before turning the
client to her side.
 Option B: Starting an IV is not necessary at this time. 43. Answer: B. The presence of fetal heart tones
Option D: Readjusting the fetal monitor is inappropriate since there is no data to The most definitive diagnosis of pregnancy is the presence of fetal heart tones. The signs in
indicate that the monitor has been applied incorrectly. answers A, C, and D are subjective and might be related to other medical conditions.
35. Answer: D. Acceleration of FHR with fetal movements Options A and C: Elevated human chorionic gonadotropin and uterine
Accelerations with movement are normal. enlargement may be related to a hydatidiform mole.
Options A, B, and C: These assessments indicate ominous findings on the fetal Option D: Breast enlargement and tenderness is often present before menses or
heart monitor. with the use of oral contraceptives.
36. Answer: C. The sensation of the bladder filling is diminished or lost. 44. Answer: C. Hypoglycemic, large for gestational age
Epidural anesthesia decreases the urge to void and sensation of a full bladder. A full The infant of a diabetic mother is usually large for gestational age. After birth, glucose
bladder will decrease the progression of labor. levels fall rapidly due to the absence of glucose from the mother.
37. Answer: B. Luteinizing hormone is high. Option A is incorrect because the infant will not be small for gestational age.
Luteinizing hormone released by the pituitary is responsible for ovulation. At about day 14, Option B is incorrect because the infant will not be hyperglycemic.
the continued increase in estrogen stimulates the release of luteinizing hormone from the Option D is incorrect because the infant will be large, not small, and will be
anterior pituitary. The LH surge is responsible for ovulation, or the release of the dominant hypoglycemic, not hyperglycemic.
follicle in preparation for conception, which occurs within the next 10 12 hours after the 45. Answer: B. An alternate method of birth control is needed when taking
LH levels peak. antibiotics.
Options A, C, and D: Estrogen levels are high at the beginning of ovulation, the When the client is taking oral contraceptives and begins antibiotics, another method of
endometrial lining is thick, not thin, and the progesterone levels are high, not low. birth control should be used. Antibiotics decrease the effectiveness of oral contraceptives.
38. Answer: C. Regularity of the menses Option A: Approximately 5 10 pounds of weight gain is not unusual.
menses Option C: If the client misses a birth control pill, she should be instructed to take
being regular. the pill as soon as she remembers the pill. If she misses two, she should take two; if
Options A, B, and D: It is not dependent on the age of the client, frequency of she misses more than two, she should take the missed pills but use another
method of birth control for the remainder of the cycle.
39. Answer: C. Diaphragm Option D: Changes in menstrual flow are expected in clients using oral
The best method of birth control for the client with diabetes is the diaphragm. contraceptives. Often these clients have lighter menses.
Options A, B, and D: Permanent intrauterine device can cause a continuing 46. Answer: B. Positive HIV
inflammatory response in diabetics that should be avoided, oral contraceptives Clients with HIV should not breastfeed because the infection can be transmitted to the baby
tend to elevate blood glucose levels, and contraceptive sponges are not good at through breast milk.
preventing pregnancy. Options A, C, and D: The clients with diabetes, hypertension, and thyroid
40. Answer: D. Sudden, stabbing pain in the lower quadrant disease can be allowed to breastfeed.
The signs of an ectopic pregnancy are vague until the fallopian tube ruptures. The client 47. Answer: A. Assess the fetal heart tones
will complain of sudden, stabbing pain in the lower quadrant that radiates down the leg or The symptoms of painless vaginal bleeding are consistent with placenta previa.
up into the chest. Option B: Cervical check for dilation is contraindicated because this can increase
Options A, B, and C: Painless vaginal bleeding is a sign of placenta previa, the bleeding.
abdominal cramping is a sign of labor, and throbbing pain in the upper quadrant is Option C: Checking for firmness of the uterus can be done, but the first action
not a sign of an ectopic pregnancy. should be to check the fetal heart tones.
41. Answer: C. Baked chicken, fruit cup, potato salad, coleslaw, yogurt, and iced tea Option D: A detailed history can be done later.
All of the choices are tasty, but the pregnant client needs a diet that is balanced and has 48. Answer: D. Her contractions are 5 minutes apart.
increased amounts of calcium. This food item contains meat, fruit, potato salad, and yogurt, The client should be advised to come to the labor and delivery unit when the contractions
which has about 360 mg of calcium. are every 5 minutes and consistent. She should also be told to report to the hospital if she
Option A: These food items are lacking in fruits and milk. experiences rupture of membranes or extreme bleeding.
Option B: The potato chips, which contain a large amount of sodium. Options A and B: She should not wait until the contractions are every 2 minutes
Option D: These food items are lacking vegetables and milk products. or until she has a bloody discharge.
42. Answer: B. Metabolic acidosis with dehydration Option C: Has a vague answer and can be related to a urinary tract infection.
The client with hyperemesis has persistent nausea and vomiting. With vomiting comes 49. Answer: A. Low birth weight
dehydration. When the client is dehydrated, she will have metabolic acidosis. Infants of mothers who smoke are often low in birth weight.
Options A and C are incorrect because they are respiratory dehydration. Option B: Infants who are large for gestational age are associated with diabetic
Option D is incorrect because the client will not be in alkalosis with persistent mothers.
vomiting.
 Option C: Preterm births are associated with smoking, but not with appropriate 7. The nurse knows that a 60-year- osteoporosis is
size for gestation. most likely related to:
Option D: Growth retardation is associated with smoking, but this does not affect A. Lack of exercise
the infant length. B. Hormonal disturbances
50. Answer: A. Within 72 hours of delivery C. Lack of calcium
To provide protection against antibody production, RhoGam should be given within 72 D. Genetic predisposition
hours. 8. A 2-year-
Options B, C, and D: These durations are too late to provide antibody protection. traction. Which finding by the nurse indicates that the traction is working properly?
RhoGam can also be given during pregnancy. A. The infant no longer complains of pain.
In Text Mode: All questions and answers are given for reading and answering at your own B. The buttocks are 15° off the bed.
pace. You can also copy this exam and make a print out. C. The legs are suspended in the traction.
D. The pins are secured within the pulley.
assess the: ment is
A. Degree of cervical dilation true regarding balanced skeletal traction? Balanced skeletal traction:
B. Fetal heart tones A. Utilizes a Steinman pin
B. Requires that both legs be secured
C. Utilizes Kirschner wires
2. A client is admitted to the labor and delivery unit. The nurse performs a vaginal D. Is used primarily to heal the fractured hips
10. The client is admitted for an open reduction internal fixation of a fractured hip.
labor? Immediately following surgery, the nurse should give priority to assessing the:
A. Active A. Serum collection (Davol) drain
B. Latent
C. Transition C. Nutritional status
D. Early D. Immobilizer
3. A newborn with narcotic abstinence syndrome is admitted to the nursery. Nursing 11. Which statement made by the family member caring for the client with a
care of the newborn should include:
A. Teaching the mother to provide tactile stimulation
B. Wrapping the newborn snugly in a blanket
C. Placing the newborn in the infant seat
D. Initiating an early infant-stimulation program
4. A client elects to have epidural anesthesia to relieve the discomfort of labor. 12. The nurse is assessing the client with a total knee replacement 2
Following the initiation of epidural anesthesia, the nurse should give priority to: hours postoperative. Which information requires notification of the doctor?
A. Checking for cervical dilation A. Bleeding on the dressing is 3cm in diameter.
B. Placing the client in a supine position B. The client has a temperature of 100.6°F (38.1°C).
blood pressure
D. Obtaining a fetal heart rate D. The urinary output has been 60 during the last 2 hours.
5. The nurse is aware that the best way to prevent postoperative wound infection in 13. The nurse is caring for the client with a 5-year-old diagnosis of plumbism. Which
the surgical client is to: information in the health history is most likely related to the development of
A. Administer a prescribed antibiotic plumbism?
B. Wash her hands for 2 minutes before care A. The client has traveled out of the country in the last 6 months.
C. Wear a mask when providing care -glass artists.
D. Ask the client to cover her mouth when she coughs C. The client lives in a house built in 1
6. The elderly client is admitted to the emergency room. Which symptom is the client D. The client has several brothers and sisters.
with a fractured hip most likely to exhibit? 14. A client with a total hip replacement requires special equipment. Which
A. Pain equipment would assist the client with a total hip replacement with activities of daily
B. Disalignment living?
C. Cool extremity A. High-seat commode
D. Absence of pedal pulses B. Recliner
C. TENS unit
D. Abduction pillow
15. An elderly client with an abdominal surgery is admitted to the unit following C. Halo traction
surgery. In anticipation of complications of anesthesia and narcotic administration, D. Crutchfield tong traction
the nurse should: 23. A client with a total knee replacement has a CPM (continuous passive motion
A. Administer oxygen via nasal cannula device) applied during the post-operative period. Which statement made by the
B. Have narcan (naloxone) available nurse indicates an understanding of the CPM machine?
C. Prepare to administer blood products
D. Prepare to do cardio resuscitation
16. Which roommate would be most suitable for the 6-year-old male with a fractured

A. 16-year-old female with scoliosis

B. 12-year-old male with a fractured femur
C. 10-year-old male with sarcoma 24. A client with a fractured hip is being taught correct use of the walker. The nurse
D. 6-year-old male with osteomyelitis is aware that the correct use of the walker is achieved if the:
17. A client with osteoarthritis has a prescription for Celebrex (celecoxib). Which A. Palms rest lightly on the handles
instruction should be included in the discharge teaching? B. Elbows are flexed 0°
A. Take the medication with milk. C. Client walks to the front of the walker
B. Report chest pain. D. Client carries the walker
C. Remain upright after taking for 30 minutes. 25. When assessing a laboring client, the nurse finds a prolapsed cord. The nurse
D. Allow 6 weeks for optimal effects. should:
18. A client with a fractured tibia has a plaster-of-Paris cast applied to immobilize A. Attempt to replace the cord
the fracture. Which action by the nurse indicates an understanding of a plaster-of- B. Place the client on her left side
Paris cast? The nurse:
A. Handles the cast with the fingertips D. Cover the cord with a dry, sterile gauze
B. Petals the cast
C. Dries the cast with a hair dryer
Answers and Rationale
D. Allows 24 hours before bearing weight 1. Answer: B. Fetal heart tones
19. The teenager with a fiberglass cast asks the nurse if it will be okay to allow his When the membranes rupture, there is often a transient drop in the fetal heart tones. The
friends to autograph his cast. Which response would be best? heart tones should return to baseline quickly. Any alteration in fetal heart tones, such as
bradycardia or tachycardia, should be reported.
Options A, C, and D: After the fetal heart tones are assessed, the nurse should
evaluate the cervical dilation, vital signs, and level of discomfort.
2. Answer: A. Active
20. The nurse is assigned to care for the client with a Steinmann pin. During pin care, The active phase of labor occurs when the client is dilated 4 7cm.
she notes that the LPN uses sterile gloves and Q-tips to clean the pin. Which action Options B and D: The latent or early phase of labor is from 1cm to 3cm in dilation.
should the nurse take at this time? Options C: The transition phase of labor is 8 10cm in dilation.
A. Assisting the LPN with opening sterile packages and peroxide 3. Answer: B. Wrapping the newborn snugly in a blanket
B. Telling the LPN that clean gloves are allowed The infant of an addicted mother will undergo withdrawal. Snugly wrapping the infant in a
C. Telling the LPN that the registered nurse should perform pin care blanket will help prevent the muscle irritability that these babies often experience.
D. Asking the LPN to clean the weights and pulleys with peroxide Options A and D: Teaching the mother to provide tactile stimulation or provide
21. A child with scoliosis has a spica cast applied. Which action specific to the spica for early infant stimulation are incorrect because he is irritable and needs quiet
cast should be taken? and little stimulation at this time.
A. Check the bowel sounds Options C: Placing the infant in an infant seat is incorrect because this will also
B. Assess the blood pressure cause movement that can increase muscle irritability.
C. Offer pain medication 4. Answer: C.
D. Check for swelling Following epidural anesthesia, the client should be checked for hypotension and signs of
22. The client with a cervical fracture is placed in traction. Which type of traction will shock every 5 minutes for 15 minutes.
be utilized at the time of discharge? Option A: The client can be checked for cervical dilation later after she is stable.
 Option B: The client should not be positioned supine because the anesthesia can The client with a total knee replacement should be assessed for anemia. A hematocrit of
move above the respiratory center and the client can stop breathing. 26% is extremely low and might require a blood transfusion.
Option D: Fetal heart tones should be assessed after the blood pressure is Options A: Bleeding of 2cm on the dressing is not extreme. Circle and date and
checked.
5. Answer: B. Wash her hands for 2 minutes before care Option B: A low-grade temperature is not unusual after surgery. Ensure that the
The best way to prevent post-operative wound infection is hand washing. client is well hydrated, and recheck the temperature in 1 hour. If the temperature
Option A: Use of prescribed antibiotics will treat infection, not prevent infections. is above 100.6°F (38.1°C), report this finding to the doctor. Tylenol will probably
Options C and D: Wearing a mask and asking the client to cover her mouth are be ordered.
good practices but will not prevent wound infections. Option D: Voiding after surgery is also not uncommon and no need for concern.
6. Answer: B. Disalignment 13. Answer B. -glass artists.
The client with a hip fracture will most likely have misalignment. Plumbism is lead poisoning. One factor associated with the consumption of lead is eating
Options A, C, and D: All fractures cause pain, and coolness of the extremities and from pottery made in Central America or Mexico that is unfired. The child lives in a house
absence of pulses are indicative of compartment syndrome or peripheral vascular built after 1976 (this is when lead was taken out of paint), and the parents make stained
disease. glass as a hobby. Stained glass is put together with lead, which can drop on the work area,
7. Answer: B. Hormonal disturbances where the child can consume the lead beads.
After menopause, women lack hormones necessary to absorb and utilize calcium. Option A: Traveling out of the country does not increase the risk of plumbism.
Options A and C: Doing weight-bearing exercises and taking calcium supplements Option C: The house was built after the lead was removed with the paint.
can help to prevent osteoporosis but are not causes. Option D: Having several siblings is unrelated to the stem.
Option D: Body types that frequently experience osteoporosis are thin Caucasian 14. Answer: A. High-seat commode
females, but they are not most likely related to osteoporosis. The equipment that can help with activities of daily living is the high-seat commode. The
8. Answer: B. The buttocks are 15° off the bed. hip should be kept higher than the knee.
Option B: The recliner is good because it prevents 90° flexion but not daily
Option A is incorrect because this does not indicate that the traction is working activities.
correctly, nor does C. Option C: A TENS (Transcutaneous Electrical Nerve Stimulation) unit helps with
pain management.
traction. Option D: An abduction pillow is used to prevent adduction of the hip and
9. Answer A. Utilizes a Steinman pin possibly dislocation of the prosthesis.
Balanced skeletal traction uses pins and screws. A Steinman pin goes through 15. Answer: B. Have narcan (naloxone) available
large bones and is used to stabilize large bones such as the femur. Narcan is the antidote for narcotic overdose.
Option B: Only the affected leg is in traction. Option A: If hypoxia occurs, the client should have oxygen administered by mask,
Option C: Kirschner wires are used to stabilize small bones such as fingers and not cannula.
toes. Options C and D: There is no data to support the administration of blood products
Option D: or cardiac resuscitation.
10. Answer A. Serum collection (Davol) drain 16. Answer: B. 12-year-old male with a fractured femur
Bleeding is a common complication of orthopedic surgery. The blood-collection device The 6-year-old should have a roommate as close to the same age as possible, so the 12-
should be checked frequently to ensure that the client is not hemorrhaging. year-old is the best match.
Option B: -threatening. Option A: The client is too old and is female.
Options C and D: When the client is in less danger, the nutritional status should Option C: The 10-year-old with sarcoma has cancer and will be treated
be assessed and an immobilizer is not used. with chemotherapy that makes him immune suppressed
11. Answer A. Option D: The 6-year-old with osteomyelitis is infectious.
17. Answer: B. Report chest pain.
the tube. Cox II inhibitors have been associated with heart attacks and strokes. Any changes in
Options B and C: The placement should be checked before feedings, and cardiac status or signs of a stroke should be reported immediately, along with any changes
indigestion can occur with the PEG tube, just as it can occur with any client. in bowel or bladder habits because bleeding has been linked to use of Cox II inhibitors.
Option D: Medications can be ordered for indigestion, but it is not a reason for Options A, C, and D: The client does not have to take the medication with milk,
alarm. A percutaneous endoscopy gastrostomy tube is used for clients who have remain upright, or allow 6 weeks for optimal effect.
experienced difficulty swallowing. The tube is inserted directly into the stomach 18. Answer: D. Allows 24 hours before bearing weight
and does not require swallowing. A plaster-of-Paris cast takes 24 hours to dry, and the client should not bear weight for 24
12. Answer C. hours.
 Option A: The cast should be handled with the palms, not the fingertips. 1. The client presents to the clinic with a serum cholesterol of 275 mg/dL and is
Option B: Petaling a cast is covering the end of the cast with cast batting or a sock, placed on rosuvastatin (Crestor). Which instruction should be given to the client?
to prevent skin irritation and flaking of the skin under the cast. A. Report muscle weakness to the physician.
Option C: The client should be told not to dry the cast with a hair dryer because B. Allow six months for the drug to take effect.
this causes hot spots and could burn the client. This also causes unequal drying. C. Take the medication with fruit juice.
19. Answer: A. D. Ask the doctor to perform a complete blood count before starting the medication.
2. The client is admitted to the hospital with hypertensive
will not harm the cast in any way, so answers B, C, and D are incorrect. crises. Diazoxide (Hyperstat) is ordered. During administration, the nurse should:
20. Answer: A. Assisting the LPN with opening sterile packages and peroxide A. Utilize an infusion pump
The nurse is performing the pin care correctly when she uses sterile gloves and Q-tips. B. Check the blood glucose level
Options B, C, and D: A licensed practical nurse can perform pin care, there is no C. Place the client in Trendelenburg position
need to clean the weights, and the nurse can help with opening the packages but it D. Cover the solution with foil
3. The 6-month-old client with a ventral septal defect is receiving Digitalis for
21. Answer: A. Check the bowel sounds regulation of his heart rate. Which finding should be reported to the doctor?
A body cast or spica cast extends from the upper abdomen to the knees or below. Bowel A. Blood pressure of 126/80
sounds should be checked to ensure that the client is not experiencing a paralytic ileus. B. Blood glucose of 110 mg/dL
Options B, C, and D: Checking the blood pressure is a treatment for any client, C. Heart rate of 60 bpm
D. Respiratory rate of 30 per minute
the stem. 4. The client admitted with angina is given a prescription for nitroglycerin. The client
22. Answer: C. Halo traction should be instructed to:
Halo traction will be ordered for the client with a cervical fracture. A. Replenish his supply every 3 months
Options A and B: B. Take one every 15 minutes if pain occurs
C. Leave the medication in the brown bottle
Option D: Crutchfield tongs are used while in the hospital and the client is D. Crush the medication and take with water
immobile. 5. The client is instructed regarding foods that are low in fat and cholesterol. Which
23. Answer: B. diet selection is lowest in saturated fats?
The controller for the continuous-passive-motion device should be placed away from the A. Macaroni and cheese
client. Many clients complain of pain while having treatments with the CPM, so they might B. Shrimp with rice
turn off the machine. The CPM flexes and extends the leg. C. Turkey breast
Option A: The client is in the bed during CPM therapy. D. Spaghetti
Option C: The client will experience pain with the treatment. 6. The client is admitted with left-sided congestive heart failure. In assessing the
Option D: Use of the CPM does not alleviate the need for physical therapy. client for edema, the nurse should check the:
24. Answer: A. Palms rest lightly on the handles A. Feet
B. Neck
than 30° but should not be extended. C. Hands
Option B: A 0° is not a relaxed angle for the elbows and will not facilitate correct D. Sacrum
walker use.
Option C: The client should walk to the middle of the walker, not to the front of the zero of the manometer at the:
the walker. A. Phlebostatic axis
Option D: The client should be taught not to carry the walker because this would B. PMI
not provide stability.
25. Answer: C. D. Tail of Spence
The client with a prolapsed cord should be treated by elevating the hips and covering the 8. The physician orders lisinopril (Zestril) and furosemide (Lasix) to be
cord with a moist, sterile saline gauze. The nurse should use her fingers to push up on the administered concomitantly to the client with hypertension. The nurse should:
presenting part until a cesarean section can be performed. A. Question the order
Options A, B, and D: The nurse should not attempt to replace the cord, turn the B. Administer the medications
client on the side, or cover with a dry gauze. C. Administer separately
In Text Mode: All questions and answers are given for reading and answering at your own D. Contact the pharmacy
pace. You can also copy this exam and make a print out. 9. The best method of evaluating the amount of peripheral edema is:
A. Weighing the client daily C. In a single dose at bedtime
B. Measuring the extremity D. 30 minutes after meals
C. Measuring the intake and output 17. A client on the psychiatric unit is in an uncontrolled rage and is threatening other
D. Checking for pitting clients and staff. What is the most appropriate action for the nurse to take?
10. A client with vaginal cancer is being treated with a radioactive vaginal implant. A. Call security for assistance and prepare to sedate the client.
sband asks the nurse if he can spend the night with his wife. The nurse B. Tell the client to calm down and ask him if he would like to play cards.
should explain that: C. Tell the client that if he continues his behavior he will be punished.
A. Overnight stays by family members is against hospital policy. D. Leave the client alone until he calms down.
B. There is no need for him to stay because staffing is adequate. 18. When the nurse checks the fundus of a client on the first postpartum day, she
C. His wife will rest much better knowing that he is at home. notes that the fundus is firm, is at the level of the umbilicus, and is displaced to the
D. Visitation is limited to 30 minutes when the implant is in place. right. The next action the nurse should take is to:
11. The nurse is caring for a client hospitalized with a facial stroke. Which diet A. Check the client for bladder distention
selection would be suited to the client? B. Assess the blood pressure for hypotension
A. Roast beef sandwich, potato chips, pickle spear, iced tea C. Determine whether an oxytocic drug was given
B. Split pea soup, mashed potatoes, pudding, milk D. Check for the expulsion of small clots
C. Tomato soup, cheese toast, Jello, coffee 19. A client is admitted to the hospital with a temperature of 99.8°F, complaints of
D. Hamburger, baked beans, fruit cup, iced tea blood-tinged hemoptysis, fatigue, and nigh
12. The physician has prescribed Novolog insulin for a client with diabetes mellitus. consistent with a diagnosis of:
Which statement indicates that the client knows when the peak action of the insulin A. Pneumonia
occurs? B. Reaction to antiviral medication
C. Tuberculosis
D. Superinfection due to low CD4 count
20. The client is seen in the clinic for treatment of migraine headaches. The drug
Imitrex (sumatriptan succinate) is prescribed for the client. Which of the following in
13. The nurse is teaching basic infant care to a group of first-time parents. The nurse
should explain that a sponge bath is recommended for the first 2 weeks of life A. Diabetes
because:
A. New parents need time to learn how to hold the baby. C. Cancer
B. The umbilical cord needs time to separate. D. Cluster headaches
C. Newborn skin is easily traumatized by washing. 21. The client with suspected meningitis is admitted to the unit. The doctor is
D. The chance of chilling the baby outweighs the benefits of bathing. performing an assessment to determine meningeal irritation and spinal nerve root
14. A client with leukemia e nurse notes:
chart, the physician orders Wellcovorin (leucovorin calcium). The rationale for A. Pain on flexion of the hip and knee
administering leucovorin calcium to a client receiving Trimetrexate is to: B. Nuchal rigidity on flexion of the neck
A. Treat iron-deficiency anemia caused by chemotherapeutic agents C. Pain when the head is turned to the left side
B. Create a synergistic effect that shortens treatment time D. Dizziness when changing positions
C. Increase the number of circulating neutrophils of daily living
D. Reverse drug toxicity and prevent tissue damage when the nurse notes that the client uses her toothbrush to brush her hair. The
15. A 4-month-old is brought to the well-baby clinic for immunization. In addition to nurse is aware that the client is exhibiting:
the DPT and polio vaccines, the baby should receive: A. Agnosia
A. HibTITER B. Apraxia
B. Mumps vaccine C. Anomia
C. Hepatitis B vaccine D. Aphasia
D. MMR 23. The client with dementia is experiencing confusion late in the afternoon and
16. The physician has prescribed Nexium (esomeprazole) for a client with erosive before bedtime. The nurse is aware that the client is experiencing what is known as:
gastritis. The nurse should administer the medication: A. Chronic fatigue syndrome
A. 30 minutes before meals B. Normal aging
B. With each meal C. Sundowning
D. Delusions
 w the client in the day the client
room eating breakfast with other clients 30 minutes before this conversation. Which C. The nurse instructs the client to dangle her legs as the nurse strikes the area below the
response would be best for the nurse to make? patella with the blunt side of the reflex hammer.
D. The nurse instructs the client to place her arms loosely at her side as the nurse strikes
the muscle insert just above the wrist.
32. A primigravida with diabetes is admitted to the labor and delivery unit at 34
weeks
25. The doctor has prescribed Exelon (rivastigmine A. Magnesium sulfate 4gm (25%) IV
disease. Which side effect is most often associated with this drug? B. Brethine 10 mcg IV
A. Urinary incontinence C. Stadol 1 mg IV push every 4 hours as needed prn for pain
B. Headaches D. Ancef 2gm IVPB every 6 hours
C. Confusion 33. A diabetic multigravida is scheduled for an amniocentesis at 32 weeks gestation
D. Nausea to determine the L/S ratio and phosphatidyl glycerol level. The L/S ratio is 1:1 and
26. A client is admitted to the labor and delivery unit in active labor. During ssessment of this data is:
examination, the nurse notes a papular lesion on the perineum. Which initial action A. The infant is at low risk for congenital anomalies.
is most appropriate? B. The infant is at high risk for intrauterine growth retardation.
A. Document the finding C. The infant is at high risk for respiratory distress syndrome.
B. Report the finding to the doctor D. The infant is at high risk for birth trauma.
C. Prepare the client for a C-section 34. Which observation in the newborn of a diabetic mother would require
D. Continue primary care as prescribed immediate nursing intervention?
27. A client with a diagnosis of HPV is at risk for which of the following? A. Crying
B. Wakefulness
B. Cervical cancer C. Jitteriness
C. Multiple myeloma D. Yawning
D. Ovarian cancer 35. The nurse caring for a client receiving intravenous magnesium sulfate must
28. During the initial interview, the client reports that she has a lesion on the closely observe for side effects associated with drug therapy. An expected side effect
perineum. Further investigation reveals a small blister on the vulva that is painful of magnesium sulfate is:
to touch. The nurse is aware that the most likely source of the lesion is: A. Decreased urinary output
A. Syphilis B. Hypersomnolence
B. Herpes C. Absence of knee jerk reflex
C. Gonorrhea D. Decreased respiratory rate
D. Condylomata 36. The client has elected to have epidural anesthesia to relieve labor pain. If the
29. A client visiting a family planning clinic is suspected of having an STI. The client experiences hypotension, the nurse would:
best diagnostic test for treponema pallidum is: A. Place her in Trendelenburg position
A. Venereal Disease Research Lab (VDRL) B. Decrease the rate of IV infusion
B. Rapid plasma reagin (RPR) C. Administer oxygen per nasal cannula
C. Florescent treponemal antibody (FTA) D. Increase the rate of the IV infusion
D. Thayer-Martin culture (TMC) 37. A client has cancer of the pancreas. The nurse should be most concerned about
30. A 15-year-old primigravida is admitted with a tentative diagnosis of HELLP which nursing diagnosis?
syndrome. Which laboratory finding is associated with HELLP syndrome? A. Alteration in nutrition
A. Elevated blood glucose B. Alteration in bowel elimination
B. Elevated platelet count C. Alteration in skin integrity
C. Elevated creatinine clearance D. Ineffective individual coping
D. Elevated hepatic enzymes 38. The nurse is caring for a client with ascites. Which is the best method to use for
31. The nurse is assessing the deep tendon reflexes of a client with preeclampsia. determining early ascites?
Which method is used to elicit the biceps reflex? A. Inspection of the abdomen for enlargement
A. The nurse places her thumb on the muscle inset in the antecubital space and taps the B. Bimanual palpation for hepatomegaly
thumb briskly with the reflex hammer.
C. Daily measurement of abdominal girth 46. The client with preeclampsia is admitted to the unit with an order for magnesium
D. Assessment for a fluid wave sulfate. Which action by the nurse indicates understanding of the possible side
39. The client arrives in the emergency department after a motor vehicle accident. effects of magnesium sulfate?
Nursing assessment findings include BP 80/34, pulse rate 120, and respirations 20. A. The nurse places a sign over the bed not to check blood pressure in the right arm.
B. The nurse places a padded tongue blade at the bedside.
A. Alteration in cerebral tissue perfusion C. The nurse inserts a Foley catheter.
B. Fluid volume deficit D. The nurse darkens the room.
C. Ineffective airway clearance 47. A 6-year-old client is admitted to the unit with a hemoglobin of 6g/dL. The
D. Alteration in sensory perception physician has written an order to transfuse 2 units of whole blood. When discussing
40. The home health nurse is visiting an 18-year-old with osteogenesis imperfecta.
Which information obtained on the visit would cause the most concern? The client: blood transfusions and that she will not allow her child to have the treatment. What
A. Likes to play football nursing action is most appropriate?
B. Drinks several carbonated drinks per day A. Ask the mother to leave while the blood transfusion is in progress
C. Has two sisters with sickle cell tract B. Encourage the mother to reconsider
D. Is taking acetaminophen to control pain C. Explain the consequences without treatment
41. The nurse working the organ transplant unit is caring for a client with a white
blood cell count of During evening visitation, a visitor brings a basket of fruit. What 48. A client is admitted to the unit 2 hours after an explosion causes burns to the
action should the nurse take? face. The nurse would be most concerned with the client developing which of the
A. Allow the client to keep the fruit following?
B. Place the fruit next to the bed for easy access by the client A. Hypovolemia
C. Offer to wash the fruit for the client B. Laryngeal edema
D. Tell the family members to take the fruit home C. Hypernatremia
42. The nurse is caring for the client following a laryngectomy when suddenly the D. Hyperkalemia
client becomes nonresponsive and pale, with a BP of 90/40 systolic. The initial 49. The nurse is evaluating nutritional outcomes for a with anorexia nervosa. Which
ld be to: data best indicates that the plan of care is effective?
A. Place the client in Trendelenburg position A. The client selects a balanced diet from the menu.
B. Increase the infusion of Dextrose in normal saline hemoglobin and hematocrit improve.
C. Administer atropine intravenously
D. Move the emergency cart to the bedside D. The client gains weight.
43. The client admitted 2 days earlier with a lung resection accidentally pulls out the 50. The client is admitted following repair of a fractured tibia and cast application.
chest tube. Which action by the nurse indicates understanding of the management of Which nursing assessment should be reported to the doctor?
chest tubes? A. Pain beneath the cast
A. Order a chest x-ray B. Warm toes
B. Reinsert the tube C. Pedal pulses weak and rapid
C. Cover the insertion site with a Vaseline gauze D. Paresthesia of the toes
D. Call the doctor
44. A client being treated with sodium warfarin has a Protime of 120 seconds. Which
Answers and Rationale
intervention would be most important to include in the nursing care plan? 1. Answer: A. Report muscle weakness to the physician.
A. Assess for signs of abnormal bleeding The client taking antilipidemics should be encouraged to report muscle weakness because
B. Anticipate an increase in the Coumadin dosage this is a sign of rhabdomyolysis.
C. Instruct the client regarding the drug therapy Option B: The medication takes effect within 1 month of beginning therapy.
D. Increase the frequency of neurological assessments Option C: The medication should be taken with water because fruit juice,
45. Which selection would provide the most calcium for the client who is 4 months particularly grapefruit, can decrease the effectiveness.
pregnant? Option D: Liver function studies should be checked before beginning the
A. A granola bar medication, not after the fact, making answer D incorrect.
B. A bran muffin 2. Answer: B. Check the blood glucose level
C. A cup of yogurt Hyperstat is given IV push for hypertensive crises, but it often causes hyperglycemia. The
D. A glass of fruit juice glucose level will drop rapidly when stopped.
Option A: Diazoxide (Hyperstat) is given by IV push.
 Option C: The client should be placed in dorsal recumbent position, not a 10. Answer: D. Visitation is limited to 30 minutes when the implant is in place.
Trendelenburg position. Clients with radium implants should have close contact limited to 30 minutes per visit. The
Option D: This medication does not have to be covered with foil. general rule is limiting time spent exposed to radium, putting distance between people and
3. Answer: C. Heart rate of 60 bpm the radium source, and using lead to shield against the radium. Teaching the family
A heart rate of 60 in the baby should be reported immediately. The dose should be held if member these principles is extremely important.
the heart rate is below 100 bpm. Options A, B, and C: These statements are not empathetic and do not address the
Options A, B, and D: The blood glucose, blood pressure, and respirations are question; therefore, they are incorrect.
within normal limits. 11. Answer: B. Split pea soup, mashed potatoes, pudding, milk
4. Answer: C. Leave the medication in the brown bottle The client with a facial stroke will have difficulty swallowing and chewing, and the foods in
Nitroglycerine should be kept in a brown bottle (or even a special air- and water-tight, answer B provide the least amount of chewing.
solid or plated silver or gold container) because of its instability and tendency to become Options A, C, and D: The following food items would require more chewing and,
less potent when exposed to air, light, or water. thus, are incorrect.
Options A and B: The supply should be replenished every 6 months, not 3 12. Answer: A.
months, and one tablet should be taken every 5 minutes until pain subsides. If the
pain does not subside, the client should report to the emergency room. NovoLog insulin onsets very quickly, so food should be available within 10 15 minutes of
Option D: The medication should be taken sublingually and should not be taking the insulin.
crushed. Option B does not address a particular type of insulin, so it is incorrect.
5. Answer: C. Turkey breast Option C: NPH insulin peaks in 8 12 hours, so a snack should be eaten at the
Turkey contains the least amount of fats and cholesterol. expected peak time. It may not be 3 p.m.
Options A, B, and D: Liver, eggs, beef, cream sauces, shrimp, cheese, and chocolate Option D: There is no need to save the dessert until bedtime.
should be avoided by the client. The client should bake meat rather than frying to 13. Answer: B. The umbilical cord needs time to separate.
avoid adding fat to the meat during cooking. The umbilical cord needs time to dry and fall off before putting the infant in the tub.
6. Answer: B. Neck Options A, C, and D: Although these statements might be important, they are not
The jugular veins in the neck should be assessed for distension. the primary answer to the question.
Options A, C, and D: The other parts of the body will be edematous in right-sided 14. Answer: D. Reverse drug toxicity and prevent tissue damage
congestive heart failure, not left-sided. Leucovorin is the antidote for Methotrexate and Trimetrexate which are folic acid
7. Answer: A. Phlebostatic axis antagonists. Leucovorin is a folic acid derivative.
The phlebostatic axis is located at the fifth intercostals space midaxillary line and is the Options A, B, and C: Leucovorin does not treat iron deficiency, increased
correct placement of the manometer. neutrophils, or have a synergistic effect.
Option B: The PMI or point of maximal impulse is located at the fifth intercostals 15. Answer: A. HibTITER
space midclavicular line. The Haemophilus influenza vaccine is given at 4 months with the polio vaccine.
Option C: Options B, C, and D: Mumps, Hepatitis B, and MMR vaccines are given later in life.
simultaneously. 16. Answer: A. 30 minutes before meals.
Option D: The Tail of Spence (the upper outer quadrant) is the area where most Proton pump inhibitors reduce the production of acid in the stomach. Proton pump
breast cancers are located and has nothing to do with the placement of a inhibitors work best when they are taken 30 minutes before the first meal of the day.
manometer. 17. Answer: A. Call security for assistance and prepare to sedate the client.
8. Answer: B. Administer the medications If the client is a threat to the staff and to other clients the nurse should call for help and
Zestril is an ACE inhibitor and is frequently given with a diuretic such as Lasix prepare to administer a medication such as Haldol to sedate him.
for hypertension. Option B: Telling the client to calm down will not work.
Options A, C, and D: The order is accurate. There is no need to question the order, Option C: Telling the client that if he continues he will be punished is a threat and
administer the medication separately, or contact the pharmacy. may further anger him.
9. Answer: B. Measuring the extremity Option D: If the client is left alone he might harm himself.
The best indicator of peripheral edema is measuring the extremity. A paper tape measure 18. Answer: A. Check the client for bladder distention
should be used rather than one of plastic or cloth, and the area should be marked with a If the fundus of the client is displaced to the side, this might indicate a full bladder. The next
pen, providing the most objective assessment. action by the nurse should be to check for bladder distention and catheterize, if necessary.
Option A: Weighing the client will not indicate peripheral edema. Options B, C, and D: These are actions that relate to postpartum hemorrhage.
Option C: Measuring the intake and output will not indicate peripheral edema. 19. Answer: C. Tuberculosis
Option D: Checking for pitting edema is less reliable than measuring with a paper A low-grade temperature, blood-tinged sputum, fatigue, and night sweats are symptoms
tape measure. consistent with tuberculosis.
 Option A: If the answer had said pneumocystis pneumonia, it would have been Nausea and gastrointestinal upset are very common in clients taking acetylcholinesterase
consistent with the symptoms given in the stem, but just saying pneumonia inhibitors such as Exelon. Other side effects include liver toxicity, dizziness, unsteadiness,
specific enough to diagnose the problem. and clumsiness.
Options B and D: They are not directly related to the stem. Options A, B, and C: The client might already be experiencing urinary
20. Answer: B. incontinence or headaches, but they are not necessarily associated, and the client
with Alzhei
preparations because they cause vasoconstriction and coronary spasms. 26. Answer: B. Report the finding to the doctor
Options A, C, and D: There is no contraindication for taking triptan drugs in Any lesion should be reported to the doctor. This can indicate a herpes lesion. Clients with
clients with diabetes, cancer, or cluster headaches. open lesions related to herpes are delivered by Cesarean section because there is a
21. Answer: A. Pain on flexion of the hip and knee possibility of transmission of the infection to the fetus with direct contact to lesions.
Option A: It is not enough to document the finding.
Option B: The Brudzinski reflex is positive if pain occurs on flexion of the head Option C: The physician must make the decision to perform a C-section.
and neck onto the chest. Option D: It is not enough to continue primary car.
Options C and D: These symptoms might be present but are not related to 27. Answer: B. Cervical cancer
The client with HPV is at higher risk for cervical and vaginal cancer related to this STI. She
22. Answer: A. Agnosia is not at higher risk for the other cancers mentioned in answers A, C, and D, so those are
Agnosia is the term used to describe the loss of the ability to recognize what objects are incorrect.
and what they are used for. For an instance, a person with agnosia might try to use a fork 28. Answer: B. Herpes
instead of a spoon, a shoe instead of a cup or a knife instead of a pencil etc. With regard to A lesion that is painful is most likely a herpetic lesion.
people, this might involve failing to recognize who people are, not due to memory loss but Option A: A chancre lesion associated with syphilis is not painful.
rather as a result of the brain not working out the identity of a person on the basis of the Option C: Gonorrhea does not present as a lesion, but is exhibited by a yellow
information supplied by the eyes. discharge.
Option B: Apraxia is the term used to describe the failure to carry out voluntary Option D: Condylomata lesions are painless warts, so answer D is incorrect.
and purposeful movements notwithstanding the fact that muscular power, 29. Answer: C. Fluorescent treponemal antibody (FTA)
sensibility, and coordination are intact. In everyday terms, this might involve the Fluorescent treponemal antibody (FTA) is the test for treponema pallidum.
inability to tie shoelaces, turn a tap on, fasten buttons or switch on a radio. Options A and B: VDRL and RPR are screening tests done for syphilis.
Options C and D: Aphasia is the term used to describe a difficulty or loss of the Option D: The Thayer-Martin culture is done for gonorrhea.
ability to speak or understand spoken, written or sign language as a result of 30. Answer: D. Elevated hepatic enzymes
damage to the corresponding nervous center. This can become apparent in a The criteria for HELLP is hemolysis, elevated liver enzymes, and low platelet count.
number of ways. It might involve exchanging a word which is linked by meaning Option A: An elevated blood glucose level is not associated with HELLP.
(e.g. time instead of clock), using the wrong word but one which sounds alike (e.g. Option B: Platelets are decreased, not elevated, in HELLP syndrome.
boat instead of coat) or using a totally different word with no apparent connection. Option C: The creatinine levels are elevated in renal disease and are not
When accompanied by echolalia (the involuntary repetition of words or phrases associated with HELLP syndrome.
spoken by another person) and the constant repetition of a word or phrase, the 31. Answer: A. The nurse places her thumb on the muscle inset in the antecubital
result can be a form of speech which is difficult for others to understand or a kind space and taps the thumb briskly with the reflex hammer.
of jargon. Anomia is a form of aphasia in which the patient is unable to recall the Option B elicits the triceps reflex.
names of everyday objects. Option C elicits the patellar reflex.
23. Answer: C. Sundowning Option D elicits the radial nerve.
32. Answer: B. Brethine 10 mcg IV
confusion occurs when the sun begins to set and continues during the night. Brethine is used cautiously because it raises the blood glucose levels.
Option A: Fatigue is not necessarily present. Options A, C, and D: Magnesium sulfate, Stadol, and Ancef are all medications that
Option B: Increased confusion at night is not part of normal aging. are commonly used in the diabetic client.
Option D: A delusion is a firm, fixed belief. 33. Answer: C. The infant is at high risk for respiratory distress syndrome.
24. Answer: C. When the L/S ratio reaches 2:1, the lungs are considered to be mature.
Option A: The L/S ratio does not indicate congenital anomalies.
Simply get him something to eat that will satisfy him until lunch. Option B: The infant is not at risk for intrauterine growth retardation.
Options A and D are incorrect because the nurse is dismissing the client. Option D: The infant will most likely be small for gestational age and will not be at
Option B is validating the delusion. risk for birth trauma.
25. Answer: D. Nausea 34. Answer: C. Jitteriness
Jitteriness is a sign of seizure in the neonate. Option D: Moving the emergency cart at the bedside is not necessary at this time.
Options A, B, and D: Crying, wakefulness, and yawning are expected in the 43. Answer: C. Cover the insertion site with a Vaseline gauze
newborn.
35. Answer: B. Hypersomnolence the insertion site with an occlusive dressing. Afterward, the nurse should call the doctor,
The client is expected to become sleepy, have hot flashes, and be lethargic. A decreasing who will order a chest x-ray and possibly reinsert the tube.
urinary output, Options A, B, and D are not the first action to be taken.
Options A, C, and D: A decreasing urinary output, absence of the knee-jerk reflex, 44. Answer: A. Assess for signs of abnormal bleeding
and decreased respirations indicate a magnesium sulfate toxicity. The normal Protime is 12 20 seconds. A Protime of 120 seconds indicates an extremely
36. Answer: D. Increase the rate of the IV infusion prolonged Protime and can result in a spontaneous bleeding episode.
If the client experiences hypotension after an injection of epidural anesthetic, the nurse Options B, C, and D may be needed at a later time but are not the most important
should turn her to the left side, apply oxygen by mask, and speed the IV infusion. If the actions to take first.
blood pressure does not return to normal, the physician should be 45. Answer: C. A cup of yogurt
contacted. Epinephrine should be kept for emergency administration. The food with the most calcium is the yogurt.
Option A: Placing the client in Trendelenburg position (head down) will allow the Options A, B, and D are good choices, but not as good as the yogurt, which has
anesthesia to move up above the respiratory center, thereby decreasing approximately 400 mg of calcium.
the diaphragm 46. Answer: C. The nurse inserts a Foley catheter.
Option B: The IV rate should be increased, not decreased. The client receiving magnesium sulfate should have a Foley catheter in place, and hourly
Option C: the oxygen should be applied by mask, not cannula. intake and output should be checked.
37. Answer: A. Alteration in nutrition Option A: There is no need to refrain from checking the blood pressure in the
Cancer of the pancreas frequently leads to severe nausea and vomiting and altered right arm.
nutrition. Option B: A padded tongue blade should be kept in the room at the bedside, just in
Options B, C, and D: The other problems are of lesser concern. case of a seizure, but this is not related to the magnesium sulfate infusion.
38. Answer: C. Daily measurement of abdominal girth Option D: Darkening the room is unnecessary.
Measuring with a paper tape measure and marking the area that is measured is the most 47. Answer: D.
objective method of estimating ascites.
Options A and D: Inspecting and checking for fluid waves are more subjective. the client is a minor, the court might order treatment.
Option B: Palpation of the liver will not determine the amount of ascites. Options A, B, and C are incorrect because it is not the primary responsibility for
39. Answer: B. Fluid volume deficit the nurse to encourage the mother to consent or explain the consequences.
The vital signs indicate hypovolemic shock. 48. Answer: B. Laryngeal edema
Options A, C, and D: They do not indicate cerebral tissue perfusion, airway The nurse should be most concerned with laryngeal edema because of the area of burn.
clearance, or sensory perception alterations. Options A, C, and D: The next priority after laryngeal edema should be
40. Answer: A. Likes to play football hypovolemia, as well as hyponatremia and hypokalemia, but these answers are not
The client with osteogenesis imperfecta is at risk for pathological fractures and is likely to of primary concern so are incorrect.
experience these fractures if he participates in contact sports. The client might experience 49. Answer: D. The client gains weight.
symptoms of hypoxia if he becomes dehydrated or deoxygenated; extreme exercise, The client with anorexia shows the most improvement by weight gain.
especially in warm weather, can exacerbate the condition. Option A: Selecting a balanced diet does little good if the client will not eat.
Options B, C, and D are not factors for concern. Option B: The hematocrit might improve by several means, such as blood
41. Answer: D. Tell the family members to take the fruit home transfusion, but that does not indicate improvement in the anorexic condition.
The client with neutropenia should not have fresh fruit because it should be peeled and/or Option C: The tissue turgor indicates fluid stasis, not an improvement of anorexia.
cooked before eating. He should also not eat foods grown on or in the ground or eat from 50. Answer: D. Paresthesia of the toes
the salad bar. The nurse should remove potted or cut flowers from the room as well. Any Paresthesia is not normal and might indicate compartment syndrome.
source of bacteria should be eliminated, if possible. Option A: At this time, pain beneath the cast is normal.
Options A, B, and C will not help prevent bacterial invasions. Options B and C:
42. Answer: B. Increase the infusion of Dextrose in normal saline be present.
Option A: In clients who have not had surgery to the face or neck, however, in this In Text Mode: All questions and answers are given for reading and answering at your
situation, this could further interfere with the airway. Increasing the infusion and own pace. You can also copy this exam and make a print out.
placing the client in supine position would be better. 1. A client with a history of abusing barbiturates abruptly stops taking
Option C: Administration of atropine IV is not necessary at this time and could the medication. The nurse should give priority to assessing the client for:
cause hyponatremia and further hypotension.
A. Depression and suicidal ideation
B. Tachycardia and diarrhea
C. Muscle cramping and abdominal pain -
D. Tachycardia and euphoric mood
2. During the assessment of a laboring client, the nurse notes that the FHT are 10. Damage to the VII cranial nerve results in:
loudest in the upper-right quadrant. The infant is most likely in which A. Facial pain
position? B. Absence of ability to smell
A. Right breech presentation C. Absence of eye movement
B. Right occiput anterior presentation D. Tinnitus
C. Left sacral anterior presentation 11. A client is receiving Pyridium (phenazopyridine hydrochloride) for
D. Left occipital transverse presentation a urinary tract infection. The client should be taught that the medication may:
3. The primary physiological alteration in the development of asthma is: A. Cause diarrhea
A. Bronchiolar inflammation and dyspnea B. Change the color of her urine
B. Hypersecretion of abnormally viscous mucus C. Cause mental confusion
C. Infectious processes causing mucosal edema D. Cause changes in taste
D. Spasm of bronchial smooth muscle 12. Which of the following tests should be performed before beginning a
4. A client with mania is unable to finish her dinner. To help her maintain prescription of Accutane?
sufficient nourishment, the nurse should: A. Check the calcium level
A. Serve high-calorie foods she can carry with her B. Perform a pregnancy test
B. Encourage her appetite by sending out for her favorite foods C. Monitor apical pulse
C. Serve her small, attractively arranged portions D. Obtain a creatinine level
D. Allow her in the unit kitchen for extra food whenever she pleases 13. A client with AIDS is taking Zovirax (acyclovir). Which nursing intervention
: is most critical during the administration of acyclovir?
A. Hips are resting on the bed, with the legs suspended at a right angle to the bed
B. Hips are slightly elevated above the bed and the legs are suspended at a right angle B. Encourage a high-carbohydrate diet
to the bed C. Utilize an incentive spirometer to improve respiratory function
C. Hips are elevated above the level of the body on a pillow and the legs are D. Encourage fluids
suspended parallel to the bed 14. A client is admitted for an MRI. The nurse should question the client
D. Hips and legs are flat on the bed, with the traction positioned at the foot of the bed regarding:
6. Which action by the nurse indicates understanding of herpes zoster? A. Pregnancy
A. The nurse covers the lesions with a sterile dressing. B. A titanium hip replacement
B. The nurse wears gloves when providing care. C. Allergies to antibiotics
C. The nurse administers a prescribed antibiotic. D. Inability to move his feet
D. The nurse administers oxygen. 15. The nurse is caring for the client receiving Amphotericin B. Which of the
7. The client has an order for a trough to be drawn on the client receiving following indicates that the client has experienced toxicity to this drug?
Vancomycin. The nurse is aware that the nurse should contact the lab for them A. Changes in vision
to collect the blood: B. Nausea
A. 15 minutes after the infusion C. Urinary frequency
B. 30 minutes before the infusion D. Changes in skin color
C. 1 hour after the infusion 16. The nurse should visit which of the following clients first?
D. 2 hours after the infusion A. The client with diabetes with a blood glucose of 95mg/dL
8. The client using a diaphragm should be instructed to: B. The client with hypertension being maintained on Lisinopril
A. Refrain from keeping the diaphragm in longer than 4 hours C. The client with chest pain and a history of angina
B. Keep the diaphragm in a cool location
C. Have the diaphragm resized if she gains 5 pounds 17. A client with cystic fibrosis is taking pancreatic enzymes. The nurse should
D. Have the diaphragm resized if she has any surgery administer this medication:
9. The nurse is providing postpartum teaching for a mother planning to A. Once per day in the morning
for B. Three times per day with meals
additional teaching?
C. Once per day at bedtime
D. Four times per day
18. Cataracts result in opacity of the crystalline lens. Which of the following 26. The nurse is caring for a 30-year-old male admitted with a stab wound.
best explains the functions of the lens? While in the emergency room, a chest tube is inserted. Which of the following
A. The lens controls stimulation of the retina. explains the primary rationale for insertion of chest tubes?
B. The lens orchestrates eye movement. A. The tube will allow for equalization of the lung expansion.
C. The lens focuses light rays on the retina. B. Chest tubes serve as a method of draining blood and serous fluid and assist in
D. The lens magnifies small objects. reinflating the lungs.
19. A client who has glaucoma is to have miotic eye drops instilled in both eyes. C. Chest tubes relieve pain associated with a collapsed lung.
The nurse knows that the purpose of the medication is to: D. Chest tubes assist with cardiac function by stabilizing lung expansion.
A. Anesthetize the cornea 27. A client who delivered this morning tells the nurse that she plans to
B. Dilate the pupils breastfeed her baby. The nurse is aware that successful breastfeeding is most
C. Constrict the pupils dependent on the:
D. Paralyze the muscles of accommodation
20. A client with a severe corneal ulcer has an order for Gentamycin gtt. q 4
hours and Neomycin 1 gtt q 4 hours. Which of the following schedules should
be used when administering the drops? D. M
A. Allow 5 minutes between the two medications. 28. The nurse is monitoring the progress of a client in labor. Which finding
B. The medications may be used together. should be reported to the physician immediately?
C. The medications should be separated by a cycloplegic drug. A. The presence of scant bloody discharge
D. The medications should not be used in the same client. B. Frequent urination
21. The client with color blindness will most likely have problems C. The presence of green-tinged amniotic fluid
distinguishing which of the following colors? D. Moderate uterine contractions
A. Orange 29. The nurse is measuring the duration of the clie
B. Violet statement is true regarding the measurement of the duration of contractions?
C. Red A. Duration is measured by timing from the beginning of one contraction to the
D. White beginning of the next contraction.
22. The client with a pacemaker should be taught to: B. Duration is measured by timing from the end of one contraction to the beginning
A. Report ankle edema of the next contraction.
B. Check his blood pressure daily C. Duration is measured by timing from the beginning of one contraction to the end of
C. Refrain from using a microwave oven the same contraction.
D. Monitor his pulse rate D. Duration is measured by timing from the peak of one contraction to the end of the
23. The client with enuresis is being taught regarding bladder retraining. The same contraction.
nurse should advise the client to refrain from drinking after: 30. The physician has ordered an intravenous infusion of Pitocin for the
A. 1900 induction of labor. When caring for the obstetric client receiving intravenous
B. 1200 Pitocin, the nurse should monitor for:
C. 1000 A. Maternal hypoglycemia
D. 0700 B. Fetal bradycardia
24. Which of the following diet instructions should be given to the client with C. Maternal hyperreflexia
recurring urinary tract infections? D. Fetal movement
A. Increase intake of meats. 31. A client with diabetes visits the prenatal clinic at 28 weeks gestation. Which
B. Avoid citrus fruits. statement is true regarding insulin needs during pregnancy?
C. Perform pericare with hydrogen peroxide. A. Insulin requirements moderate as the pregnancy progresses.
D. Drink a glass of cranberry juice every day. B. A decreased need for insulin occurs during the second trimester.
25. The physician has prescribed NPH insulin for a client with diabetes C. Elevations in human chorionic gonadotrophin decrease the need for insulin.
mellitus. Which statement indicates that the client knows when the peak action D. Fetal development depends on adequate insulin regulation.
of the insulin occurs? 32. A client in the prenatal clinic is assessed to have a blood pressure of
180/96. The nurse should give priority to:
A. Providing a calm environment 39. The nurse is responsible for performing a neonatal assessment on a full-
B. Obtaining a diet history term infant. At 1 minute, the nurse could expect to find:
C. Administering an analgesic A. An apical pulse of 100
D. Assessing fetal heart tones B. An absence of tonus
C. Cyanosis of the feet and hands
infant is at risk for: D. Jaundice of the skin and sclera
A. Down syndrome 40. A client with sickle cell anemia is admitted to the labor and delivery unit
B. Respiratory distress syndrome during the first phase of labor
for:
D. Pathological jaundice A. Supplemental oxygen
34. A client with a missed abortion at 29 weeks gestation is admitted to the B. Fluid restriction
hospital. The client will most likely be treated with: C. Blood transfusion
A. Magnesium sulfate D. Delivery by Caesarean section
B. Calcium gluconate 41. A client with diabetes has an order for ultrasonography. Preparation for an
C. Dinoprostone (Prostin E.) ultrasound includes:
D. Bromocriptine (Parlodel) A. Increasing fluid intake
35. A client with preeclampsia has been receiving an infusion containing B. Limiting ambulation
magnesium sulfate for a blood pressure that is 160/80; deep tendon reflexes C. Administering an enema
are 1 plus, and the urinary output for the past hour is 100mL. The nurse D. Withholding food for 8 hours
should: 42. An infant who weighs 8 pounds at birth would be expected to weigh how
many pounds at 1 year?
pressure A. 14 pounds
B. Stop the infusion of magnesium sulfate and contact the physician B. 16 pounds
C. Slow the infusion rate and turn the client on her left side C. 18 pounds
D. Administer calcium gluconate IV push and continue to monitor the blood pressure D. 24 pounds
36. Which statement made by the nurse describes the inheritance pattern of 43. A pregnant client with a history of alcohol addiction is scheduled for a
autosomal recessive disorders? nonstress test. The nonstress test:
A. An affected newborn has unaffected parents. A. Determines the lung maturity of the fetus
B. An affected newborn has one affected parent. B. Measures the activity of the fetus
C. Affected parents have a one in four chance of passing on the defective gene. C. Shows the effect of contractions on the fetal heart rate
D. Affected parents have unaffected children who are carriers. D. Measures the neurological well-being of the fetus
37. A pregnant client, age 32, asks the nurse why her doctor has recommended 44. A full-term male has hypospadias. Which statement describes hypospadias?
a serum alpha fetoprotein. The nurse should explain that the doctor has A. The urethral opening is absent.
recommended the test: B. The urethra opens on the dorsal side of the penis.
A. Because it is a state law C. The penis is shorter than usual.
B. To detect cardiovascular defects D. The urethral meatus opens on the underside of the penis.
C. Because of her age 45. A gravida 3 para 2 is admitted to the labor unit. Vaginal exam reveals that
D. To detect neurological defects
38. A client with hypothyroidism asks the nurse if she will still need to take priority nursing diagnosis at this time is:
A. Alteration in coping related to pain
knowledge that: B. Potential for injury related to precipitate delivery
A. There is no need to t C. Alteration in elimination related to anesthesia
thyroid-stimulating hormone. D. Potential for fluid volume deficit related to NPO status
B. Regulation of thyroid medication is more difficult because the thyroid gland 46. The client with varicella will most likely have an order for which category
increases in size during pregnancy. of medication?
C. It is more difficult to maintain thyroid regulation during pregnancy due to a A. Antibiotics
slowing of metabolism. B. Antipyretics
D. Fetal growth is arrested if thyroid medication is continued during pregnancy. C. Antivirals
D. Anticoagulants
47. A client is admitted complaining of chest pain. Which of the following drug The client with mania is seldom sitting long enough to eat and burns many calories
orders should the nurse question? for energy. Answer B is incorrect because the client should be treated the same as
A. Nitroglycerin other clients. Small meals are not a correct option for this client. Allowing her into
B. Ampicillin the kitchen gives her privileges that other clients do not have and should not be
C. Propranolol allowed, so answer D is incorrect.
D. Verapamil 5. Answer: B. Hips are slightly elevated above the bed and the legs are
48. Which of the following instructions should be included in the teaching for suspended at a right angle to the bed
the client with rheumatoid arthritis?
A. Avoid exercise because it fatigues the joints. elevated 15° off the bed. Answer A is incorrect because the hips should not be resting
B. Take prescribed anti-inflammatory medications with meals. on the bed. Answer C is incorrect because the hips should not be above the level of
C. Alternate hot and cold packs to affected joints. the body. Answer D is incorrect because the hips and legs should not be flat on the
D. Avoid weight-bearing activity. bed.
49. A client with acute pancreatitis is experiencing severe abdominal pain. 6. Answer: B. The nurse wears gloves when providing care.
Which of the following orders should be questioned by the nurse? Herpes zoster is shingles. Clients with shingles should be placed in contact
A. Meperidine 100 mg IM q 4 hours PRN pain precautions. Wearing gloves during care will prevent transmission of the virus.
B. Mylanta 30 ccs q 4 hours via NG Covering the lesions with a sterile gauze is not necessary, antibiotics are not
C. Cimetidine 300 mg PO q.i.d. prescribed for herpes zoster, and oxygen is not necessary for shingles; therefore,
D. Morphine 8 mg IM q 4 hours PRN pain answers A, C, and D are incorrect.
50. The client is admitted to the chemical dependence unit with an order for 7. Answer: B. 30 minutes before the infusion
continuous observation. The nurse is aware that the doctor has ordered A trough level should be drawn 30 minutes before the third or fourth dose. The times
continuous observation because: in answers A, C, and D are incorrect times to draw blood levels.
A. Hallucinogenic drugs create both stimulant and depressant effects. 8. Answer: B. Keep the diaphragm in a cool location
B. Hallucinogenic drugs induce a state of altered perception. The client using a diaphragm should keep the diaphragm in a cool location. Answers
C. Hallucinogenic drugs produce severe respiratory depression. A, C, and D are incorrect. She should refrain from leaving the diaphragm in longer
D. Hallucinogenic drugs induce rapid physical dependence. than 8 hours, not 4 hours. She should have the diaphragm resized when she gains or
Answers and Rationale loses 10 pounds or has abdominal surgery.
9. Answer: C. -ho
1. Answer: B. Tachycardia and diarrhea Mothers who plan to breastfeed should drink plenty of liquids, and four glasses is not
Barbiturates create a sedative effect. When the client stops taking barbiturates, he enough in a 24-hour period. Wearing a support bra is a good practice for the mother
will experience tachycardia, diarrhea, and tachypnea. Answer A is incorrect even who is breastfeeding as well as the mother who plans to bottle-feed, so answer A is
though depression and suicidal ideation go along with barbiturate use; it is not the incorrect. Expressing milk from the breast will stimulate milk production, making
priority. Muscle cramps and abdominal pain are vague symptoms that could be answer B incorrect. Allowing the water to run over the breast will also facilitate
associated with other problems. Tachycardia is associated with stopping
barbiturates, but euphoria is not.
10. Answer: A. Facial pain
2. Answer: A. Right breech presentation The facial nerve is cranial nerve VII. If damage occurs, the client will experience facial
If the fetal heart tones are heard in the right upper abdomen, the infant is in a breech pain. The auditory nerve is responsible for hearing loss and tinnitus, eye movement
presentation. If the infant is positioned in the right occiput anterior presentation, the
is controlled by the Trochlear or C IV, and the olfactory nerve controls smell;
FHTs will be located in the right lower quadrant, so answer B is incorrect. If the fetus therefore, answers B, C, and D are incorrect.
is in the sacral position, the FHTs will be located in the center of the abdomen, so 11. Answer: B. Change the color of her urine
answer C is incorrect. If the FHTs are heard in the left lower abdomen, the infant is Clients taking Pyridium should be taught that the medication will turn the urine
most likely in the left occiput transverse position, making answer D incorrect. orange or red. It is not associated with diarrhea, mental confusion, or changes in
3. Answer: D. Spasm of bronchial smooth muscle taste; therefore, answers A, C, and D are incorrect. Pyridium can also cause a
Asthma is the presence of bronchial spasms. This spasm can be brought on by yellowish color to skin and sclera if taken in large doses.
allergies or anxiety. Answer A is incorrect because the primary physiological 12. Answer: B. Perform a pregnancy test
alteration is not inflammation. Answer B is incorrect because there is the production Accutane is contraindicated for use by pregnant clients because it causes teratogenic
of abnormally viscous mucus, not a primary alteration. Answer C is incorrect
effects. Calcium levels, apical pulse, and creatinine levels are not necessary;
because infection is not primary to asthma. therefore, answers A, C, and D are incorrect.
4. Answer: A. Serve high-calorie foods she can carry with her
13. Answer: D. Encourage fluids
Clients taking Acyclovir should be encouraged to drink plenty of fluids because renal disease. If the edema is present in the hands and face, it should be reported. Checking
impairment can occur. Limiting activity is not necessary, nor is eating a high- the blood pressure daily is not necessary for these clients. The client with a
carbohydrate diet. Use of an incentive spirometer is not specific to clients taking pacemaker can use a microwave oven, but he should stand about 5 feet from the oven
Acyclovir; therefore, answers A, B, and C are incorrect. while it is operating.
14. Answer: A. Pregnancy 23. Answer: A. 1900
Although there are no evidence to suggest MRI scans can pose a risk during Clients who are being retrained for bladder control should be taught to withhold
pregnancy, it is considered precaution to not perform MRI during pregnancy, fluids after about 7 p.m., or 1 The times in answers B, C, and D are too early in the
particularly in the first three months. This is particularly the case during the first day.
trimester of pregnancy, as organogenesis takes place during this period. The 24. Answer: D. Drink a glass of cranberry juice every day.
concerns in pregnancy are the same as for MRI in general, but the fetus may be more Cranberry juice is more alkaline and, when metabolized by the body, is excreted with
sensitive to the effects particularly to heating and to noise. Clients with a titanium acidic urine. Bacteria does not grow freely in acidic urine. Increasing intake of meats
hip replacement can have an MRI. No antibiotics are used with this test and the client is not associated with urinary tract infections, so answer A is incorrect. The client
should remain still only when instructed, so answers C and D are not specific to this does not have to avoid citrus fruits and peri care should be done, but hydrogen
test. peroxide is drying, so answers B and C are incorrect.
15. Answer: D. Changes in skin color 25. Answer: C.
Clients taking Amphotericin B should be monitored for liver, renal, and bone marrow NPH insulin peaks in 8 12 hours, so a snack should be offered at that time. NPH
function because this drug is toxic to the kidneys and liver, and causes bone insulin onsets in 90 120 minutes, so answer A is incorrect. Answer B is untrue
marrow suppression. Jaundice is a sign of liver toxicity and is not specific to the use because NPH insulin is time released and does not usually cause sudden
of Amphotericin B. Changes in vision are not related, and nausea is a side effect, not a hypoglycemia. Answer D is incorrect, but the client should eat a bedtime snack.
sign of toxicity; nor is urinary frequency. Thus, answers A, B, and C are incorrect. 26. Answer: B. Chest tubes serve as a method of draining blood and serous fluid
16. Answer: C. The client with chest pain and a history of angina and assist in reinflating the lungs.
The client with chest pain should be seen first because this could indicate Chest tubes work to reinflate the lung and drain serous fluid. The tube does not
a myocardial infarction. The client in answer A has a blood glucose within normal equalize expansion of the lungs. Pain is associated with collapse of the lung, and
limits. The client in answer B is maintained on blood pressure medication. The client insertion of chest tubes is painful, so answers A and C are incorrect. Answer D is true,
in answer D is in no distress. but this is not the primary rationale for performing chest tube insertion.
17. Answer: B. Three times per day with meals 27. Answer: D.
Pancreatic enzymes should be given with meals for optimal effects. These enzymes Success with breastfeeding depends on many factors, but the most dependable
assist the body in digesting needed nutrients. Answers A, C, and D are incorrect reason for success is desire and willingness to continue the breastfeeding until the
methods of administering pancreatic enzymes.
18. Answer: C. The lens focuses light rays on the retina. and the size of the mo
The lens allows light to pass through the pupil and focus light on the retina. The lens and C are incorrect.
does not stimulate the retina, assist with eye movement, or magnify small objects, so 28. Answer: C. The presence of green-tinged amniotic fluid
answers A, B, and D are incorrect. Green-tinged amniotic fluid is indicative of meconium staining. This finding indicates
19. Answer: C. Constrict the pupils fetal distress. The presence of scant bloody discharge is normal, as are frequent
Miotic eye drops constrict the pupil and allow aqueous humor to drain out of the urination and moderate uterine contractions, making answers A, B, and D incorrect.
Canal of Schlemm. They do not anesthetize the cornea, dilate the pupil, or paralyze 29. Answer: C. Duration is measured by timing from the beginning of one
the muscles of the eye, making answers A, B, and D incorrect. contraction to the end of the same contraction.
20. Answer: A. Allow 5 minutes between the two medications. Duration is measured from the beginning of one contraction to the end of the same
When using eyedrops, allow 5 minutes between the two medications; therefore, contraction. Answer A refers to frequency. Answer B is incorrect because we do not
answer B is incorrect. These medications can be used by the same client but it is not measure from the end of one contraction to the beginning of the next contraction.
necessary to use a cycloplegic with these medications, making answers C and D Duration is not measured from the peak of the contraction to the end, as stated in D.
incorrect. 30. Answer: B. Fetal bradycardia
21. Answer: B. Violet The client receiving Pitocin should be monitored for decelerations. There is no
Clients with color blindness will most likely have problems distinguishing violets, association with Pitocin use and hypoglycemia, maternal hyperreflexia, or fetal
blues, and green. The colors in answers A, C, and D are less commonly affected. movement; therefore, answers A, C, and D are incorrect.
22. Answer: D. Monitor his pulse rate 31. Answer: D. Fetal development depends on adequate insulin regulation.
The client with a pacemaker should be taught to count and record his pulse rate. Fetal development depends on adequate nutrition and insulin regulation. Insulin
Answers A, B, and C are incorrect. Ankle edema is a sign of right-sided congestive needs increase during the second and third trimesters, insulin requirements do not
heart failure. Although this is not normal, it is often present in clients with heart moderate as the pregnancy progresses, and elevated human chorionic gonadotrophin
elevates insulin needs, not decreases them; therefore, answers A, B, and C are Cyanosis of the feet and hands is acrocyanosis. This is a normal finding 1 minute after
incorrect. birth. An apical pulse should be 120 160, and the baby should have muscle tone,
32. Answer: A. Providing a calm environment making answers A and B incorrect. Jaundice immediately after birth is pathological
A calm environment is needed to prevent seizure activity. Any stimulation can jaundice and is abnormal, so answer D is incorrect.
precipitate seizures. Obtaining a diet history should be done later, and administering 40. Answer: A. Supplemental oxygen
an analgesic is not indicated because there is no data in the stem to indicate pain. Clients with sickle cell crises are treated with heat, hydration, oxygen, and pain relief.
Therefore, answers B and C are incorrect. Assessing the fetal heart tones is Fluids are increased, not decreased. Blood transfusions are usually not required, and
important, but this is not the highest priority in this situation as stated in answer D. the client can be delivered vaginally; thus, answers B, C, and D are incorrect.
33. Answer: A. Down syndrome 41. Answer: A. Increasing fluid intake
The client who is age 42 is at risk for fetal anomalies such as Down syndrome and Before ultrasonography, the client should be taught to drink plenty of fluids and not
other chromosomal aberrations. Answers B, C, and D are incorrect because the client void. The client may ambulate, an enema is not needed, and there is no need to
is not at higher risk for respiratory distress syndrome or pathological jaundice, and withhold food for 8 hours. Therefore, answers B, C, and D are incorrect.
42. Answer: D. 24 pounds
34. Answer: C. Dinoprostone (Prostin E.) By 1 year of age, the infant is expected to triple his birth weight. Answers A, B, and C
The client with a missed abortion will have induction of labor. Prostin E. is a form of are incorrect because they are too low.
prostaglandin used to soften the cervix. Magnesium sulfate is used for preterm 43. Answer: B. Measures the activity of the fetus
labor and preeclampsia, calcium gluconate is the antidote for magnesium sulfate, and A nonstress test is done to evaluate periodic movement of the fetus. It is not done to
Pardel is a dopamine receptor stimul evaluate lung maturity as in answer A. An oxytocin challenge test shows the effect of
answers A, B, and D are incorrect. Pardel was used at one time to dry breast milk. contractions on fetal heart rate and a nonstress test does not measure neurological
35. Answer: A. Continue the infusion of magnesium sulfate while monitoring well-being of the fetus, so answers C and D are incorrect.
44. Answer: D. The urethral meatus opens on the underside of the penis.
Hypospadias is a congenital abnormality in which the urethral meatus is on the
alteration from normal is the decreased deep tendon reflexes. The nurse should underside of the penis.
continue to monitor the blood pressure and check the magnesium level. The 45. Answer: A. Alteration in coping related to pain
therapeutic level is 4.8 9.6mg/dL. Answers B, C, and D are incorrect. There is no Transition is the time during labor when the client loses concentration due to intense
need to stop the infusion at this time or slow the rate. Calcium gluconate is the contractions. Potential for injury related to precipitate delivery has nothing to do
antidote for magnesium sulfate, but there is no data to indicate toxicity. with the dilation of the cervix, so answer B is incorrect. There is no data to indicate
36. Answer: C. Affected parents have a one in four chance of passing on the that the client has had anesthesia or fluid volume deficit, making answers C and D
defective gene. incorrect.
Autosomal recessive disorders can be passed from the parents to the infant. If both 46. Answer: C. Antivirals
parents pass the trait, the child will get two abnormal genes and the disease results. Varicella is chicken pox. This herpes virus is treated with antiviral medications. The
Parents can also pass the trait to the infant. Answer A is incorrect because, to have an client is not treated with antibiotics or anticoagulants as stated in answers A and D.
affected newborn, the parents must be carriers. Answer B is incorrect because both The client might have a fever before the rash appears, but when the rash appears, the
parents must be carriers. Answer D is incorrect because the parents might have temperature is usually gone, so answer B is incorrect.
affected children. 47. Answer: B. Ampicillin
37. Answer: D. To detect neurological defects Clients with chest pain can be treated with nitroglycerin, a beta blocker such as
Alpha fetoprotein is a screening test done to detect neural tube defects such as spina propranolol, or Verapamil. There is no indication for an antibiotic such as Ampicillin,
bifida. The test is not mandatory, as stated in answer A. It does not indicate so answers A, C, and D are incorrect.
48. Answer: B. Take prescribed anti-inflammatory medications with meals.
so answers B and C are incorrect. Anti-inflammatory drugs should be taken with meals to avoid stomach upset.
38. Answer: B. Regulation of thyroid medication is more difficult because the Answers A, C, and D are incorrect. Clients with rheumatoid arthritis should exercise,
thyroid gland increases in size during pregnancy. but not to the point of pain. Alternating hot and cold is not necessary, especially
During pregnancy, the thyroid gland triples in size. This makes it more difficult to because warm, moist soaks are more useful in decreasing pain. Weight-bearing
regulate thyroid medication. Answer A is incorrect because there could be a need for activities such as walking are useful but is not the best answer for the stem.
thyroid medication during pregnancy. Answer C is incorrect because the thyroid 49. Answer: D. Morphine 8 mg IM q 4 hours PRN pain
function does not slow. Fetal growth is not arrested if thyroid medication is Morphine is contraindicated in clients with gallbladder disease and pancreatitis
continued, so answer D is incorrect. because morphine causes spasms of the Sphincter of Oddi. Meperidine, Mylanta, and
39. Answer: C. Cyanosis of the feet and hands Cimetidine are ordered for pancreatitis, making answers A, B, and C incorrect.
50. Answer: B. Hallucinogenic drugs induce a state of altered perception.
Hallucinogenic drugs can cause hallucinations. Continuous observation is ordered to prescribed Glucagon for emergency use. The mother asks the purpose of this
prevent the client from harming himself during withdrawal. Answers A, C, and D are medication. Which of the following statements by the nurse is correct?
create both stimulant and depressant A. Glucagon enhances the effect of insulin in case the blood sugar remains high one
effects or produce severe respiratory depression. However, they do produce hour after injection.
psychological dependence rather than physical dependence. B. Glucagon treats hypoglycemia resulting from insulin overdose.
In Text Mode: All questions and answers are given for reading and answering at your C. Glucagon treats lipoatrophy from insulin injections.
own pace. You can also copy this exam and make a print out. D. Glucagon prolongs the effect of insulin, allowing fewer injections.
1. A patient arrives at the emergency department complaining 6. An infant with congestive heart failure is receiving diuretic therapy at home.
of midsternal chest pain. Which of the following nursing action should take Which of the following symptoms would indicate that the dosage may need to
priority? be increased?
A. A complete history with emphasis on preceding events. A. Sudden weight gain.
B. An electrocardiogram. B. Decreased blood pressure.
C. Careful assessment of vital signs. C. Slow, shallow breathing.
D. Chest exam with auscultation. D. Bradycardia.
2. A patient has been hospitalized with pneumonia and is about to be 7. A patient taking Dilantin (phenytoin) for a seizure disorder is experiencing
discharged. A nurse provides discharge instructions to a patient and his family. breakthrough seizures. A blood sample is taken to determine the serum drug
Which misunderstanding by the family indicates the need for more detailed level. Which of the following would indicate a sub-therapeutic level?
information? A. 15 mcg/mL.
A. The patient may resume normal home activities as tolerated but should avoid B. 4 mcg/mL.
physical exertion and get adequate rest. C. 10 mcg/dL.
B. The patient should resume a normal diet with emphasis on nutritious, healthy D. 5 mcg/dL.
foods. 8. A patient arrives at the emergency department complaining of back pain. He
C. The patient may discontinue the prescribed course of oral antibiotics once the reports taking at least 3 acetaminophen tablets every three hours for the past
symptoms have completely resolved. week without relief. Which of the following symptoms suggests acetaminophen
D. The patient should continue use of the incentive spirometer to keep airways open toxicity?
and free of secretions. A. Tinnitus.
3. A nurse is caring for an elderly Vietnamese patient in the terminal stages of B. Diarrhea.
lung cancer. Many family members are in the room around the clock C. Hypertension.
performing unusual rituals and bringing ethnic foods. Which of the following D. Hepatic damage.
actions should the nurse take? 9. A nurse is caring for a cancer patient receiving
A. Restrict visiting hours and ask the family to limit visitors to two at a time. subcutaneous morphine sulfate for pain. Which of the following nursing
B. Notify visitors with a sign on the door that the patient is limited to clear fluids only actions is most important in the care of this patient?
with no solid food allowed. A. Monitor urine output.
C. If possible, keep the other bed in the room unassigned to provide privacy and B. Monitor respiratory rate.
comfort to the family. C. Monitor heart rate.
D. Contact the physician to report the unusual rituals and activities. D. Monitor temperature.
4. The charge nurse on the cardiac unit is planning assignments for the day. 10. A patient arrives at the emergency department with severe lower leg pain
Which of the following is the most appropriate assignment for the float nurse after a fall in a touch football game. Following routine triage, which of the
that has been reassigned from labor and delivery? following is the appropriate next step in assessment and treatment?
A. A one-week postoperative coronary bypass patient, who is being evaluated for A. Apply heat to the painful area.
placement of a pacemaker prior to discharge. B. Apply an elastic bandage to the leg.
B. A suspected myocardial infarction patient on telemetry, just admitted from the C. X-ray the leg.
Emergency Department and scheduled for an angiogram. D. Give pain medication.
C. A patient with unstable angina being closely monitored for pain 11. A nurse caring for several patients on the cardiac unit is told that one is
and medication titration. scheduled for implantation of an automatic internal cardioverter-defibrillator.
D. A postoperative valve replacement patient who was recently admitted to the unit Which of the following patients is most likely to have this procedure?
because all surgical beds were filled. A. A patient admitted for myocardial infarction without cardiac muscle damage.
5. A newly diagnosed 8-year-old child with type I diabetes mellitus and his B. A post-operative coronary bypass patient, recovering on schedule.
mother are receiving diabetes education prior to discharge. The physician has
C. A patient with a history of ventricular tachycardia and syncopal episodes. A. Painful cervical lymph nodes.
D. A patient with a history of atrial tachycardia and fatigue. B. Night sweats and fatigue.
12. A patient is scheduled for a magnetic resonance imaging (MRI) scan for C. Nausea and vomiting.
suspected lung cancer. Which of the following is a contraindication to the study D. Weight gain.
for this patient?
A. The patient is allergic to shellfish.
B. The patient has a pacemaker. disease were correct, which of the following cells would the pathologist expect
C. The patient suffers from claustrophobia. to find?
D. The patient takes antipsychotic medication. A. Reed-Sternberg cells.
13. A nurse calls a physician with the concern that a patient has developed B. Lymphoblastic cells.
a pulmonary embolism. Which of the following symptoms has the nurse most
likely observed?
A. The patient is somnolent with decreased response to the family. 20. A patient is about to undergo bone marrow aspiration and biopsy and
B. The patient suddenly complains of chest pain and shortness of breath. expresses fear and anxiety about the procedure. Which of the following is the
C. The patient has developed a wet cough and the nurse hears crackles on most effective nursing response?
auscultation of the lungs. A. Warn the patient to stay very still because the smallest movement will increase her
D. The patient has a fever, chills, and loss of appetite. pain.
14. A patient comes to the emergency department with abdominal pain. Work- B. Encourage the family to stay in the room for the procedure.
up reveals the presence of a rapidly enlarging abdominal aortic aneurysm. C. Stay with the patient and focus on slow, deep breathing for relaxation.
Which of the following actions should the nurse expect? D. Delay the procedure to allow the patient to deal with her feelings.
A. The patient will be admitted to the medicine unit for observation and medication.
B. The patient will be admitted to the day surgery unit for sclerotherapy.
Answers and Rationale
C. The patient will be admitted to the surgical unit and resection will be scheduled. 1. Answer: C. Careful assessment of vital signs.
D. The patient will be discharged home to follow-up with his cardiologist in 24 hours. The priority nursing action for a patient arriving at the ED in distress is always
15. A patient with leukemia is receiving chemotherapy that is known to assessment of vital signs. This indicates the extent of physical compromise and
depress bone marrow. A CBC (complete blood count) reveals a platelet count of provides a baseline by which to plan further assessment and treatment. A thorough
25,000/microliter. Which of the following actions related specifically to the medical history, including onset of symptoms, will be necessary and it is likely that an
platelet count should be included on the nursing care plan? electrocardiogram will be performed as well, but these are not the first priority.
A. Monitor for fever every 4 hours. Similarly, chest exam with auscultation may offer useful information after vital signs
B. Require visitors to wear respiratory masks and protective clothing. are assessed.
C. Consider transfusion of packed red blood cells. 2. Answer: C. The patient may discontinue the prescribed course of oral
D. Check for signs of bleeding, including examination of urine and stool for blood. antibiotics once the symptoms have completely resolved.
16. A patient is undergoing the induction stage of treatment for leukemia. The It is always critical that patients being discharged from the hospital take prescribed
medications as instructed. In the case of antibiotics, a full course must be completed
nurse teaches family members about infectious precautions. Which of the
following statements by family members indicates that the family needs more even after symptoms have resolved to prevent incomplete eradication of the
education? organism and recurrence of infection. The patient should resume normal activities as
tolerated, as well as a nutritious diet. Continued use of the incentive spirometer after
A. We will bring in books and magazines for entertainment.
B. We will bring in personal care items for comfort. discharge will speed recovery and improve lung function.
C. We will bring in fresh flowers to brighten the room. 3. Answer: C. If possible, keep the other bed in the room unassigned to provide
D. We will bring in family pictures and get well cards. privacy and comfort to the family.
17. A nurse is caring for a patient with acute lymphoblastic leukemia (ALL). When a family member is dying, it is most helpful for nursing staff to provide a
Which of the following is the most likely age range of the patient? culturally sensitive environment to the degree possible within the hospital routine.
A. 3-10 years. In the Vietnamese culture, it is important that the dying be surrounded by loved ones
B. 25-35 years. and not left alone. Traditional rituals and foods are thought to ease the transition to
C. 45-55 years. the next life. When possible, allowing the family privacy for this traditional behavior
is best for them and the patient. Answers A, B, and D are incorrect because they
D. over 60 years.
18. A patient is admitted to the oncology unit for diagnosis of suspected create unnecessary conflict with the patient and family.
4. Answer: A. A one-week postoperative coronary bypass patient, who is being
disease? evaluated for placement of a pacemaker prior to discharge.
The charge nurse planning assignments must consider the skills of the staff and the 12. Answer: B. The patient has a pacemaker.
needs of the patients. The labor and delivery nurse who is not experienced with the The implanted pacemaker will interfere with the magnetic fields of the MRI scanner
needs of cardiac patients should be assigned to those with the least acute needs. The and may be deactivated by them. Shellfish/iodine allergy is not a contraindication
patient who is one-week post-operative and nearing discharge is likely to require because the contrast used in MRI scanning is not iodine-based. Open MRI scanners
routine care. A new patient admitted with suspected MI and scheduled for and anti-anxiety medications are available for patients with claustrophobia.
angiography would require continuous assessment as well as coordination of care Psychiatric medication is not a contraindication to MRI scanning.
that is best carried out by experienced staff. The unstable patient requires staff that 13. Answer: B. The patient suddenly complains of chest pain and shortness of
can immediately identify symptoms and respond appropriately. A postoperative breath.
patient also requires close monitoring and cardiac experience. Typical symptoms of pulmonary embolism include chest pain, shortness of breath,
5. Answer: B. Glucagon treats hypoglycemia resulting from insulin overdose. and severe anxiety. The physician should be notified immediately. A patient with
Glucagon is given to treat insulin overdose in an unresponsive patient. Following pulmonary embolism will not be sleepy or have a cough with crackles on exam. A
Glucagon administration, the patient should respond within 15-20 minutes at which patient with fever, chills and loss of appetite may be developing pneumonia.
time oral carbohydrates should be given. Glucagon reverses rather than enhances or 14. Answer: C. The patient will be admitted to the surgical unit and resection
prolongs the effects of insulin. Lipoatrophy refers to the effect of repeated insulin will be scheduled.
injections on subcutaneous fat. A rapidly enlarging abdominal aortic aneurysm is at significant risk of rupture and
6. Answer: A. Sudden weight gain. should be resected as soon as possible. No other appropriate treatment options
Weight gain is an early symptom of congestive heart failure due to accumulation of currently exist.
fluid. When diuretic therapy is inadequate, one would expect an increase in blood 15. Answer: D. Check for signs of bleeding, including examination of urine and
pressure, tachypnea, and tachycardia to result. stool for blood.
7. Answer: B. 4 mcg/mL. A platelet count of 25,000/microliter is severely thrombocytopenic and should
The therapeutic serum level for Dilantin is 10 20 mcg/mL. A level of 4 mcg/mL is prompt the initiation of bleeding precautions, including monitoring urine and stool
subtherapeutic and may be caused by patient non-compliance or increased for evidence of bleeding. Monitoring for fever and requiring protective clothing are
metabolism of the drug. A level of 15 mcg/mL is therapeutic. Choices C and D are indicated to prevent infection if white blood cells are decreased. Transfusion of red
expressed in mcg/dL, which is the incorrect unit of measurement. cells is indicated for severe anemia.
8. Answer: D. Hepatic damage. 16. Answer: C. We will bring in fresh flowers to brighten the room.
Acetaminophen in even moderately large doses can cause serious liver damage that During induction chemotherapy, the leukemia patient is severely
may result in death. Immediate evaluation of liver function is indicated with immunocompromised and at risk of serious infection. Fresh flowers, fruit, and plants
consideration of N-acetylcysteine administration as an antidote. Tinnitus is can carry microbes and should be avoided. Books, pictures, and other personal items
associated with aspirin overdose, not acetaminophen. Diarrhea and hypertension are can be cleaned with antimicrobials before being brought into the room to minimize
not associated with acetaminophen. the risk of contamination.
9. Answer: B. Monitor respiratory rate. 17. Answer: A. 3-10 years.
Morphine sulfate can suppress respiration and respiratory reflexes, such as cough. The peak incidence of ALL is at 4 years (range 3-10). It is uncommon after the mid-
Patients should be monitored regularly for these effects to avoid respiratory teen years. The peak incidence of chronic myelogenous leukemia (CML) is 45-55
compromise. Morphine sulfate does not significantly affect urine output, heart rate, years. The peak incidence of acute myelogenous leukemia (AML) occurs at 60 years.
or body temperature. Two-thirds of cases of chronic lymphocytic leukemia (CLL) occur after 60 years.
10. Answer: C. X-ray the leg. 18. Answer: B. Night sweats and fatigue.
Following triage, an x-ray should be performed to rule out fracture. Ice, not heat,
should be applied to a recent sports injury. An elastic bandage may be applied and tachycardia. The disease is characterized by painless, enlarged cervical lymph nodes.
pain medication given once fracture has been excluded. Weight loss occurs early in the disease. Nausea and vomiting are not typically
11. Answer: C. A patient with a history of ventricular tachycardia and syncopal
episodes. 19. Answer: A. Reed-Sternberg cells.
An automatic internal cardioverter-defibrillator delivers an electric shock to the -Sternberg cells are found
heart to terminate episodes of ventricular tachycardia and ventricular fibrillation. on pathologic examination of the excised lymph node. Lymphoblasts are immature
This is necessary in a patient with significant ventricular symptoms, such as cells found in the bone marrow of patients with acute lymphoblastic leukemia.
tachycardia resulting in syncope. A patient with myocardial infarction that resolved
with no permanent cardiac damage would not be a candidate. A patient recovering sts found in patients with acute myelogenous leukemia.
well from coronary bypass would not need the device. Atrial tachycardia is less 20. Answer: C. Stay with the patient and focus on slow, deep breathing for
serious and is treated conservatively with medication and cardioversion as a last relaxation.
resort.
Slow, deep breathing is the most effective method of reducing anxiety and stress. It 6. A patient with a history of congestive heart failure arrives at the clinic
reduces the level of carbon dioxide in the brain to increase calm and relaxation. complaining of dyspnea. Which of the following actions is the first the nurse
Warning the patient to remain still will likely increase her anxiety. Encouraging should perform?
family members to stay with the patient may make her worry about their anxiety as A. Ask the patient to lie down on the exam table.
well as her own. Delaying the procedure is unlikely to allay her fears. B. Draw blood for chemistry panel and arterial blood gas (ABG).
In Text Mode: All questions and answers are given for reading and answering at your C. Send the patient for a chest x-ray.
own pace. You can also copy this exam and make a print out. D. Check blood pressure.
1. A mother complains to the clinic nurse that her 2 ½-year-old son is not yet 7. A clinic patient has recently been prescribed nitroglycerin for treatment
toilet trained. She is particularly concerned that, although he reliably uses the of angina. He calls the nurse complaining of frequent headaches. Which of the
urine for long periods. following responses to the patient is correct?
Which of the following statements by the nurse is correct?
A. The child should have been trained by age 2 and may have a psychological
cause bleeding
B. Bladder control is usually achieved before bowel control, and the child should be
required to sit on the potty seat until he passes urine.
C. Bowel control is usually achieved before bladder control, and the average age for
completion of toilet training varies widely from 24 to 36 months.
D. The 8. A patient received surgery and chemotherapy for colon cancer, completing
unacceptable. therapy 3 months previously, and she is now in remission. At a follow-up
2. The mother of a 14-month-old child reports to the nurse that her child will appointment, she complains of fatigue following activity and difficulty with
not fall asleep at night without a bottle of milk in the crib and often wakes concentration at her weekly bridge games. Which of the following explanations
during the night asking for another. Which of the following instructions by the could account for her symptoms?
nurse is correct? A. The symptoms may be the result of anemia caused by chemotherapy.
A. Allow the child to have the bottle at bedtime, but withhold the one later in the B. The patient may be immunosuppressed.
night. C. The patient may be depressed.
B. Put juice in the bottle instead of milk. D. The patient may be dehydrated.
C. Give only a bottle of water at bedtime. 9. A clinic patient has a hemoglobin concentration of 10.8 g/dL and reports
D. Do not allow bottles in the crib. sticking to a strict vegetarian diet. Which of the follow nutritional advice is
3. Which of the following actions is NOT appropriate in the care of a 2-month- appropriate?
old infant? A. The diet is providing adequate sources of iron and requires no changes.
A. Place the infant on her back for naps and bedtime. B. The patient should add meat to her diet; a vegetarian diet is not advised.
B. Allow the infant to cry for 5 minutes before responding if she wakes during the C. The patient should use iron cookware to prepare foods, such as dark green, leafy
night as she may fall back asleep. vegetables and legumes, which are high in iron.
C. Talk to the infant frequently and make eye contact to encourage language D. A cup of coffee or tea should be added to every meal.
development. 10. A hospitalized patient is receiving packed red blood cells (PRBCs) for
D. Wait until at least 4 months to add infant cereals and strained fruits to the diet. treatment of severe anemia. Which of the following is the most accurate
4. An older patient asks a nurse to recommend strategies to statement?
prevent constipation. Which of the following suggestions would be helpful? A. Transfusion reaction is most likely immediately after the infusion is completed.
Note: More than one answer may be correct. B. PRBCs are best infused slowly through a 20g. IV catheter.
A. Get moderate exercise for at least 30 minutes each day. C. PRBCs should be flushed with a 5% dextrose solution.
B. Drink 6-8 glasses of water each day. D. A nurse should remain in the room during the first 15 minutes of infusion.
C. Eat a diet high in fiber. 11. Emergency department triage is an important nursing function. A nurse
bowel movement every day. working the evening shift is presented with four patients at the same time.
5. A child is admitted to the hospital with suspected rheumatic fever. Which of Which of the following patients should be assigned the highest priority?
the following observations is NOT confirming of the diagnosis? A. A patient with low-grade fever, headache, and myalgias for the past 72 hours.
A. A reddened rash visible over the trunk and extremities. B. A patient who is unable to bear weight on the left foot, with swelling and bruising
B. A history of sore throat that was self-limited in the past month. following a running accident.
C. A negative antistreptolysin O titer. C. A patient with abdominal and chest pain following a large, spicy meal.
D. An unexplained fever.
D. A child with a one-inch bleeding laceration on the chin but otherwise well after 18. A two-year-old child has sustained an injury to the leg and refuses to walk.
falling while jumping on his bed. The nurse in the emergency department documents swelling of the lower
12. A patient is admitted to the hospital with a calcium level of 6.0 mg/dL. affected leg. Which of the following does the nurse suspect is the cause of the
Which of the following symptoms would you NOT expect to see in this patient?
A. Numbness in hands and feet. A. Possible fracture of the tibia.
B. Muscle cramping. B. Bruising of the gastrocnemius muscle.
C. Hypoactive bowel sounds. C. Possible fracture of the radius.
sign. D. No anatomic injury, the child wants his mother to carry him.
13. A nurse cares for a patient who has a nasogastric tube attached to low 19. A toddler has recently been diagnosed with cerebral palsy. Which of the
suction because of a suspected bowel obstruction. Which of the following following information should the nurse provide to the parents? Note: More
arterial blood gas results might be expected in this patient? than one answer may be correct.
A. pH 7.52, PCO2 54 mmHg. A. Regular developmental screening is important to avoid secondary developmental
B. pH 7.42, PCO2 40 mmHg. delays.
C. pH 7.25, PCO2 25 mmHg. B. Cerebral palsy is caused by injury to the upper motor neurons and results in motor
D. pH 7.38, PCO2 36 mmHg. dysfunction, as well as possible ocular and speech difficulties.
14. A patient is admitted to the hospital for routine elective surgery. Included C. Developmental milestones may be slightly delayed but usually will require no
in the list of current medications is Coumadin (warfarin) at a high dose. additional intervention.
Concerned about the possible effects of the drug, particularly in a patient D. Parent support groups are helpful for sharing strategies and managing health care
scheduled for surgery, the nurse anticipates which of the following actions? issues.
A. Draw a blood sample for prothrombin (PT) and international normalized ratio
(INR) level. The parents are receiving genetic counseling prior to planning
B. Administer vitamin K. another pregnancy. Which of the following statements includes the most
C. Draw a blood sample for type and crossmatch and request blood from the blood accurate information?
bank. -linked recessive disorder, so daughters have a 50% chance of
D. Cancel the surgery after the patient reports stopping the Coumadin one week being carriers and sons a 50% chance of developing the disease.
previously. -linked recessive disorder, so both daughters and sons have a
15. The follow lab results are received for a patient. Which of the following 50% chance of developing the disease.
results are abnormal? Note: More than one answer may be correct. C. Each child has a 1 in 4 (25%) chance of developing the disorder.
A. Hemoglobin 10.4 g/dL. D. Sons only have a 1 in 4 (25%) chance of developing the disorder.
B. Total cholesterol 340 mg/dL.
C. Total serum protein 7.0 g/dL.
Answers and Rationale
D. Glycosylated hemoglobin A1C 5.4%. 1. Answer: C. Bowel control is usually achieved before bladder control, and the
16. A nurse is assigned to the pediatric rheumatology clinic and is assessing a average age for completion of toilet training varies widely from 24 to 36
months.
child who has just been diagnosed with juvenile idiopathic arthritis. Which of
the following statements about the disease is most accurate? Toddlers typically learn bowel control before bladder control, with boys often taking
A. The child has a poor chance of recovery without joint deformity. longer to complete toilet training than girls. Many children are not trained until 36
months and this should not cause concern. Later training is rarely caused by
B. Most children progress to adult rheumatoid arthritis.
C. Nonsteroidal anti-inflammatory drugs are the first choice in treatment. psychological factors and is much more commonly related to individual
D. Physical activity should be minimized. developmental maturity. Reprimanding the child will not speed the process and may
17. A child is admitted to the hospital several days after stepping on a sharp be confusing.
object that punctured her athletic shoe and entered the flesh of her foot. The 2. Answer: C. Give only a bottle of water at bedtime.
physician is concerned about osteomyelitis and has ordered Babies and toddlers should not fall asleep with bottles containing liquid other than
parenteral antibiotics. Which of the following actions is done immediately plain water due to the risk of dental decay. Sugars in milk or juice remain in
before the antibiotic is started? the mouth during sleep and cause caries, even in teeth that have not yet erupted.
A. The admission orders are written. When water is substituted for milk or juice, babies will often lose interest in the
bottle at night.
B. A blood culture is drawn.
C. A complete blood count with differential is drawn. 3. Answer: B. Allow the infant to cry for 5 minutes before responding if she
wakes during the night as she may fall back asleep.
D. The parents arrive.
Infants under 6 months may not be able to sleep for long periods because their 10. Answer: D. A nurse should remain in the room during the first 15 minutes
stomachs are too small to hold adequate nourishment to take them through the night. of infusion.
After 6 months, it may be helpful to let babies put themselves back to sleep after Transfusion reaction is most likely during the first 15 minutes of infusion, and a
waking during the night, but not prior to 6 months. Infants should always be placed nurse should be present during this period. PRBCs should be infused through a 19g
on their backs to sleep. Research has shown a dramatic decrease in sudden infant or larger IV catheter to avoid slow flow, which can cause clotting. PRBCs must be
death syndrome (SIDS) with back sleeping. Eye contact and verbal engagement with flushed with 0.45% normal saline solution. Other intravenous solutions will
infants are important to language development. The best diet for infants under 4 hemolyze the cells.
months of age is breast milk or infant formula. 11. Answer: C. A patient with abdominal and chest pain following a large, spicy
4. Answers: A, B, and C meal.
A daily bowel movement is not necessary if the patient is comfortable and the bowels Emergency triage involves quick patient assessment to prioritize the need for further
move regularly. Moderate exercise, such as walking, encourages bowel health, as evaluation and care. Patients with trauma, chest pain, respiratory distress, or acute
does generous water intake. A diet high in fiber is also helpful. Laxatives should be neurological changes are always classified number one priority. Though the patient
used as a last resort and should not be taken regularly. Over time, laxatives can with chest pain presented in the question recently ate a spicy meal and may be
desensitize the bowel and worsen constipation. suffering from heartburn, he also may be having an acute myocardial infarction and
5. Answer: C. A negative antistreptolysin O titer. require urgent attention. The patient with fever, headache and muscle aches
Rheumatic fever is caused by an untreated group A B hemolytic (classic flu symptoms) should be classified as non-urgent. The patient with the foot
Streptococcus infection in the previous 2-6 weeks, confirmed by a positive injury may have sustained a sprain or fracture, and the limb should be x-rayed as
antistreptolysin O titer. Rheumatic fever is characterized by a red rash over the trunk soon as is practical, but the damage is unlikely to worsen if there is a delay. The
and extremities as well as fever and other symptoms. -urgent.
6. Answer: D. Check blood pressure. 12. Answer: C. Hypoactive bowel sounds.
A patient with congestive heart failure and dyspnea may have pulmonary edema, Normal serum calcium is 8.5 10 mg/dL. The patient is hypocalcemic. Increased
which can cause severe hypertension gastric motility, resulting in hyperactive (not hypoactive) bowel sounds, abdominal
should be the first action. Lying flat on the exam table would likely worsen the cramping and diarrhea is an indication of hypocalcemia. Numbness in hands and feet
dyspnea, and the patient may not tolerate it. Blood draws for chemistry and ABG will
be required, but not prior to the blood pressure assessment. the sustained twitching of facial muscles following tapping in the area of the
7. Answer: cheekbone and is a hallmark of hypocalcemia.
13. Answer: A. pH 7.52, PCO2 54 mmHg.
Nitroglycerin is a potent vasodilator and often produces unwanted effects such as A patient on nasogastric suction is at risk of metabolic alkalosis as a result of loss of
headache, dizziness, and hypotension. Patients should be counseled, and the dose hydrochloric acid in gastric fluid. Of the answers given, only answer A (pH 7.52, PCO2
titrated, to minimize these effects. In spite of the side effects, nitroglycerine is 54 mm Hg) represents alkalosis. Answer B is a normal blood gas. Answer C
effective at reducing myocardial oxygen consumption and increasing blood flow. The represents respiratory acidosis. Answer D is borderline normal with slightly low
patient should not stop the medication. Nitroglycerine does not cause bleeding in the PCO2.
brain. 14. Answer: A. Draw a blood sample for prothrombin (PT) and international
8. Answer: A. The symptoms may be the result of anemia caused by normalized ratio (INR) level.
chemotherapy. The effect of Coumadin is to inhibit clotting. The next step is to check the PT and INR
Three months after surgery and chemotherapy the patient is likely to be feeling the n
after-effects, which often includes anemia because of bone-marrow suppression. antidote to Coumadin and may be used in a patient who is at imminent risk of
There is no evidence that the patient is immunosuppressed, and fatigue is not a dangerous bleeding. Preparation for transfusion, as described in option C, is only
typical symptom of immunosuppression. The information given does not indicate indicated in the case of significant blood loss. If lab results indicate an
that depression or dehydration is a cause of her symptoms. anticoagulation level that would place the patient at risk of excessive bleeding, the
9. Answer: C. The patient should use iron cookware to prepare foods, such as surgeon may choose to delay surgery and discontinue the medication.
dark green, leafy vegetables and legumes, which are high in iron. 15. Answer: A and B
Normal hemoglobin values range from 11.5-15.0. This vegetarian patient is mildly Normal hemoglobin in adults is 12 16 g/dL. Total cholesterol levels of 200 mg/dL
anemic. When food is prepared in iron cookware its iron content is increased. In or below are considered normal. Total serum protein of 7.0-g/dL and glycosylated
addition, dark green leafy vegetables, such as spinach and kale, and legumes are high hemoglobin A1c of 5.4% are both normal levels.
in iron. Mild anemia does not require that animal sources of iron be added to the diet. 16. Answer: C. Nonsteroidal anti-inflammatory drugs are the first choice in
Many non-animal sources are available. Coffee and tea increase gastrointestinal treatment.
activity and inhibit absorption of iron. Nonsteroidal anti-inflammatory drugs are important first line treatment for juvenile
idiopathic arthritis (formerly known as juvenile rheumatoid
arthritis). NSAIDs require 3-4 weeks for the therapeutic anti-inflammatory effects to B. Put juice in the bottle instead of milk.
be realized. Half of children with the disorder recover without joint deformity, and C. Give only a bottle of water at bedtime.
about a third will continue with symptoms into adulthood. Physical activity is an D. Do not allow bottles in the crib.
integral part of therapy. 3. Which of the following actions is NOT appropriate in the care of a 2-month-
17. Answer: B. A blood culture is drawn. old infant?
Antibiotics must be started after the blood culture is drawn, as they may interfere A. Place the infant on her back for naps and bedtime.
with the identification of the causative organism. The blood count will reveal the B. Allow the infant to cry for 5 minutes before responding if she wakes during the
presence of infection but does not help identify an organism or guide antibiotic night as she may fall back asleep.
treatment. Parental presence is important for the adjustment of the child but not for C. Talk to the infant frequently and make eye contact to encourage language
the administration of medication. development.
18. Answer: A. Possible fracture of the tibia. D. Wait until at least 4 months to add infant cereals and strained fruits to the diet.
sal to walk, combined with swelling of the limb is suspicious for 4. An older patient asks a nurse to recommend strategies to
fracture. Toddlers will often continue to walk on a muscle that is bruised or strained. prevent constipation. Which of the following suggestions would be helpful?
The radius is found in the lower arm and is not relevant to this question. Toddlers Note: More than one answer may be correct.
rarely feign injury to be carried, and swelling indicates a physical injury. A. Get moderate exercise for at least 30 minutes each day.
19. Answers: A, B and D. B. Drink 6-8 glasses of water each day.
Delayed developmental milestones are characteristic of cerebral palsy, so regular C. Eat a diet high in fiber.
screening and intervention is essential. Because of injury to upper motor neurons,
children may have ocular and speech difficulties. Parent support groups help families 5. A child is admitted to the hospital with suspected rheumatic fever. Which of
to share and cope. Physical therapy and other interventions can minimize the extent the following observations is NOT confirming of the diagnosis?
of the delay in developmental milestones. A. A reddened rash visible over the trunk and extremities.
20. Answer: -linked recessive disorder, so daughters have B. A history of sore throat that was self-limited in the past month.
a 50% chance of being carriers and sons a 50% chance of developing the C. A negative antistreptolysin O titer.
disease. D. An unexplained fever.
The recessive Duchenne gene is located on one of the two X chromosomes of a female 6. A patient with a history of congestive heart failure arrives at the clinic
carrier. If her son receives the X bearing the gene he will be affected. Thus, there is a complaining of dyspnea. Which of the following actions is the first the nurse
50% chance of a son being affected. Daughters are not affected, but 50% are carriers should perform?
because they inherit one copy of the defective gene from the mother. The other X A. Ask the patient to lie down on the exam table.
chromosome comes from the father, who cannot be a carrier. B. Draw blood for chemistry panel and arterial blood gas (ABG).
In Text Mode: All questions and answers are given for reading and answering at your C. Send the patient for a chest x-ray.
own pace. You can also copy this exam and make a print out. D. Check blood pressure.
1. A mother complains to the clinic nurse that her 2 ½-year-old son is not yet 7. A clinic patient has recently been prescribed nitroglycerin for treatment
toilet trained. She is particularly concerned that, although he reliably uses the of angina. He calls the nurse complaining of frequent headaches. Which of the
urine for long periods. following responses to the patient is correct?
Which of the following statements by the nurse is correct?
A. The child should have been trained by age 2 and may have a psychological
problem that is responsible for his cause bleeding
B. Bladder control is usually achieved before bowel control, and the child should be troglycerine because it causes
required to sit on the potty seat until he passes urine.
C. Bowel control is usually achieved before bladder control, and the average age for
completion of toilet training varies widely from 24 to 36 months.
8. A patient received surgery and chemotherapy for colon cancer, completing
unacceptable. therapy 3 months previously, and she is now in remission. At a follow-up
2. The mother of a 14-month-old child reports to the nurse that her child will appointment, she complains of fatigue following activity and difficulty with
not fall asleep at night without a bottle of milk in the crib and often wakes concentration at her weekly bridge games. Which of the following explanations
during the night asking for another. Which of the following instructions by the could account for her symptoms?
nurse is correct? A. The symptoms may be the result of anemia caused by chemotherapy.
A. Allow the child to have the bottle at bedtime, but withhold the one later in the B. The patient may be immunosuppressed.
night.
C. The patient may be depressed. D. Cancel the surgery after the patient reports stopping the Coumadin one week
D. The patient may be dehydrated. previously.
9. A clinic patient has a hemoglobin concentration of 10.8 g/dL and reports 15. The follow lab results are received for a patient. Which of the following
sticking to a strict vegetarian diet. Which of the follow nutritional advice is results are abnormal? Note: More than one answer may be correct.
appropriate? A. Hemoglobin 10.4 g/dL.
A. The diet is providing adequate sources of iron and requires no changes. B. Total cholesterol 340 mg/dL.
B. The patient should add meat to her diet; a vegetarian diet is not advised. C. Total serum protein 7.0 g/dL.
C. The patient should use iron cookware to prepare foods, such as dark green, leafy D. Glycosylated hemoglobin A1C 5.4%.
vegetables and legumes, which are high in iron. 16. A nurse is assigned to the pediatric rheumatology clinic and is assessing a
D. A cup of coffee or tea should be added to every meal. child who has just been diagnosed with juvenile idiopathic arthritis. Which of
10. A hospitalized patient is receiving packed red blood cells (PRBCs) for the following statements about the disease is most accurate?
treatment of severe anemia. Which of the following is the most accurate A. The child has a poor chance of recovery without joint deformity.
statement? B. Most children progress to adult rheumatoid arthritis.
A. Transfusion reaction is most likely immediately after the infusion is completed. C. Nonsteroidal anti-inflammatory drugs are the first choice in treatment.
B. PRBCs are best infused slowly through a 20g. IV catheter. D. Physical activity should be minimized.
C. PRBCs should be flushed with a 5% dextrose solution. 17. A child is admitted to the hospital several days after stepping on a sharp
D. A nurse should remain in the room during the first 15 minutes of infusion. object that punctured her athletic shoe and entered the flesh of her foot. The
11. Emergency department triage is an important nursing function. A nurse physician is concerned about osteomyelitis and has ordered
working the evening shift is presented with four patients at the same time. parenteral antibiotics. Which of the following actions is done immediately
Which of the following patients should be assigned the highest priority? before the antibiotic is started?
A. A patient with low-grade fever, headache, and myalgias for the past 72 hours. A. The admission orders are written.
B. A patient who is unable to bear weight on the left foot, with swelling and bruising B. A blood culture is drawn.
following a running accident. C. A complete blood count with differential is drawn.
C. A patient with abdominal and chest pain following a large, spicy meal. D. The parents arrive.
D. A child with a one-inch bleeding laceration on the chin but otherwise well after 18. A two-year-old child has sustained an injury to the leg and refuses to walk.
falling while jumping on his bed. The nurse in the emergency department documents swelling of the lower
12. A patient is admitted to the hospital with a calcium level of 6.0 mg/dL. affected leg. Which of the following does the nurse suspect is the cause of the
Which of the following symptoms would you NOT expect to see in this patient?
A. Numbness in hands and feet. A. Possible fracture of the tibia.
B. Muscle cramping. B. Bruising of the gastrocnemius muscle.
C. Hypoactive bowel sounds. C. Possible fracture of the radius.
D. No anatomic injury, the child wants his mother to carry him.
13. A nurse cares for a patient who has a nasogastric tube attached to low 19. A toddler has recently been diagnosed with cerebral palsy. Which of the
suction because of a suspected bowel obstruction. Which of the following following information should the nurse provide to the parents? Note: More
arterial blood gas results might be expected in this patient? than one answer may be correct.
A. pH 7.52, PCO2 54 mmHg. A. Regular developmental screening is important to avoid secondary developmental
B. pH 7.42, PCO2 40 mmHg. delays.
C. pH 7.25, PCO2 25 mmHg. B. Cerebral palsy is caused by injury to the upper motor neurons and results in motor
D. pH 7.38, PCO2 36 mmHg. dysfunction, as well as possible ocular and speech difficulties.
14. A patient is admitted to the hospital for routine elective surgery. Included C. Developmental milestones may be slightly delayed but usually will require no
in the list of current medications is Coumadin (warfarin) at a high dose. additional intervention.
Concerned about the possible effects of the drug, particularly in a patient D. Parent support groups are helpful for sharing strategies and managing health care
scheduled for surgery, the nurse anticipates which of the following actions? issues.
A. Draw a blood sample for prothrombin (PT) and international normalized ratio
(INR) level. The parents are receiving genetic counseling prior to planning
B. Administer vitamin K. another pregnancy. Which of the following statements includes the most
C. Draw a blood sample for type and crossmatch and request blood from the blood accurate information?
bank. -linked recessive disorder, so daughters have a 50% chance of
being carriers and sons a 50% chance of developing the disease.
 -linked recessive disorder, so both daughters and sons have a 7. Answer: e because it
50% chance of developing the disease.
C. Each child has a 1 in 4 (25%) chance of developing the disorder. Nitroglycerin is a potent vasodilator and often produces unwanted effects such as
D. Sons only have a 1 in 4 (25%) chance of developing the disorder. headache, dizziness, and hypotension. Patients should be counseled, and the dose
Answers and Rationale titrated, to minimize these effects. In spite of the side effects, nitroglycerine is
effective at reducing myocardial oxygen consumption and increasing blood flow. The
1. Answer: C. Bowel control is usually achieved before bladder control, and the patient should not stop the medication. Nitroglycerine does not cause bleeding in the
average age for completion of toilet training varies widely from 24 to 36 brain.
months. 8. Answer: A. The symptoms may be the result of anemia caused by
Toddlers typically learn bowel control before bladder control, with boys often taking chemotherapy.
longer to complete toilet training than girls. Many children are not trained until 36 Three months after surgery and chemotherapy the patient is likely to be feeling the
months and this should not cause concern. Later training is rarely caused by after-effects, which often includes anemia because of bone-marrow suppression.
psychological factors and is much more commonly related to individual There is no evidence that the patient is immunosuppressed, and fatigue is not a
developmental maturity. Reprimanding the child will not speed the process and may typical symptom of immunosuppression. The information given does not indicate
be confusing.
that depression or dehydration is a cause of her symptoms.
2. Answer: C. Give only a bottle of water at bedtime. 9. Answer: C. The patient should use iron cookware to prepare foods, such as
Babies and toddlers should not fall asleep with bottles containing liquid other than
dark green, leafy vegetables and legumes, which are high in iron.
plain water due to the risk of dental decay. Sugars in milk or juice remain in Normal hemoglobin values range from 11.5-15.0. This vegetarian patient is mildly
the mouth during sleep and cause caries, even in teeth that have not yet erupted. anemic. When food is prepared in iron cookware its iron content is increased. In
When water is substituted for milk or juice, babies will often lose interest in the
addition, dark green leafy vegetables, such as spinach and kale, and legumes are high
bottle at night. in iron. Mild anemia does not require that animal sources of iron be added to the diet.
3. Answer: B. Allow the infant to cry for 5 minutes before responding if she Many non-animal sources are available. Coffee and tea increase gastrointestinal
wakes during the night as she may fall back asleep. activity and inhibit absorption of iron.
Infants under 6 months may not be able to sleep for long periods because their 10. Answer: D. A nurse should remain in the room during the first 15 minutes
stomachs are too small to hold adequate nourishment to take them through the night. of infusion.
After 6 months, it may be helpful to let babies put themselves back to sleep after Transfusion reaction is most likely during the first 15 minutes of infusion, and a
waking during the night, but not prior to 6 months. Infants should always be placed nurse should be present during this period. PRBCs should be infused through a 19g
on their backs to sleep. Research has shown a dramatic decrease in sudden infant or larger IV catheter to avoid slow flow, which can cause clotting. PRBCs must be
death syndrome (SIDS) with back sleeping. Eye contact and verbal engagement with flushed with 0.45% normal saline solution. Other intravenous solutions will
infants are important to language development. The best diet for infants under 4 hemolyze the cells.
months of age is breast milk or infant formula. 11. Answer: C. A patient with abdominal and chest pain following a large, spicy
4. Answers: A, B, and C meal.
A daily bowel movement is not necessary if the patient is comfortable and the bowels Emergency triage involves quick patient assessment to prioritize the need for further
move regularly. Moderate exercise, such as walking, encourages bowel health, as
evaluation and care. Patients with trauma, chest pain, respiratory distress, or acute
does generous water intake. A diet high in fiber is also helpful. Laxatives should be neurological changes are always classified number one priority. Though the patient
used as a last resort and should not be taken regularly. Over time, laxatives can with chest pain presented in the question recently ate a spicy meal and may be
desensitize the bowel and worsen constipation.
suffering from heartburn, he also may be having an acute myocardial infarction and
5. Answer: C. A negative antistreptolysin O titer. require urgent attention. The patient with fever, headache and muscle aches
Rheumatic fever is caused by an untreated group A B hemolytic (classic flu symptoms) should be classified as non-urgent. The patient with the foot
Streptococcus infection in the previous 2-6 weeks, confirmed by a positive injury may have sustained a sprain or fracture, and the limb should be x-rayed as
antistreptolysin O titer. Rheumatic fever is characterized by a red rash over the trunk soon as is practical, but the damage is unlikely to worsen if there is a delay. The
and extremities as well as fever and other symptoms. chi -urgent.
6. Answer: D. Check blood pressure. 12. Answer: C. Hypoactive bowel sounds.
A patient with congestive heart failure and dyspnea may have pulmonary edema, Normal serum calcium is 8.5 10 mg/dL. The patient is hypocalcemic. Increased
which can cause severe hypertension gastric motility, resulting in hyperactive (not hypoactive) bowel sounds, abdominal
should be the first action. Lying flat on the exam table would likely worsen the
cramping and diarrhea is an indication of hypocalcemia. Numbness in hands and feet
dyspnea, and the patient may not tolerate it. Blood draws for chemistry and ABG will and muscle cramps are als
be required, but not prior to the blood pressure assessment.
the sustained twitching of facial muscles following tapping in the area of the
cheekbone and is a hallmark of hypocalcemia.
13. Answer: A. pH 7.52, PCO2 54 mmHg. 50% chance of a son being affected. Daughters are not affected, but 50% are carriers
A patient on nasogastric suction is at risk of metabolic alkalosis as a result of loss of because they inherit one copy of the defective gene from the mother. The other X
hydrochloric acid in gastric fluid. Of the answers given, only answer A (pH 7.52, PCO2 chromosome comes from the father, who cannot be a carrier.
54 mm Hg) represents alkalosis. Answer B is a normal blood gas. Answer C In Text Mode: All questions and answers are given for reading and answering at your
represents respiratory acidosis. Answer D is borderline normal with slightly low own pace. You can also copy this exam and make a print out.
PCO2. 1. A patient is admitted to the hospital with a diagnosis of primary
14. Answer: A. Draw a blood sample for prothrombin (PT) and international hyperparathyroidism. A nurse
normalized ratio (INR) level. which of the following changes in laboratory findings?
The effect of Coumadin is to inhibit clotting. The next step is to check the PT and INR A. Elevated serum calcium.
B. Low serum parathyroid hormone (PTH).
antidote to Coumadin and may be used in a patient who is at imminent risk of C. Elevated serum vitamin D.
dangerous bleeding. Preparation for transfusion, as described in option C, is only D. Low urine calcium.
indicated in the case of significant blood loss. If lab results indicate an 2. A patient with
anticoagulation level that would place the patient at risk of excessive bleeding, the Which of the following diet modifications is NOT recommended?
surgeon may choose to delay surgery and discontinue the medication. A. A diet high in grains.
15. Answer: A and B B. A diet with adequate caloric intake.
Normal hemoglobin in adults is 12 16 g/dL. Total cholesterol levels of 200 mg/dL C. A high protein diet.
or below are considered normal. Total serum protein of 7.0-g/dL and glycosylated D. A restricted sodium diet.
hemoglobin A1c of 5.4% are both normal levels. 3. A patient with a history of diabetes mellitus is in the second post-operative
16. Answer: C. Nonsteroidal anti-inflammatory drugs are the first choice in day following cholecystectomy. She has complained of nausea
treatment. eat solid foods. The nurse enters the room to find the patient confused and
Nonsteroidal anti-inflammatory drugs are important first line treatment for juvenile
idiopathic arthritis (formerly known as juvenile rheumatoid symptoms?
arthritis). NSAIDs require 3-4 weeks for the therapeutic anti-inflammatory effects to A. Anesthesia reaction.
be realized. Half of children with the disorder recover without joint deformity, and B. Hyperglycemia.
about a third will continue with symptoms into adulthood. Physical activity is an C. Hypoglycemia.
integral part of therapy. D. Diabetic ketoacidosis.
17. Answer: B. A blood culture is drawn. 4. A nurse assigned to the emergency department evaluates a patient who
Antibiotics must be started after the blood culture is drawn, as they may interfere underwent fiberoptic colonoscopy 18 hours previously. The patient reports
with the identification of the causative organism. The blood count will reveal the increasing abdominal pain, fever, and chills. Which of the following conditions
presence of infection but does not help identify an organism or guide antibiotic poses the most immediate concern?
treatment. Parental presence is important for the adjustment of the child but not for A. Bowel perforation.
the administration of medication. B. Viral gastroenteritis.
18. Answer: A. Possible fracture of the tibia. C. Colon cancer.
D. Diverticulitis.
fracture. Toddlers will often continue to walk on a muscle that is bruised or strained. 5. A patient is admitted to the same day surgery unit for liver biopsy. Which of
The radius is found in the lower arm and is not relevant to this question. Toddlers the following laboratory tests assesses coagulation? Select all that apply.
rarely feign injury to be carried, and swelling indicates a physical injury. A. Partial thromboplastin time.
19. Answers: A, B and D. B. Prothrombin time.
Delayed developmental milestones are characteristic of cerebral palsy, so regular C. Platelet count.
screening and intervention is essential. Because of injury to upper motor neurons, D. Hemoglobin
children may have ocular and speech difficulties. Parent support groups help families E. Complete Blood Count
to share and cope. Physical therapy and other interventions can minimize the extent F. White Blood Cell Count
of the delay in developmental milestones. 6. A patient on the cardiac telemetry unit unexpectedly goes into ventricular
20. Answer: -linked recessive disorder, so daughters have fibrillation. The advanced cardiac life support team prepares to defibrillate.
a 50% chance of being carriers and sons a 50% chance of developing the Which of the following choices indicates the correct placement of the
disease. conductive gel pads?
The recessive Duchenne gene is located on one of the two X chromosomes of a female A. The left clavicle and right lower sternum.
carrier. If her son receives the X bearing the gene he will be affected. Thus, there is a B. Right of midline below the bottom rib and the left shoulder.
C. The upper and lower halves of the sternum. A. Observe for evidence of spontaneous bleeding.
D. The right side of the sternum just below the clavicle and left of the precordium. B. Limit visitors to family only.
7. The nurse performs an initial abdominal assessment on a patient newly C. Give aspirin in case of headaches.
D. Impose immune precautions.
14. A nurse in the emergency department assesses a patient who has been
ich of the following statements is correct? taking long-term corticosteroids to treat renal disease. Which of the following
A. The frequency and intensity of bowel sounds varies depending on the phase of is a typical side effect of corticosteroid treatment? Note: More than one answer
digestion. may be correct.
B. In the presence of intestinal obstruction, bowel sounds will be louder and higher A. Hypertension.
pitched. B. Cushingoid features.
C. A swishing or buzzing sound may represent the turbulent blood flow of a bruit and C. Hyponatremia.
is not normal. D. Low serum albumin.
D. All of the above. 15. A nurse is caring for patients in the oncology unit. Which of the following is
8. A patient arrives in the emergency department and reports splashing the most important nursing action when caring for a neutropenic patient?
concentrated household cleaner in his eye. Which of the following nursing A. Change the disposable mask immediately after use.
actions is a priority? B. Change gloves immediately after use.
A. Irrigate the eye repeatedly with normal saline solution. C. Minimize patient contact.
B. Place fluorescein drops in the eye. D. Minimize conversation with the patient.
C. Patch the eye. 16. A nurse is counseling patients at a health clinic on the importance of
D. Test visual acuity. immunizations. Which of the following information is the most accurate
9. A nurse is caring for a patient who has had hip replacement. The nurse regarding immunizations?
should be most concerned about which of the following findings? A. All infectious diseases can be prevented with proper immunization.
A. Complaints of pain during repositioning. B. Immunizations provide natural immunity from disease.
B. Scant bloody discharge on the surgical dressing. C. Immunizations are risk-free and should be universally administered.
C. Complaints of pain following physical therapy. D. Immunization provides acquired immunity from some specific diseases.
D. Temperature of 101.8 F (38.7 C). 17. A patient is brought to the emergency department after a bee sting. The
10. A child is admitted to the hospital with an uncontrolled seizure disorder. family reports a history of severe allergic reaction, and the patient appears to
The admitting physician writes orders for actions to be taken in the event of have some oral swelling. Which of the following is the most urgent nursing
a seizure. Which of the following actions would NOT be included? action?
A. Notify the physician. A. Consult a physician.
B. Maintain a patent airway.
C. Position the patient on his/her side with the head flexed forward. C. Administer epinephrine subcutaneously.
D. Administer rectal diazepam. D. Administer diphenhydramine (Benadryl) orally.
11. A patient who has received chemotherapy for cancer treatment is given an 18. A mother calls the clinic to report that her son has recently
injection of Epoetin. Which of the following should reflect the findings in started medication to treat attention deficit/hyperactivity disorder (ADHD).
a complete blood count (CBC) drawn several days later? The mother fears her son is experiencing side effects of the medicine. Which of
A. An increase in neutrophil count. the following side effects are typically related to medications used for ADHD?
B. An increase in hematocrit. Note: More than one answer may be correct:
C. An increase in platelet count. A. Poor appetite.
D. An increase in serum iron. B. Insomnia.
12. A patient is admitted to the hospital with suspected polycythemia vera. C. Sleepiness.
Which of the following symptoms is consistent with the diagnosis? Select all D. Agitation.
that apply. 19. A patient at a mental health clinic is taking Haldol (haloperidol) for
A. Weight loss. treatment of schizophrenia. She calls the clinic to report abnormal movements
B. Increased clotting time. of her face and tongue. The nurse concludes that the patient is experiencing
C. Hypertension. which of the following symptoms:
D. Headaches. A. Co-morbid depression.
13. A nurse is caring for a patient with a platelet count of 20,000/microliter. B. Psychotic hallucinations.
Which of the following is an important intervention?
C. Negative symptoms of schizophrenia. 8. Answer: A. Irrigate the eye repeatedly with normal saline solution.
D. Tardive dyskinesia. Emergency treatment following a chemical splash to the eye includes immediate
20. A patient with newly diagnosed diabetes mellitus is learning to recognize irrigation with normal saline. The irrigation should be continued for at least 10
the symptoms of hypoglycemia. Which of the following symptoms is indicative minutes. Fluorescein drops are used to check for scratches on the cornea due to their
of hypoglycemia? fluorescent properties and are not part of the initial care of a chemical splash, nor is
A. Polydipsia. patching the eye. Following irrigation, visual acuity will be assessed.
B. Confusion. 9. Answer: D. Temperature of 101.8 F (38.7 C).
C. Blurred vision. Post-surgical nursing assessment after hip replacement should be principally
D. Polyphagia. concerned with the risk of neurovascular complications and the development
Answers and Rationale of infection. A temperature of 101.8 F (38.7 C) postoperatively is higher than the low
grade that is to be expected and should raise concern. Some pain during
1. Answer: A. Elevated serum calcium. repositioning and following physical therapy is to be expected and can be managed
The parathyroid glands regulate the calcium level in the blood. In with analgesics. A small amount of bloody drainage on the surgical dressing is a
hyperparathyroidism, the serum calcium level will be elevated. Parathyroid hormone result of normal healing.
levels may be high or normal but not low. The body will lower the level of vitamin D
10. Answer:
in an attempt to lower calcium. Urine calcium may be elevated, with calcium spilling During a witnessed seizure, nursing actions should focus
over from elevated serum levels. This may cause renal stones.
safely and curtailing the seizure. Restraining the limbs is not indicated because
2. Answer: D. A restricted sodium diet. strong muscle contractions could cause injury. A side-lying position with head flexed
isease requires normal dietary sodium to prevent excess forward allows for drainage of secretions and prevents the tongue from falling back,
fluid loss. Adequate caloric intake is recommended with a diet high in protein and
blocking the airway. Rectal diazepam may be a treatment ordered by the physician,
complex carbohydrates, including grains. who should be notified of the seizure.
3. Answer: C. Hypoglycemia. 11. Answer: B. An increase in hematocrit.
A postoperative diabetic patient who is unable to eat is likely to be suffering from Epoetin is a form of erythropoietin, which stimulates the production of red blood
hypoglycemia. Confusion and shakiness are common symptoms. An anesthesia cells, causing an increase in hematocrit. Epoetin is given to patients who are anemic,
reaction would not occur on the second post-operative day. Hyperglycemia and often as a result of chemotherapy treatment. Epoetin has no effect on neutrophils,
ketoacidosis do not cause confusion and shakiness. platelets, or serum iron.
4. Answer: A. Bowel perforation. 12. Answer: B, C, and D
Bowel perforation is the most serious complication of fiberoptic colonoscopy. Polycythemia vera is a condition in which the bone marrow produces too many red
Important signs include progressive abdominal pain, fever, chills, and tachycardia, blood cells. This causes an increase in hematocrit and viscosity of the blood. Patients
which indicate advancing peritonitis. Viral gastroenteritis and colon cancer do not can experience headaches, dizziness, and visual disturbances. Cardiovascular effects
cause these symptoms. Diverticulitis may cause pain, fever, and chills, but is far less include increased blood pressure and delayed clotting time. Weight loss is not a
serious than perforation and peritonitis. manifestation of polycythemia vera.
5. Answer: A, B, and C 13. Answer: A. Observe for evidence of spontaneous bleeding.
Prothrombin time, partial thromboplastin time, and platelet count are all included in
Platelet counts under 30,000/microliter may cause spontaneous petechiae and
coagulation studies. The hemoglobin level, though important information prior to an bruising, particularly in the extremities. When the count falls below 15,000,
invasive procedure like liver biopsy, does not assess coagulation. spontaneous bleeding into the brain and internal organs may occur. Headaches may
6. Answer: D. The right side of the sternum just below the clavicle and left of
be a sign and should be watched for. Aspirin disables platelets and should never be
the precordium. used in the presence of thrombocytopenia. Thrombocytopenia does not compromise
One gel pad should be placed to the right of the sternum, just below the clavicle and immunity, and there is no reason to limit visitors as long as any physical trauma is
the other just left of the precordium, as indicated by the anatomic location of the prevented.
heart. To defibrillate, the paddles are placed over the pads. Options A, B, and C are 14. Answers: A, B, and D
not consistent with the position of the heart and are therefore incorrect responses. Side effects of corticosteroids include weight gain, fluid retention with hypertension,
7. Answer: D. All of the above. Cushingoid features, a low serum albumin, and suppressed inflammatory response.
All of the statements are true. The gurgles and clicks described in the question Patients are encouraged to eat a diet high in protein, vitamins, and minerals and low
represent normal bowel sounds, which vary with the phase of digestion. Intestinal in sodium. Corticosteroids cause hypernatremia, not hyponatremia.
obstruction causes the sounds to intensify as the normal flow is blocked by the
15. Answer: B. Change gloves immediately after use.
obstruction. The swishing and buzzing sound of turbulent blood flow may be heard The neutropenic patient is at risk of infection. Changing gloves immediately after use
in the abdomen in the presence of abdominal aortic aneurism, for example, and
protects patients from contamination with organisms picked up on hospital surfaces.
should always be considered abnormal. This contamination can have serious consequences for an immunocompromised
patient. Changing the respiratory mask is desirable, but not nearly as urgent as A. A congenital condition leading to renal dysfunction.
changing gloves. Minimizing contact and conversation are not necessary and may B. Prior infection with group A Streptococcus within the past 10-14 days.
C. Viral infection of the glomeruli.
16. Answer: D. Immunization provides acquired immunity from some specific D. Nephrotic syndrome.
diseases. 4. An infant with hydrocele is seen in the clinic for a follow-up visit at 1 month
Immunization is available for the prevention of some, but not all, specific diseases. of age. The scrotum is smaller than it was at birth, but fluid is still visible on
illumination. Which of the following actions is the physician likely to
specific pathogen. Natural immunity is present at birth because the infant acquires recommend?
maternal antibodies Immunization, like all medication, cannot be risk-free and A. Massaging the groin area twice a day until the fluid is gone.
should be considered based on the risk of the disease in question. B. Referral to a surgeon for repair.
17. Answer: B. Maintain a patent airway. C. No treatment is necessary; the fluid is reabsorbing normally.
The patient may be experiencing an anaphylactic reaction. The most urgent action is D. Keeping the infant in a flat, supine position until the fluid is gone.
to maintain an airway, particularly with visible oral swelling, followed by the 5. A nurse is caring for a patient with peripheral vascular disease (PVD). The
administration of epinephrine by subcutaneous injection. The physician will see the patient complains of burning and tingling of the hands and feet and cannot
patient as soon as possible with the above actions underway. Oral diphenhydramine tolerate touch of any kind. Which of the following is the most likely explanation
is indicated for mild allergic reactions and is not appropriate for anaphylaxis. for these symptoms?
18. Answers: A, B, and D A. Inadequate tissue perfusion leading to nerve damage.
ADHD in children is frequently treated with CNS stimulant medications, which B. Fluid overload leading to compression of nerve tissue.
increase focus and improve concentration. Children often experience insomnia, C. Sensation distortion due to psychiatric disturbance.
agitation, and decreased appetite. Sleepiness is not a side effect of stimulants. D. Inflammation of the skin on the hands and feet.
19. Answer: D. Tardive dyskinesia. 6. A nurse is assessing a clinic patient with a diagnosis of hepatitis A. Which of
Abnormal facial movements and tongue protrusion in a patient taking haloperidol is the following is the most likely route of transmission?
most likely due to tardive dyskinesia, an adverse reaction to the antipsychotic. A. Sexual contact with an infected partner.
Depression may occur along with schizophrenia and would be characterized by such B. Contaminated food.
symptoms as loss of affect, appetite and/or sleep changes, and anhedonia. C. Blood transfusion.
These depressive changes and lack of volition are part of the negative symptoms of D. Illegal drug use.
schizophrenia. Psychotic hallucinations may be visual or auditory but do not include 7. A leukemia patient has a relative who wants to donate blood for transfusion.
abnormal movements. Which of the following donor medical conditions would prevent this?
20. Answer: B. Confusion. A. A history of hepatitis C five years previously.
Hypoglycemia in diabetes mellitus causes confusion, indicating the need for B. Cholecystitis requiring cholecystectomy one year previously.
carbohydrates. Polydipsia, blurred vision, and polyphagia are symptoms of C. Asymptomatic diverticulosis.
hyperglycemia.
In Text Mode: All questions and answers are given for reading and answering at your 8. A physician has diagnosed acute gastritis in a clinic patient. Which of the
own pace. You can also copy this exam and make a print out. following medications would be contraindicated for this patient?
1. A child is admitted to the hospital with a diagnosis of Wilms tumor, stage II. A. Naproxen sodium (Naprosyn).
Which of the following statements most accurately describes this stage? B. Calcium carbonate.
A. The tumor is less than 3 cm. in size and requires no chemotherapy. C. Clarithromycin (Biaxin).
B. The tumor did not extend beyond the kidney and was completely resected. D. Furosemide (Lasix).
C. The tumor extended beyond the kidney but was completely resected. 9. The nurse is conducting nutrition counseling for a patient with cholecystitis.
D. The tumor has spread into the abdominal cavity and cannot be resected. Which of the following information is important to communicate?
2. A teen patient is admitted to the hospital by his physician who suspects a A. The patient must maintain a low calorie diet.
diagnosis of acute glomerulonephritis. Which of the following findings is B. The patient must maintain a high protein/low carbohydrate diet.
consistent with this diagnosis? Note: More than one answer may be correct. C. The patient should limit sweets and sugary drinks.
A. Urine specific gravity of 1.040. D. The patient should limit fatty foods.
B. Urine output of 350 ml in 24 hours. 10. A patient admitted to the hospital with myocardial infarction develops
-colore severe pulmonary edema. Which of the following symptoms should the nurse
D. Generalized edema. expect the patient to exhibit?
3. Which of the following conditions most commonly causes acute A. Slow, deep respirations.
glomerulonephritis? B. Stridor.
C. Bradycardia. of transfusion. Which of the following complications is most likely the cause of
D. Air hunger.
11. A nurse is evaluating a postoperative patient and notes a moderate amount A. Febrile non-hemolytic reaction.
of serous drainage on the dressing 24 hours after surgery. Which of the B. Allergic transfusion reaction.
following is the appropriate nursing action? C. Acute hemolytic reaction.
A. Notify the surgeon about evidence of infection immediately. D. Fluid overload.
B. Leave the dressing intact to avoid disturbing the wound site. 18. A patient in labor and delivery has just received an amniotomy. Which of
C. Remove the dressing and leave the wound site open to air. the following is correct? Note: More than one answer may be correct.
D. Change the dressing and document the clean appearance of the wound site. A. Frequent checks for cervical dilation will be needed after the procedure.
12. A patient returns to the emergency department less than 24 hours after B. Contractions may rapidly become stronger and closer together after the
having a fiberglass cast applied for a fractured right radius. Which of the procedure.
following patient complaints would cause the nurse to be concerned about C. The FHR (fetal heart rate) will be followed closely after the procedure due to the
impaired perfusion to the limb? possibility of cord compression.
A. Severe itching under the cast. D. The procedure is usually painless and is followed by a gush of amniotic fluid.
B. Severe pain in the right shoulder. 19. A nurse is counseling the mother of a newborn infant
C. Severe pain in the right lower arm. with hyperbilirubinemia. Which of the following instructions by the nurse is
D. Increased warmth in the fingers. NOT correct?
13. An older patient with osteoarthritis is preparing for discharge. Which of the A. Continue to breastfeed frequently, at least every 2-4 hours.
following information is correct. B. Follow up with th
A. Increased physical activity and daily exercise will help decrease discomfort the serum bilirubin and exam.
associated with the condition. C. Watch for signs of dehydration, including decreased urinary output and changes in
B. Joint pain will diminish after a full night of rest. skin turgor.
C. Nonsteroidal anti-inflammatory medications should be taken on an D. Keep the baby quiet and swaddled, and place the bassinet in a dimly lit area.
empty stomach. 20. A nurse is giving discharge instructions to the parents of a healthy
D. Acetaminophen (Tylenol) is a more effective anti-inflammatory newborn. Which of the following instructions should the nurse provide
than ibuprofen (Motrin). regarding car safety and the trip home from the hospital?
14. Which patient should NOT be prescribed alendronate (Fosamax) A. The infant should be restrained in an infant car seat, properly secured in the back
for osteoporosis? seat in a rear-facing position.
A. A female patient being treated for high blood pressure with an ACE inhibitor. B. The infant should be restrained in an infant car seat, properly secured in the front
B. A patient who is allergic to iodine/shellfish. passenger seat.
C. A patient on a calorie restricted diet. C. The infant should be restrained in an infant car seat facing forward or rearward in
D. A patient on bed rest who must maintain a supine position. the back seat.
15. Which of the following strategies is NOT effective for prevention of Lyme D. For the trip home from the hospital, the parent may sit in the back seat and hold
disease? the newborn.
A. Insect repellant on the skin and clothes when in a Lyme endemic area.
B. Long sleeved shirts and long pants.
Answers and Rationale
1. Answer: C. The tumor extended beyond the kidney but was completely
C. Prophylactic antibiotic therapy prior to anticipated exposure to ticks.
D. Careful examination of skin and hair for ticks following anticipated exposure. resected.
16. A nurse is performing routine assessment of an IV site in a patient receiving The staging of Wilms tumor is confirmed at surgery as follows: Stage I, the tumor is
both IV fluids and medications through the line. Which of the following would limited to the kidney and completely resected; stage II, the tumor extends beyond the
indicate the need for discontinuation of the IV line as the next nursing action? kidney but is completely resected; stage III, residual non hematogenous tumor is
A. The patient complains of pain on movement. confined to the abdomen; stage IV, hematogenous metastasis has occurred with
B. The area proximal to the insertion site is reddened, warm, and painful. spread beyond the abdomen; and stage V, bilateral renal involvement is present at
C. The IV solution is infusing too slowly, particularly when the limb is elevated. diagnosis.
D. A hematoma is visible in the area of the IV insertion site. 2. Answers: A, B, and C
Acute glomerulonephritis is characterized by high urine specific gravity related to
17. A hospitalized patient has received transfusions of 2 units of blood over the
past few hours. A nurse enters the room to find the patient sitting up in bed,
cells. There is periorbital edema, but generalized edema is seen in nephrotic
dyspneic and uncomfortable. On assessment, crackles are heard in the bases of
both lungs, probably indicating that the patient is experiencing a complication syndrome, not acute glomerulonephritis.
3. Answer: B. Prior infection with group A Streptococcus within the past 10-14 wound. The surgical site is typically covered by gauze dressings for a minimum of 48-
days. 72 hours to ensure that initial healing has begun.
Acute glomerulonephritis is most commonly caused by the immune response to a 12. Answer: C. Severe pain in the right lower arm.
prior upper respiratory infection with group A Streptococcus. Glomerular Impaired perfusion to the right lower arm as a result of a closed cast may cause
inflammation occurs about 10-14 days after the infection, resulting in scant, dark neurovascular compromise and severe pain, requiring immediate cast removal.
urine and retention of body fluid. Periorbital edema and hypertension are common Itching under the cast is common and fairly benign. Neurovascular compromise in
signs at diagnosis. the arm would not cause pain in the shoulder, as perfusion there would not be
4. Answer: C. No treatment is necessary; the fluid is reabsorbing normally. affected. Impaired perfusion would cause the fingers to be cool and pale. Increased
A hydrocele is a collection of fluid in the scrotum that results from a patent tunica warmth would indicate increased blood flow or infection.
vaginalis. Illumination of the scrotum with a pocket light demonstrates the clear 13. Answer: A. Increased physical activity and daily exercise will help decrease
fluid. In most cases the fluid reabsorbs within the first few months of life and no discomfort associated with the condition.
treatment is necessary. Massaging the area or placing the infant in a supine position Physical activity and daily exercise can help to improve movement and decrease pain
would have no effect. Surgery is not indicated. in osteoarthritis. Joint pain and stiffness are often at their worst during the early
5. Answer: A. Inadequate tissue perfusion leading to nerve damage. morning after several hours of decreased movement. Acetaminophen is a pain
Patients with peripheral vascular disease often sustain nerve damage as a result of reliever, but does not have anti-inflammatory activity. Ibuprofen is a strong anti-
inadequate tissue perfusion. Fluid overload is not characteristic of PVD. There is inflammatory, but should always be taken with food to avoid GI distress.
nothing to indicate psychiatric disturbance in the patient. Skin changes in PVD are 14. Answer: D. A patient on bed rest who must maintain a supine position.
secondary to decreased tissue perfusion rather than primary inflammation. Alendronate can cause significant gastrointestinal side effects, such as esophageal
6. Answer: B. Contaminated food. irritation, so it should not be taken if a patient must stay in supine position. It should
Hepatitis A is the only type that is transmitted by the fecal-oral route through be taken upon rising in the morning with 8 ounces of water on an empty stomach to
contaminated food. Hepatitis B, C, and D are transmitted through infected bodily increase absorption. The patient should not eat or drink for 30 minutes after
fluids. administration and should not lie down. ACE inhibitors are not contraindicated with
7. Answer: A. A history of hepatitis C five years previously. alendronate and there is no iodine allergy relationship.
Hepatitis C is a viral infection transmitted through bodily fluids, such as blood, 15. Answer: C. Prophylactic antibiotic therapy prior to anticipated exposure to
causing inflammation of the liver. Patients with hepatitis C may not donate blood for ticks.
transfusion due to the high risk of infection in the recipient. Cholecystitis Prophylactic use of antibiotics is not indicated to prevent Lyme disease. Antibiotics
are used only when symptoms develop following a tick bite. Insect repellant should
blood donation. be used on skin and clothing when exposure is anticipated. Clothing should be
8. Answer: A. Naproxen sodium (Naprosyn). designed to cover as much exposed area as possible to provide an effective barrier.
Naproxen sodium is a nonsteroidal anti-inflammatory drug that can cause Close examination of skin and hair can reveal the presence of a tick before a bite
inflammation of the upper GI tract. For this reason, it is contraindicated in a patient occurs.
with gastritis. Calcium carbonate is used as an antacid for the relief of indigestion and 16. Answer: B. The area proximal to the insertion site is reddened, warm, and
is not contraindicated. Clarithromycin is an antibacterial often used for the treatment painful.
of Helicobacter pylori in gastritis. Furosemide is a loop diuretic and is An IV site that is red, warm, painful and swollen indicates that phlebitis has
contraindicated in a patient with gastritis. developed and the line should be discontinued and restarted at another site. Pain on
9. Answer: D. The patient should limit fatty foods. movement should be managed by maneuvers such as splinting the limb with an IV
Cholecystitis, inflammation of the gallbladder, is most commonly caused by the board or gently shifting the position of the catheter before making a decision to
presence of gallstones, which may block bile (necessary for fat absorption) from remove the line. An IV line that is running slowly may simply need flushing or
entering the intestines. Patients should decrease dietary fat by limiting foods like repositioning. A hematoma at the site is likely a result of minor bleeding at the time
fatty meats, fried foods, and creamy desserts to avoid irritation of the gallbladder. of insertion and does not require discontinuation of the line.
10. Answer: D. Air hunger. 17. Answer: D. Fluid overload.
Patients with pulmonary edema experience air hunger, anxiety, and agitation. Fluid overload occurs when then the fluid volume infused over a short period is too
Respiration is fast and shallow and heart rate increases. Stridor is noisy breathing great for the vascular system, causing fluid leak into the lungs. Symptoms include
caused by laryngeal swelling or spasm and is not associated with pulmonary edema. dyspnea, rapid respirations, and discomfort as in the patient described. Febrile non-
11. Answer: D. Change the dressing and document the clean appearance of the hemolytic reaction results in fever. Symptoms of allergic transfusion reaction would
wound site. include flushing, itching, and a generalized rash. Acute hemolytic reaction may occur
A moderate amount of serous drainage from a recent surgical site is a sign of normal when a patient receives blood that is incompatible with his blood type. It is the most
healing. Purulent drainage would indicate the presence of infection. A soiled dressing serious adverse transfusion reaction and can cause shock and death.
should be changed to avoid bacterial growth and to examine the appearance of the 18. Answer: B, C, and D
Uterine contractions typically become stronger and occur more closely together C. Prevents DVT (deep vein thrombosis).
following amniotomy. The FHR is assessed immediately after the procedure and D. Prevent constipations.
followed closely to detect changes that may indicate cord compression. The 5. A patient arrives in the emergency department with symptoms of myocardial
procedure itself is painless and results in the quick expulsion of amniotic fluid. infarction, progressing to cardiogenic shock. Which of the following symptoms
Following amniotomy, cervical checks are minimized because of the risk of infection should the nurse expect the patient to exhibit with cardiogenic shock?
19. Answer: D. Keep the baby quiet and swaddled, and place the bassinet in a A. Hypertension.
dimly lit area. B. Bradycardia.
An infant discharged home with hyperbilirubinemia (newborn jaundice) should be C. Bounding pulse.
placed in a sunny rather than dimly lit area with skin exposed to help process the D. Confusion.
bilirubin. Frequent feedings will help to metabolize the bilirubin. A recheck of the 6. A patient in the cardiac unit is concerned about the risk factors associated
serum bilirubin and a physical exam within 72 hours will confirm that the level is with atherosclerosis. Which of the following are hereditary risk factors for
falling and the infant is thriving and is well hydrated. Signs of dehydration, including developing atherosclerosis?
decreased urine output and skin changes, indicate inadequate fluid intake and will A. Family history of heart disease.
worsen the hyperbilirubinemia. B. Overweight.
20. Answer: A. The infant should be restrained in an infant car seat, properly C. Smoking.
secured in the back seat in a rear-facing position. D. Age.
All infants under 1 year of age weighing less than 20 lbs. should be placed in a rear- 7. Claudication is a well-known effect of peripheral vascular disease. Which of
facing infant car seat secured properly in the back seat. Infant car seats should never the following facts about claudication is correct? More than one answer may be
be placed in the front passenger seat. Infants should always be placed in an approved correct.
car seat during travel, even on that first ride home from the hospital. A. It results when oxygen demand is greater than oxygen supply.
In Text Mode: All questions and answers are given for reading and answering at your B. It is characterized by pain that often occurs during rest.
own pace. You can also copy this exam and make a print out. C. It is a result of tissue hypoxia.
1. A nurse is administering IV furosemide to a patient admitted with congestive D. It is characterized by cramping and weakness.
heart failure. After the infusion, which of the following symptoms is NOT 8. A nurse is providing discharge information to a patient with peripheral
expected? vascular disease. Which of the following information should be included in
A. Increased urinary output. instructions?
B. Decreased edema. A. Walk barefoot whenever possible.
C. Decreased pain. B. Use a heating pad to keep feet warm.
D. Decreased blood pressure. C. Avoid crossing the legs.
2. There are a number of risk factors associated with coronary artery disease. D. Use antibacterial ointment to treat skin lesions at risk of infection.
Which of the following is a modifiable risk factor?
A. Obesity. disease) complains of cold and stiffness in the fingers. Which of the following
B. Heredity. descriptions is most likely to fit the patient?
C. Gender. A. An adolescent male.
D. Age. B. An elderly woman.
3. Tissue plasminogen activator (t-PA) is considered for treatment of a patient C. A young woman.
who arrives in the emergency department following onset of symptoms D. An elderly man.
of myocardial infarction. Which of the following is a contraindication for 10. A 23 year old patient in the 27th week of pregnancy has been hospitalized
treatment with t-PA? on complete bed rest for 6 days. She experiences sudden shortness of breath,
A. Worsening chest pain that began earlier in the evening. accompanied by chest pain. Which of the following conditions is the most likely
B. History of cerebral hemorrhage. cause of her symptoms?
C. History of prior myocardial infarction. A. Myocardial infarction due to a history of atherosclerosis.
D. Hypertension. B. Pulmonary embolism due to deep vein thrombosis (DVT).
4. Following myocardial infarction, a hospitalized patient is encouraged to C. Anxiety
practice frequent leg exercises and ambulate in the hallway as directed by his D. Congestive heart failure due to fluid overload.
physician. Which of the following choices reflects the purpose of exercise for 11. Thrombolytic therapy is frequently used in the treatment of
this patient? suspected stroke. Which of the following is a significant complication
A. Increases fitness and prevents future heart attacks. associated with thrombolytic therapy?
B. Prevents bedsores.
A. Air embolus. A. Scarlet fever is caused by infection with group A Streptococcus bacteria.
B. Cerebral hemorrhage.
C. Expansion of the clot. C. Petechiae occur on the soft palate.
D. Resolution of the clot. D. The pharynx is red and swollen.
12. An infant is brought to the clinic by his mother, who has noticed that he 19. A child weighing 30 kg arrives at the clinic with diffuse itching as the result
holds his head in an unusual position and always faces to one side. Which of the of an allergic reaction to an insect bite. Diphenhydramine (Benadryl) 25 mg 3
following is the most likely explanation? times a day is prescribed. The correct pediatric dose is 5 mg/kg/day. Which of
A. Torticollis, with shortening of the sternocleidomastoid muscle. the following best describes the prescribed drug dose?
B. Craniosynostosis, with premature closure of the cranial sutures. A. It is the correct dose.
C. Plagiocephaly, with flattening of one side of the head. B. The dose is too low.
D. Hydrocephalus, with increased head size. C. The dose is too high.
stating that he is not to D. The dose should be increased or decreased, depending on the symptoms.
participate in sports due to a diagnosis of Osgood-Schlatter disease. Which of 20. The mother of a 2-month-old infant brings the child to the clinic for a well
the following statements about the disease is correct? baby check. She is concerned because she feels only one testis in the scrotal sac.
Which of the following statements about the undescended testis is the most
B. The student will most likely require surgical intervention. accurate?
C. The student experiences pain in the inferior aspect of the knee. A. Normally, the testes are descended by birth.
D. The student is trying to avoid participation in physical education. B. The infant will likely require surgical intervention.
14. The clinic nurse asks a 13-year-old female to bend forward at the waist C. The infant probably has with only one testis.
with arms hanging freely. Which of the following assessments is the nurse most D. Normally, the testes descend by one year of age.
likely conducting?
A. Spinal flexibility.
Answers and Rationale
B. Leg length disparity. 1. Answer: C. Decreased pain.
C. Hypostatic blood pressure. Furosemide, a loop diuretic, does not alter pain. Furosemide acts on the kidneys to
D. Scoliosis. increase urinary output. Fluid may move from the periphery, decreasing edema.
15. A clinic nurse interviews a parent who is suspected of abusing her child. Fluid load is reduced, lowering blood pressure.
Which of the following characteristics is the nurse LEAST likely to find in an 2. Answer: A. Obesity.
abusing parent? Obesity is an important risk factor for coronary artery disease that can be modified
A. Low self-esteem. by improved diet and weight loss. Family history of coronary artery disease, male
B. Unemployment. gender, and advancing age increase risk but cannot be modified.
C. Self-blame for the injury to the child. 3. Answer: B. History of cerebral hemorrhage.
D. Single status. A history of cerebral hemorrhage is a contraindication to tPA because it may increase
16. A nurse in the emergency department is observing a 4-year-old child for the risk of bleeding. TPA acts by dissolving the clot blocking the coronary artery and
works best when administered within 6 hours of onset of symptoms. Prior MI is not a
signs of increased intracranial pressure after a fall from a bicycle, resulting in
head trauma. Which of the following signs or symptoms would be cause for contraindication to tPA. Patients receiving tPA should be observed for changes in
concern? blood pressure, as tPA may cause hypotension.
4. Answer: C. Prevents DVT (deep vein thrombosis).
A. Bulging anterior fontanel.
B. Repeated vomiting. Exercise is important for all hospitalized patients to prevent deep vein thrombosis.
C. Signs of sleepiness at 10 PM. Muscular contraction promotes venous return and prevents hemostasis in the lower
D. Inability to read short words from a distance of 18 inches. extremities. This exercise is not sufficiently vigorous to increase physical fitness, nor
17. A nonimmunized child appears at the clinic with a visible rash. Which of the is it intended to prevent bedsores or constipation.
following observations indicates the child may have rubeola (measles)? 5. Answer: D. Confusion.
A. Small blue-white spots are visible on the oral mucosa. Cardiogenic shock severely impairs the pumping function of the heart muscle,
B. The rash begins on the trunk and spreads outward. causing diminished blood flow to the organs of the body. This results in diminished
C. There is low-grade fever. brain function and confusion, as well as hypotension, tachycardia, and weak pulse.
Cardiogenic shock is a serious complication of myocardial infarction with a high
18. A child is seen in the emergency department for scarlet fever. Which of the mortality rate.
6. Answer: A. Family history of heart disease.
following descriptions of scarlet fever is NOT correct?
Family history of heart disease is an inherited risk factor that is not subject to responding to ice, rest, and analgesics. Continued participation will worsen the
lifestyle change. Having a first degree relative with heart disease has been shown to condition and the symptoms.
significantly increase risk. Overweight and smoking are risk factors that are subject 14. Answer: D. Scoliosis.
to lifestyle change and can reduce risk significantly. Advancing age increases risk of A check for scoliosis, a lateral deviation of the spine, is an important part of the
atherosclerosis but is not a hereditary factor. routine adolescent exam. It is assessed by having the teen bend at the waist with
7. Answers: A, C, and D arms dangling, while observing for lateral curvature and uneven rib level. Scoliosis is
Claudication describes the pain experienced by a patient with peripheral vascular more common in female adolescents. Choices A, B, and C are not part of the routine
disease when oxygen demand in the leg muscles exceeds the oxygen supply. This adolescent exam.
most often occurs during activity when demand increases in muscle tissue. The tissue 15. Answer: C. Self-blame for the injury to the child.
becomes hypoxic, causing cramping, weakness, and discomfort. The profile of a parent at risk of abusive behavior includes a tendency to blame the
8. Answer: C. Avoid crossing the legs. child or others for the injury sustained. These parents also have a high incidence of
Patients with peripheral vascular disease should avoid crossing the legs because this low self-esteem, unemployment, unstable financial situation, and single status.
can impede blood flow. Walking barefoot is not advised, as foot protection is 16. Answer: B. Repeated vomiting.
important to avoid trauma that may lead to serious infection. Heating pads can cause Increased pressure caused by bleeding or swelling within the skull can damage
injury, which can also increase the risk of infection. Skin lesions at risk for delicate brain tissue and may become life threatening. Repeated vomiting can be an
infection should be examined and treated by a physician. early sign of pressure as the vomit center within the medulla is stimulated. The
9. Answer: C. A young woman. anterior fontanel is closed in a 4-year-old child. Evidence of sleepiness at 10 PM is
normal for a four year old. The average 4-year-old child cannot read yet, so this too is
with rheumatologic disorders, such as lupus and rheumatoid arthritis. normal.
10. Answer: B. Pulmonary embolism due to deep vein thrombosis (DVT). 17. Answer: A. Small blue-white spots are visible on the oral mucosa.
In a hospitalized patient on prolonged bed rest, he most likely cause of sudden onset s are small blue-white spots visible on the oral mucosa and are
shortness of breath and chest pain is pulmonary embolism. Pregnancy and prolonged characteristic of measles infection. The body rash typically begins on the face and
inactivity both increase the risk of clot formation in the deep veins of the legs. These
clots can then break loose and travel to the lungs. Myocardial infarction and the lesions found in varicella (chicken pox).
atherosclerosis are unlikely in a 27-year-old woman, as is congestive heart failure 18. Answer: C. Petechiae occur on the soft palate.
due to fluid overload. There is no reason to suspect an anxiety disorder in this Petechiae on the soft palate are characteristic of rubella infection. Choices A, B, and D
patient. Though anxiety is a possible cause of her symptoms, the seriousness of are characteristic of scarlet fever, a result of group A Streptococcus infection.
pulmonary embolism demands that it be considered first. 19. Answer: B. The dose is too low.
11. Answer: B. Cerebral hemorrhage. This child weighs 30 kg, and the pediatric dose of diphenhydramine is 5 mg/kg/day
Cerebral hemorrhage is a significant risk when treating a stroke victim with (5 X 30 = 150/day). Therefore, the correct dose is 150 mg/day. Divided into 3 doses
thrombolytic therapy intended to dissolve a suspected clot. Success of the treatment per day, the child should receive 50 mg 3 times a day rather than 25 mg 3 times a
demands that it be instituted as soon as possible, often before the cause of stroke has day. Dosage should not be titrated based on symptoms without consulting a
been determined. Air embolism is not a concern. Thrombolytic therapy does not lead physician.
to expansion of the clot, but to resolution, which is the intended effect. 20. Answer: D. Normally, the testes descend by one year of age.
12. Answer: A. Torticollis, with shortening of the sternocleidomastoid muscle. Normally, the testes descend by one year of age. In young infants, it is common for
In torticollis, the sternocleidomastoid muscle is contracted, limiting range of motion the testes to retract into the inguinal canal when the environment is cold or the
of the neck and causing the chin to point to the opposing side. In craniosynostosis cremasteric reflex is stimulated. Exam should be done in a warm room with warm
one of the cranial sutures, often the sagittal, closes prematurely, causing the head to hands. It is most likely that both testes are present and will descend by a year. If not,
grow in an abnormal shape. Plagiocephaly refers to the flattening of one side of the a full assessment will determine the appropriate treatment.
head, caused by the infant being placed supine in the same position over In Text Mode: All questions and answers are given for reading and answering at your own
time. Hydrocephalus is caused by a build-up of cerebrospinal fluid in the brain pace. You can also copy this exam and make a printout.
resulting in large head size. 1. Mrs. Chua a 78-year-old client is admitted with the diagnosis of mild chronic heart
13. Answer: C. The student experiences pain in the inferior aspect of the knee. failure. The nurse
Osgood-Schlatter disease occurs in adolescents in rapid growth phase when the chronic heart failure would be:
infrapatellar ligament of the quadriceps muscle pulls on the tibial tubercle, causing A. Stridor
pain and swelling in the inferior aspect of the knee. Osgood-Schlatter disease is B. Crackles
commonly caused by activities that require repeated use of the quadriceps, including C. Wheezes
track and soccer. Swimming is not a likely cause. The condition is usually self-limited, D. Friction rubs
2. Patrick who is hospitalized following a myocardial infarction asks the nurse why C. Can recognize the risk factors of Myocardial Infarction
he is taking morphine. The nurse explains that morphine: D. Can Participate in cardiac rehabilitation walking program
A. Decrease anxiety and restlessness 10. A 68-year-old client is diagnosed with a right-sided brain attack and is admitted
B. Prevents shock and relieves pain to the hospital. In caring for this client, the nurse should plan to:
C. Dilates coronary blood vessels A. Application of elastic stockings to prevent flaccid by muscle
D. Helps prevent fibrillation of the heart B. Use hand roll and extend the left upper extremity on a pillow to prevent contractions
3. Which of the following should the nurse teach the client about the signs C. Use a bed cradle to prevent dorsiflexion of feet
of digitalis toxicity? D. Do passive range of motion exercise
A. Increased appetite 11. Nurse Liza is assigned to care for a client who has returned to the nursing unit
B. Elevated blood pressure a
C. Skin rash over the chest and back A. Hourly urine output
D. Visual disturbances such as seeing yellow spots B. Temperature
4. Nurse Trisha teaches a client with heart failure to take oral Furosemide in the C. Able to turn side to side
D. Able to sips clear liquid
A. Retard rapid drug absorption 12. A 64-year-old male client with a long history of cardiovascular problem
B. Excrete excessive fluids accumulated at night including hypertension and angina is to be scheduled for cardiac catheterization.
C. Prevents sleep disturbances during night During pre-cardiac catheterization teaching, Nurse Cherry should inform the client
D. Prevention of electrolyte imbalance that t
5. What would be the primary goal of therapy for a client with pulmonary edema and A. To determine the existence of CHD
heart failure? B. To visualize the disease process in the coronary arteries
A. Enhance comfort C. To obtain the heart chambers pressure
B. Increase cardiac output D. To measure oxygen content of different heart chambers
C. Improve respiratory status 13. During the first several hours after a cardiac catheterization, it would be most
D. Peripheral edema decreased
6. Nurse Linda is caring for a client with head injury and monitoring the client with A. Elevate clients bed at 45°
decerebrate posturing. Which of the following is a characteristic of this type of B. Instruct the client to cough and deep breathe every 2 hours
posturing?
A. Upper extremity flexion with lower extremity flexion D. Monitor clients temperature every hour
B. Upper extremity flexion with lower extremity extension 14. Kate who has undergone mitral valve replacement suddenly experiences
C. Extension of the extremities after a stimulus continuous bleeding from the surgical incision during postoperative period. Which
D. Flexion of the extremities after stimulus of the following pharmaceutical agents should Nurse Aiza prepare to administer to
7. A female client is taking Cascara Sagrada. Nurse Betty informs the client that the Kate?
following maybe experienced as side effects of this medication: A. Protamine Sulfate
A. GI bleeding B. Quinidine Sulfate
B. Peptic ulcer disease C. Vitamin C
C. Abdominal cramps D. Coumadin
D. Partial bowel obstruction 15. In reducing the risk of endocarditis, good dental care is an important measure.
8. Dr. Marquez orders a continuous intravenous nitroglycerin infusion for the client To promote good dental care in client with mitral stenosis in teaching plan should
suffering from myocardial infarction. Which of the following is the most essential
nursing action? A. Dental floss
A. Monitoring urine output frequently B. Electric toothbrush
B. Monitoring blood pressure every 4 hours C. Manual toothbrush
C. Obtaining serum potassium levels daily D. Irrigation device
D. Obtaining infusion pump for the medication 16. Among the following signs and symptoms, which would most likely be present in
9. During the second day of hospitalization of the client after a Myocardial Infarction. a client with mitral regurgitation?
Which of the following is an expected outcome? A. Altered level of consciousness
A. Able to perform self-care activities without pain B. Exertional Dyspnea
B. Severe chest pain C. Increase creatine phosphokinase concentration
D. Chest pain
17. Kris with a history of chronic infection of the urinary system complains of 24. Nurse Donna is aware that the shift of body fluids associated with Intravenous
urinary frequency and burning sensation. To figure out whether the current problem administration of albumin occurs in the process of:
is of renal origin, the nurse should assess whether the client has discomfort or pain A. Osmosis
B. Diffusion
A. Urinary meatus C. Active transport
B. Pain in the Labium D. Filtration
C. Suprapubic area 25. Myrna a 52-year-old client with a fractured left tibia has a long leg cast and she is
D. Right or left costovertebral angle using crutches to ambulate. Nurse Joy assesses for which sign and symptom that
18. Nurse Perry is evaluating the renal function of a male client. After documenting indicates complication associated with crutch walking?
urine volume and characteristics, Nurse Perry assesses which signs as the best A. Left leg discomfort
indicator of renal function. B. Weak biceps brachii
A. Blood pressure C. Triceps muscle spasm
B. Consciousness D. Forearm weakness
C. Distension of the bladder 26. Which of the following statements should the nurse teach the neutropenic client
D. Pulse rate and his family to avoid?
19. John suddenly experiences a seizure, and Nurse Gina notice that John exhibits A. Performing oral hygiene after every meal
uncontrollable jerking movements. Nurse Gina documents that John experienced B. Using suppositories or enemas
which type of seizure? C. Performing perineal hygiene after each bowel movement
A. Tonic seizure D. Using a filter mask
B. Absence seizure 27. A female client is experiencing painful and rigid abdomen and is diagnosed with
C. Myoclonic seizure perforated peptic ulcer. A surgery has been scheduled and a nasogastric tube is
D. Clonic seizure inserted. The nurse should place the client before surgery in
20. Smoking cessation is critical strategy for the client A. Sims position
Jasmin anticipates that the male client will go home with a prescription for which B. Supine position
medication? C. Semi-fowlers position
A. Paracetamol D. Dorsal recumbent position
B. Ibuprofen 28. Which nursing intervention ensures adequate ventilating exchange after
C. Nitroglycerin surgery?
D. Nicotine (Nicotrol) A. Remove the airway only when client is fully conscious
B. Assess for hypoventilation by auscultating the lungs
realizes that the etiology of the disease is unknown but it is characterized by: C. Position client laterally with the neck extended
A. Episodic vasospastic disorder of capillaries D. Maintain humidified oxygen via nasal cannula
B. Episodic vasospastic disorder of small veins 29. George who has undergone thoracic surgery has chest tube connected to a water-
C. Episodic vasospastic disorder of the aorta seal drainage system attached to suction. Presence of excessive bubbling is identified
D. Episodic vasospastic disorder of the small arteries in water-
22. Nurse Jamie should explain to male client with diabetes that self-monitoring of
blood glucose B. Check the system for air leaks
A. More accurate C. Recognize the system is functioning correctly
B. Can be done by the client D. Decrease the amount of suction pressure
C. It is easy to perform 30. A client who has been diagnosed with hypertension is being taught to restrict
D. It is not influenced by drugs intake of sodium. The nurse would know that the teachings are effective if the client
23. Jessie weighed 210 pounds on admission to the hospital. After 2 days of diuretic
therapy, Jessie weighs 205.5 pounds. The nurse could estimate the amount of fluid A. I can eat celery sticks and carrots
B. I can eat broiled scallops
A. 0.3 L C. I can eat shredded wheat cereal
B. 1.5 L D. I can eat spaghetti on rye bread
C. 2.0 L 31. A male client with a history of cirrhosis and alcoholism is admitted with severe
D. 3.5 L dyspnea resulted to ascites. The nurse should be aware that the ascites is most likely
A. Pressure in the portal vein 39. A client who has undergone a cholecystectomy asks the nurse whether there are
B. Production of serum albumin any dietary restrictions that must be followed. Nurse Hilary would recognize that the
C. Secretion of bile salts dietary teaching was well understood when the client tells a family member that:
D. Interstitial osmotic pressure
32. A newly admitted client
excisional cervical lymph node biopsy under local anesthesia. What does the nurse
assess first after the procedure?
A. Vital signs 40. Nurse Rachel teaches a client who has been recently diagnosed with hepatitis
B. Incision site A about untoward signs and symptoms related to Hepatitis that may develop. The
C. Airway one that should be reported immediately to the physician is:
D. Level of consciousness A. Restlessness
33. A client has 15% blood loss. Which of the following nursing assessment findings B. Yellow urine
indicates hypovolemic shock? C. Nausea
A. Systolic blood pressure less than 90mm Hg D. Clay-colored stools
B. Pupils unequally dilated 41. Which of the following antituberculosis drugs can damage the 8th cranial nerve?
C. Respiratory rate of 4 breath/min A. Isoniazid (INH)
D. Pulse rate less than 60 bpm B. Para Aminosalicylic acid (PAS)
34. Nurse Lucy is planning to give preoperative teaching to a client who will be C. Ethambutol hydrochloride (Myambutol)
undergoing rhinoplasty. Which of the following should be included? D. Streptomycin
A. Results of the surgery will be immediately noticeable postoperatively 42. The client asks Nurse Annie the causes of peptic ulcer. Nurse Annie responds that
B. Normal saline nose drops will need to be administered preoperatively recent research indicates that peptic ulcers are the result of which of the following:
C. After surgery, nasal packing will be in place 8 to 10 days A. Genetic defect in gastric mucosa
D. Aspirin-containing medications should not be taken 14 days before surgery B. Stress
35. Paul is admitted to the hospital due to metabolic acidosis caused by Diabetic C. Diet high in fat
ketoacidosis (DKA). The nurse prepares which of the following medications as an D. Helicobacter pylori infection
initial treatment for this problem? 43. Ryan has undergone subtotal gastrectomy. The nurse should expect that
A. Regular insulin nasogastric tube drainage will be what color for about 12 to 24 hours after surgery?
B. Potassium A. Bile green
C. Sodium bicarbonate B. Bright red
D. Calcium gluconate C. Cloudy white
36. Dr. Marquez tells a client that an increased intake of foods that are rich in D. Dark brown
Vitamin E and beta-carotene are important for healthier skin. The nurse teaches the 44. Nurse Joan is assigned to come for client who has just undergone eye surgery.
client that excellent food sources of both of these substances are: Nurse Joan plans to teach the client activities that are permitted during the
A. Fish and fruit jam postoperative period. Which of the following is best recommended for the client?
B. Oranges and grapefruit A. Watching circus
C. Carrots and potatoes B. Bending over
D. Spinach and mangoes C. Watching TV
37. A client has Gastroesophageal Reflux Disease (GERD). The nurse should teach the D. Lifting objects
45. A client suffered from a lower leg injury and seeks treatment in the emergency
A. Rest in sitting position room. There is a prominent deformity to the lower aspect of the leg, and the injured
B. Take a short walk leg appears shorter than the other leg. The affected leg is painful, swollen and
C. Drink plenty of water beginning to become ecchymotic. The nurse interprets that the client is
D. Lie down at least 30 minutes experiencing:
38. After gastroscopy, an adaptation that indicates major complication would be: A. Fracture
A. Nausea and vomiting B. Strain
B. Abdominal distention C. Sprain
C. Increased GI motility D. Contusion
D. Difficulty in swallowing 46. Nurse Jenny is instilling an otic solution into an adult male client left ear. Nurse
Jenny avoids doing which of the following as part of the procedure
A. Pulling the auricle backward and upward Option B: The primary goal of therapy for the client with pulmonary edema or
B. Warming the solution to room temperature heart failure is increasing cardiac output. Pulmonary edema is an acute medical
C. Pacing the tip of the dropper on the edge of ear canal emergency requiring immediate intervention.
D. Placing client in side lying position 6. Answer: C. Extension of the extremities after a stimulus
47. Nurse Bea should instruct the male client with an ileostomy to report Option C: Decerebrate posturing is the extension of the extremities after a
immediately which of the following symptom? stimulus which may occur with upper brain stem injury.
A. Absence of drainage from the ileostomy for 6 or more hours 7. Answer: C. Abdominal cramps
B. Passage of liquid stool in the stoma Option C: The most frequent side effects of Cascara Sagrada (Laxative) is
C. Occasional presence of undigested food abdominal cramps and nausea.
D. A temperature of 37.6 °C 8. Answer: D. Obtaining infusion pump for the medication
48. Jerry has diagnosed with appendicitis. He develops a fever, hypotension, and Option D: Administration of Intravenous Nitroglycerin infusion requires pump for
tachycardia. The nurse suspects which of the following complications? accurate control of medication.
A. Intestinal obstruction 9. Answer: A. Able to perform self-care activities without pain
B. Peritonitis Option A: By the 2nd day of hospitalization after suffering a Myocardial Infarction,
C. Bowel ischemia Clients are able to perform care without chest pain
D. Deficient fluid volume 10. Answer: B. Use hand roll and extend the left upper extremity on a pillow to
49. Which of the following compilations should the nurse carefully monitors a client prevent contractions
with acute pancreatitis? Option B: The left side of the body will be affected in a right-sided brain attack.
A. Myocardial Infarction 11. Answer: A. Hourly urine output
B. Cirrhosis Option A: After nephrectomy, it is necessary to measure urine output hourly. This
C. Peptic ulcer is done to assess the effectiveness of the remaining kidney also to detect renal
D. Pneumonia failure early.
50. Which of the following symptoms during the icteric phase of viral hepatitis 12. Answer: B. To visualize the disease process in the coronary arteries
should the nurse expect the client to inhibit? Option B: The lumen of the arteries can be assessed by cardiac
A. Watery stool catheterization. Angina is usually caused by narrowing of the coronary arteries.
B. Yellow sclera 13. Answer: C.
C. Tarry stool Option C: Blood pressure is monitored to detect hypotension which may indicate
D. Shortness of breath shock or hemorrhage. Apical pulse is taken to detect arrhythmias related to
Answers & Rationale cardiac irritability.
14. Answer: A. Protamine Sulfate
Here are the answers and rationale for this exam. Counter check your answers to those Option A: Protamine Sulfate is used to prevent continuous bleeding in client who
below and tell us your scores. If you have any disputes or need more clarification to a has undergone open heart surgery.
certain question, please direct them to the comments section. 15. Answer: C. Manual toothbrush
1. Answer: B. Crackles
Option C: The use of electronic toothbrush, irrigation device or dental floss may
Option B: Left-sided heart failure causes fluid accumulation in the cause bleeding of gums, allowing bacteria to enter and increasing the risk of
capillary network of the lung. Fluid eventually enters alveolar spaces and causes endocarditis.
crackling sounds at the end of inspiration.
16. Answer: B. Exertional Dyspnea
2. Answer: B. Prevents shock and relieves pain Option B: Weight gain due to retention of fluids and worsening heart failure
Option B: Morphine is a central nervous system depressant used to relieve the causes exertional dyspnea in clients with mitral regurgitation.
pain associated with myocardial infarction, it also decreases apprehension and 17. Answer: D. Right or left costovertebral angle
prevents cardiogenic shock. Option D: Discomfort or pain is a problem that originates in the kidney. It is felt at
3. Answer: D. Visual disturbances such as seeing yellow spots the costovertebral angle on the affected side.
Option D: Seeing yellow spots and colored vision are common symptoms 18. Answer: A. Blood pressure
of digitalis toxicity Option A: Perfusion can be best estimated by blood pressure, which is an indirect
4. Answer: C. Prevents sleep disturbances during night reflection of the adequacy of cardiac output.
Option C: When diuretics are taken in the morning, client will void frequently
19. Answer: C. Myoclonic seizure
during daytime and will not need to void frequently at night. Option C: Myoclonic seizure is characterized by sudden uncontrollable jerking
5. Answer: B. Increase cardiac output
movements of a single or multiple muscle group.
20. Answer: D. Nicotine (Nicotrol)
 Option D: Nicotine (Nicotrol) is given in controlled and decreasing doses for the Option A: Metabolic acidosis is anaerobic metabolism caused by lack of ability of
management of nicotine withdrawal syndrome. the body to use circulating glucose. Administration of insulin corrects this
21. Answer: D. Episodic vasospastic disorder of the small arteries problem.
Option D: isease is characterized by vasospasms of the small 36. Answer: D. Spinach and mangoes
cutaneous arteries that involves fingers and toes. Option D: Beta-carotene and Vitamin E are antioxidants which help to inhibit
22. Answer: A. More accurate oxidation. Vitamin E is found in the following foods: wheat germ, corn, nuts, seeds,
Option A: Urine testing provides an indirect measure that maybe influenced by olives, spinach, asparagus and other green leafy vegetables. Food sources of beta-
kidney function while blood glucose testing is a more direct and accurate measure. carotene include dark green vegetables, carrots, mangoes and tomatoes.
23. Answer: C. 2.0 L 37. Answer: A. Rest in sitting position
Option C: One liter of fluid approximately weighs 2.2 pounds. A 4.5 pound weight Option A: Gravity speeds up digestion and prevents reflux of stomach contents
loss equals to approximately 2L. into the esophagus.
24. Answer: A. Osmosis 38. Answer: B. Abdominal distention
Option A: Osmosis is the movement of fluid from an area of lesser solute Option B: Abdominal distension may be associated with pain, may indicate
concentration to an area of greater solute concentration. perforation, a complication that could lead to peritonitis.
25. Answer: D. Forearm weakness 39. Answer: D.
Option D: Forearm muscle weakness is a probable sign of radial nerve injury Option D: It may take 4 to 6 months to eat anything, but most people can eat
caused by crutch pressure on the axillae. anything they want.
26. Answer: B. Using suppositories or enemas 40. Answer: D. Clay-colored stools
Option B: Neutropenic client is at risk for infection especially bacterial infection of Option D: Clay-colored stools are indicative of hepatic obstruction
the gastrointestinal and respiratory tract. 41. Answer: D. Streptomycin
27. Answer: C. Semi-fowlers position Option D: Streptomycin is an aminoglycoside and damage on the 8th cranial nerve
Option C: Semi-fowlers position will localize the spilled stomach contents in the (ototoxicity) is a common side effect of aminoglycosides.
lower part of the abdominal cavity. 42. Answer: D. Helicobacter pylori infection
28. Answer: C. Position client laterally with the neck extended Option D: Most peptic ulcer is caused by Helicobacter pylori which is a gram
Option C: Positioning the client laterally with the neck extended does not obstruct negative bacterium.
the airway so that drainage of secretions and oxygen and carbon dioxide exchange 43. Answer: D. Dark brown
can occur. Option D: 12 to 24 hours after subtotal gastrectomy gastric drainage is normally
29. Answer: B. Check the system for air leaks brown, which indicates digested food.
Option B: Excessive bubbling indicates an air leak which must be eliminated to 44. Answer: C. Watching TV
permit lung expansion. Option C: Watching TV is permissible because the eye does not need to move
30. Answer: C. I can eat shredded wheat cereal rapidly with this activity, and it does not increase intraocular pressure.
Option C: Wheat cereal has a low sodium content. 45. Answer: A. Fracture
31. Answer: A. Pressure in the portal vein Option A: Common signs and symptoms of fracture include pain, deformity,
Option A: Enlarged cirrhotic liver impinges the portal system causing increased shortening of the extremity, crepitus and swelling.
hydrostatic pressure resulting to ascites. 46. Answer: C. Pacing the tip of the dropper on the edge of ear canal
32. Answer: C. Airway Option C:
Option C: Assessing for an open airway is the priority. The procedure involves the 47. Answer: A. Absence of drainage from the ileostomy for 6 or more hours
neck, the anesthesia may have affected the swallowing reflex or the inflammation Option A: Sudden decrease in drainage or onset of severe abdominal pain should
may have closed in on the airway leading to ineffective air exchange. be reported immediately to the physician because it could mean that obstruction
33. Answer: A. Systolic blood pressure less than 90mm Hg has been developed.
Option A: Typical signs and symptoms of hypovolemic shock includes systolic 48. Answer: B. Peritonitis
blood pressure of less than 90 mm Hg. Option B: Complications of acute appendicitis are peritonitis, perforation and
34. Answer: D. Aspirin-containing medications should not be taken 14 days before abscess development.
surgery 49. Answer: D. Pneumonia
Option D: Aspirin-containing medications should not be taken 14 days before Option D: A client with acute pancreatitis is prone to complications associated
surgery to decrease the risk of bleeding. with respiratory system.
35. Answer: A. Regular insulin 50. Answer: B. Yellow sclera
Option B: Liver inflammation and obstruction block the normal flow of bile.
Excess bilirubin turns the skin and sclera yellow and the urine dark and frothy.
In Text Mode: All questions and answers are given for reading and answering at your own 8. Nurse Hazel receives emergency laboratory results for a client with chest pain and
pace. You can also copy this exam and make a printout. immediately informs the physician. An increased myoglobin level suggests which of
1. Marco who was diagnosed with brain tumor was scheduled for craniotomy. In the following?
preventing the development of cerebral edema after surgery, the nurse should A. Liver disease
expect the use of: B. Myocardial damage
A. Diuretics C. Hypertension
B. Antihypertensive D. Cancer
C. Steroids 9. Nurse Maureen would expect a client with mitral stenosis would demonstrate
D. Anticonvulsants symptoms associated with congestion in the:
2. Halfway through the administration of blood, the female client complains of A. Right atrium
lumbar pain. After stopping the infusion Nurse Hazel should: B. Superior vena cava
A. Increase the flow of normal saline C. Aorta
B. Assess the pain further D. Pulmonary
C. Notify the blood bank 10. A client has been diagnosed with hypertension. The nurse priority nursing
D. Obtain vital signs. diagnosis would be:
3. Nurse Maureen knows that the positive diagnosis of HIV infection is made based A. Ineffective health maintenance
on which of the following: B. Impaired skin integrity
A. A history of high-risk sexual behaviors. C. Deficient fluid volume
B. Positive ELISA and western blot tests D. Pain
C. Identification of an associated opportunistic infection 11. Nurse Hazel teaches the client with angina about common expected side effects
D. Evidence of extreme weight loss and high fever of nitroglycerin including:
4. Nurse Maureen is aware that a client who has been diagnosed with chronic renal A. high blood pressure
failure recognizes an adequate amount of high-biologic-value protein when the food B. stomach cramps
the client selected from the menu was: C. headache
A. Raw carrots D. shortness of breath
B. Apple juice 12. The following are lipid abnormalities. Which of the following is a risk factor for
C. Whole wheat bread the development of atherosclerosis and PVD?
D. Cottage cheese A. High levels of low-density lipid (LDL) cholesterol
5. Kenneth who was diagnosed with uremic syndrome has the potential to develop B. High levels of high-density lipid (HDL) cholesterol
complications. Which among the following complications should the nurse C. Low concentration triglycerides
anticipates: D. Low levels of LDL cholesterol.
A. Flapping hand tremors 13. Which of the following represents a significant risk immediately after surgery for
B. An elevated hematocrit level repair of aortic aneurysm?
C. Hypotension A. Potential wound infection
D. Hypokalemia B. Potential ineffective coping
6. A client is admitted to the hospital with benign prostatic hyperplasia, the nurse C. Potential electrolyte balance
most relevant assessment would be: D. Potential alteration in renal perfusion
A. Flank pain radiating in the groin 14. Nurse Josie should instruct the client to eat which of the following foods to obtain
B. Distention of the lower abdomen the best supply of Vitamin B12?
C. Perineal edema A. dairy products
D. Urethral discharge B. vegetables
7. A cli C. Grains
scrotum was edematous and painful. The nurse should: D. Broccoli
A. Assist the client with sitz bath 15. Karen has been diagnosed with aplastic anemia. The nurse monitors for changes
B. Apply war soaks in the scrotum in which of the following physiologic functions?
C. Elevate the scrotum using a soft support A. Bowel function
D. Prepare for a possible incision and drainage B. Peripheral sensation
C. Bleeding tendencies
D. Intake and output
16. Lydia is scheduled for elective splenectomy. Before the client goes to surgery, the 24. Patricia a 20-year-old college student with diabetes mellitus requests additional
nurse in charge final assessment would be: information about the advantages of using a pen-like insulin delivery devices. The
A. signed consent nurse explains that the advantages of these devices over syringes include:
B. vital signs A. Accurate dose delivery
C. name band B. Shorter injection time
D. empty bladder C. Lower cost with reusable insulin cartridges
17. What is the peak age range for acquiring acute lymphocytic leukemia (ALL)? D. Use of smaller gauge needle.
A. 4 to 12 years. 25.
B. 20 to 30 years applied. To assess for damage to major blood vessels from the fracture tibia, the
C. 40 to 50 years nurse in charge should monitor the client for:
D. 60 60 70 years A. Swelling of the left thigh
18. Marie with acute lymphocytic leukemia suffers from nausea and headache. These B. Increased skin temperature of the foot
clinical manifestations may indicate all of the following except: C. Prolonged reperfusion of the toes after blanching
A. effects of radiation D. Increased blood pressure
B. chemotherapy side effects 26. After a long leg cast is removed, the male client should:
C. meningeal irritation A. Cleanse the leg by scrubbing with a brisk motion
D. gastric distension B. Put leg through full range of motion twice daily
19. A client has been diagnosed with Disseminated Intravascular Coagulation (DIC). C. Report any discomfort or stiffness to the physician
Which of the following is contraindicated with the client? D. Elevate the leg when sitting for long periods of time.
A. Administering Heparin 27. While performing a physical assessment of a male client with gout of the great
B. Administering Coumadin toe, Nurse Vivian should assess for additional tophi (urate deposits) on the:
C. Treating the underlying cause A. Buttocks
D. Replacing depleted blood products B. Ears
20. Which of the following findings is the best indication that fluid replacement for C. Face
the client with hypovolemic shock is adequate? D. Abdomen
A. Urine output greater than 30ml/hr 28. Nurse Katrina would recognize that the demonstration of crutch walking with
B. Respiratory rate of 21 breaths/minute tripod gait was understood when the client places weight on the:
C. Diastolic blood pressure greater than 90 mmHg A. Palms of the hands and axillary regions
D. Systolic blood pressure greater than 110 mmHg B. Palms of the hand
21. Which of the following signs and symptoms would Nurse Maureen include in C. Axillary regions
teaching plan as an early manifestation of laryngeal cancer? D. Feet, which are set apart
A. Stomatitis 29. Mang Jose with rheumatoid arthritis
B. Airway obstruction
C. Hoarseness with Mang Jose should encourage:
D. Dysphagia A. Active joint flexion and extension
22. Karina a client with myasthenia gravis is to receive immunosuppressive therapy. B. Continued immobility until pain subsides
The nurse understands that this therapy is effective because it: C. Range of motion exercises twice daily
A. Promotes the removal of antibodies that impair the transmission of impulses D. Flexion exercises three times daily
B. Stimulates the production of acetylcholine at the neuromuscular junction. 30. A male client has undergone spinal surgery, the nurse should:
C. Decreases the production of autoantibodies that attack the acetylcholine receptors.
D. Inhibits the breakdown of acetylcholine at the neuromuscular junction. B. Log-roll the client to prone position
23. A female client is receiving IV Mannitol. An assessment specific to safe irculation
administration of the said drug is: D. Encourage client to drink plenty of fluids
A. Vital signs q4h 31. Marina with acute renal failure moves into the diuretic phase after one week of
B. Weighing daily therapy. During this phase the client must be assessed for signs of developing:
C. Urine output hourly A. Hypovolemia
D. Level of consciousness q4h B. renal failure
C. metabolic acidosis
D. hyperkalemia
32. Nurse Judith obtains a specimen of clear nasal drainage from a client with a head 40. A 65 year old female is experiencing flare-
injury. Which of the following tests differentiates mucus from cerebrospinal action could aggravate the cause of flare-ups?
fluid (CSF)? A. Sleeping in cool and humidified environment
A. Protein B. Daily baths with fragrant soap
B. Specific gravity C. Using clothes made from 100% cotton
C. Glucose D. Increasing fluid intake
D. Microorganism 41. Atropine sulfate (Atropine) is indicated in all but one of the following client?
33. A 22-year-old client suffered from his first tonic-clonic seizure. Upon awakening, A. A client with high blood
seizure? Which of the following B. A client with bowel obstruction
would the nurse include in the primary cause of tonic-clonic seizures in adults more C. A client with glaucoma
the 20 years? D. A client with U.T.I.
A. Electrolyte imbalance 42. Among the following clients, which among them is high risk for potential hazards
B. Head trauma from the surgical experience?
C. Epilepsy A. 67-year-old client
D. Congenital defect B. 49-year-old client
34. What is the priority nursing assessment in the first 24 hours after admission of C. 33-year-old client
the client with thrombotic CVA? D. 15-year-old client
A. Pupil size and pupillary response 43. Nurse Jon assesses vital signs on a client undergone epidural anesthesia. Which
B. cholesterol level of the following would the nurse assess next?
C. Echocardiogram A. Headache
D. Bowel sounds B. Bladder distension
35. Nurse Linda is preparing a client with multiple sclerosis for discharge from the C. Dizziness
hospital to home. Which of the following instruction is most appropriate? D. Ability to move legs
44. Nurse Katrina should anticipate that all of the following drugs may be used in the
isease except:
fatigue A. Antiemetics
D. B. Diuretics
36. The nurse is aware the early indicator of hypoxia in the unconscious client is: C. Antihistamines
A. Cyanosis D. Glucocorticoids
B. Increased respirations 45. Which of the following complications associated with tracheostomy tube?
C. Hypertension A. Increased cardiac output
D. Restlessness B. Acute respiratory distress syndrome (ARDS)
37. A client is experiencing spinal shock. Nurse Myrna should expect the function of C. Increased blood pressure
the bladder to be which of the following? D. Damage to laryngeal nerves
A. Normal 46. Nurse Faith should recognize that fluid shift in an client with burn injury results
B. Atonic from increase in the:
C. Spastic A. Total volume of circulating whole blood
D. Uncontrolled B. Total volume of intravascular plasma
38. Which of the following stage is the carcinogen irreversible? C. Permeability of capillary walls
A. Progression stage D. Permeability of kidney tubules
B. Initiation stage 47. An 83-year-old woman has several ecchymotic areas on her right arm. The
C. Regression stage bruises are probably caused by:
D. Promotion stage A. increased capillary fragility and permeability
39. Among the following components thorough pain assessment, which is the most B. increased blood supply to the skin
significant? C. self-inflicted injury
A. Effect D. elder abuse
B. Cause 48. Nurse Anna is aware that early adaptation of client with renal carcinoma is:
C. Causing factors A. nausea and vomiting
D. Intensity B. flank pain
C. weight gain impaired skin integrity. It is the asymptomatic nature of hypertension that makes
D. intermittent hematuria it so difficult to treat.
49. A male client with tuberculosis asks Nurse Brian how long 11. Answer: C. headache
the chemotherapy Option C: Because of its widespread vasodilating effects, nitroglycerin often
A. 1 to 3 weeks produces side effects such as headache, hypotension, and dizziness.
B. 6 to 12 months 12. Answer: A. High levels of low-density lipid (LDL) cholesterol
C. 3 to 5 months Option A: An increase in LDL cholesterol concentration has been documented at
D. 3 years and more risk factor for the development of atherosclerosis. LDL cholesterol is not broken
50. A client has undergone laryngectomy. The immediate nursing priority would be: down into the liver but is deposited into the wall of the blood vessels.
A. Keep trachea free of secretions 13. Answer: D. Potential alteration in renal perfusion
B. Monitor for signs of infection Option D: There is a potential alteration in renal perfusion manifested by
C. Provide emotional support decreased urine output. The altered renal perfusion may be related to
D. Promote means of communication renal artery embolism, prolonged hypotension, or prolonged aortic cross-
Answers and Rationale clamping during the surgery.
14. Answer: A. dairy products
Below are the answers and rationale for this examination. If you have any disputes or Option A: Good source of vitamin B12 are dairy products and meats.
clarifications needed, please comment below.
15. Answer: C. Bleeding tendencies
1. Answer: C. Steroids Option C:
Option C: Glucocorticoids (steroids) are used for their anti-inflammatory action, blood cells, and platelets. The client is at risk for bruising and bleeding tendencies.
which decreases the development of edema.
16. Answer: B. vital signs
2. Answer: A. Increase the flow of normal saline Option B: An elective procedure is scheduled in advance so that all preparations
Option A: The blood must be stopped at once, and then normal saline should be can be completed ahead of time. The vital signs are the final check that must be
infused to keep the line patent and maintain blood volume. completed before the client leaves the room so that continuity of care and
3. Answer: B. Positive ELISA and western blot tests assessment is provided for.
Option B: These tests confirm the presence of HIV antibodies that occur in 17. Answer: A. 4 to 12 years.
response to the presence of the human immunodeficiency virus (HIV). Option A: The peak incidence of Acute Lymphocytic Leukemia (ALL) is 4 years of
4. Answer: D. Cottage cheese age. It is uncommon after 15 years of age.
Option D: One cup of cottage cheese contains approximately 225 calories, 27 g of 18. Answer: D. gastric distension
protein, 9 g of fat, 30 mg cholesterol, and 6 g of carbohydrate. Proteins of high Option D: Acute Lymphocytic Leukemia (ALL) does not cause gastric distention. It
biologic value (HBV) contain optimal levels of amino acids essential for life. does invade the central nervous system, and clients experience headaches and
5. Answer: A. Flapping hand tremors vomiting from meningeal irritation.
Option A: Elevation of uremic waste products causes irritation of the nerves, 19. Answer: B. Administering Coumadin
resulting in flapping hand tremors. Option B: Disseminated Intravascular Coagulation (DIC) has not been found to
6. Answer: B. Distention of the lower abdomen
respond to oral anticoagulants such as Coumadin.
Option B: This indicates that the bladder is distended with urine, therefore 20. Answer: A. Urine output greater than 30ml/hr
palpable. Option A: U
7. Answer: C. Elevate the scrotum using a soft support
response to therapy for hypovolemic shock. Urine output should be consistently
Option C: Elevation increases lymphatic drainage, reducing edema and pain. greater than 30 to 35 mL/hr.
8. Answer: B. Myocardial damage 21. Answer: C. Hoarseness
Option B: Detection of myoglobin is a diagnostic tool to determine whether Option C: Early warning signs of laryngeal cancer can vary depending on tumor
myocardial damage has occurred. location. Hoarseness lasting 2 weeks should be evaluated because it is one of the
9. Answer: D. Pulmonary most common warning signs.
Option D: When mitral stenosis is present, the left atrium has difficulty emptying 22. Answer: C. Decreases the production of autoantibodies that attack the
its contents into the left ventricle because there is no valve to prevent backward acetylcholine receptors.
flow into the pulmonary vein, the pulmonary circulation is under pressure. Option C:
10. Answer: A. Ineffective health maintenance
production of antibodies that attack the acetylcholine receptors at the
Option A: Managing hypertension is the priority for the client with hypertension. neuromuscular junction
Clients with hypertension frequently do not experience pain, deficient volume, or
23. Answer: C. Urine output hourly
 Option C: The osmotic diuretic mannitol is contraindicated in the presence of Option B: In spinal shock, the bladder becomes completely atonic and will
inadequate renal function or heart failure because it increases the intravascular continue to fill unless the client is catheterized.
volume that must be filtered and excreted by the kidney. 38. Answer: A. Progression stage
24. Answer: A. Accurate dose delivery Option A: Progression stage is the change of tumor from the preneoplastic state or
Option A: These devices are more accurate because they are easy to use and have low degree of malignancy to a fast-growing tumor that cannot be reversed.
improved adherence to insulin regimens by young people because 39. Answer: D. Intensity
the medication can be administered discreetly. Option D: Intensity is the major indicative of severity of pain and it is important
25. Answer: C. Prolonged reperfusion of the toes after blanching for the evaluation of the treatment.
Option C: Damage to blood vessels may decrease the circulatory perfusion of the 40. Answer: B. Daily baths with fragrant soap
toes, this would indicate the lack of blood supply to the extremity. Option B: The use of fragrant soap is very drying to skin hence causing the
26. Answer: D. Elevate the leg when sitting for long periods of time. pruritus.
Option D: Elevation will help control the edema that usually occurs. 41. Answer: C. A client with glaucoma
27. Answer: B. Ears Option C: Atropine sulfate is contraindicated with glaucoma patients because it
Option B: Uric acid has a low solubility, it tends to precipitate and form deposits increases intraocular pressure.
at various sites where blood flow is least active, including cartilaginous tissue such 42. Answer: A. 67-year-old client
as the ears. Option A: A 67-year-old client is greater risk because the older adult client is more
28. Answer: B. Palms of the hand likely to have a less-effective immune system.
Option B: 43. Answer: B. Bladder distension
in the axilla. Option B: The last area to return sensation is in the perineal area, and the nurse in
29. Answer: A. Active joint flexion and extension charge should monitor the client for distended bladder.
Option A: Active exercises, alternating extension, flexion, abduction, and 44. Answer: D. Glucocorticoids
adduction, mobilize exudates in the joints relieves stiffness and pain. Option D: Glucocorticoids play no significant role in disease treatment.
30. Answer: C. 45. Answer: D. Damage to laryngeal nerves
Option C: Alteration in sensation and circulation indicates damage to the spinal Option D: Tracheostomy tube has several potential complications including
cord, if these occur, notify the physician immediately. bleeding, infection and laryngeal nerve damage.
31. Answer: A. Hypovolemia 46. Answer: C. Permeability of capillary walls
Option A: In the diuretic phase fluid retained during the oliguric phase is excreted Option C: In burn, the capillaries and small vessels dilate, and cell damage causes
and may reach 3 to 5 liters daily, hypovolemia may occur and fluids should be the release of a histamine-like substance. The substance causes the capillary walls
replaced. to become more permeable and significant quantities of fluid are lost.
32. Answer: C. Glucose 47. Answer: A. increased capillary fragility and permeability
Option C: The constituents of CSF are similar to those of blood plasma. An Option A: Aging process involves increased capillary fragility and permeability.
examination for glucose content is done to determine whether a body fluid is a Older adults have a decreased amount of subcutaneous fat and cause an increased
mucus or a CSF. A CSF normally contains glucose. incidence of bruise-like lesions caused by collection of extravascular blood in
33. Answer: B. Head trauma loosely structured dermis.
Option B: Trauma is one of the primary cause of brain damage and seizure activity 48. Answer: D. intermittent hematuria
in adults. Other common causes of seizure activity in adults include Option D: Intermittent pain is the classic sign of renal carcinoma. It is primarily
neoplasms, withdrawal from drugs and alcohol, and vascular disease. due to capillary erosion by the cancerous growth.
34. Answer: A. Pupil size and papillary response 49. Answer: B. 6 to 12 months
Option A: It is crucial to monitor the pupil size and pupillary response to indicate Option B: Tubercle bacillus is a drug-resistant organism and takes a long time to
changes around the cranial nerves. be eradicated. Usually a combination of three drugs is used for minimum of 6
35. Answer: C. months and at least six months beyond culture conversion.
Option C: The nurse most positive approach is to encourage the client with 50. Answer: A. Keep trachea free of secretions
multiple sclerosis to stay active, use stress reduction techniques and avoid fatigue Option A: Patent airway is the most priority; therefore removal of secretions is
because it is important to support the immune system while remaining active. necessary.
36. Answer: D. Restlessness 1. A client is scheduled for insertion of an inferior vena cava (IVC) filter. Nurse
Option D: Restlessness is an early indicator of hypoxia. The nurse should suspect Patricia consults the physician about withholding which regularly
hypoxia in unconscious client who suddenly becomes restless. scheduled medication on the day before the surgery?
37. Answer: B. Atonic A. Potassium Chloride
B. Warfarin Sodium
C. Furosemide A. Prevents ovulation
D. Docusate B. Has a mutagenic effect on ova
2. A nurse is planning to assess the corneal reflex on unconscious client. Which of the C. Decreases the effectiveness of oral contraceptives
following is the safest stimulus to touch D. Increases the risk of vaginal infection
A. Cotton buds 10. A client has undergone gastrectomy. Nurse Jovy is aware that the best position
B. Sterile glove for the client is:
C. Sterile tongue depressor A. Left side-lying
D. Wisp of cotton
3. A female client develops an infection at the catheter insertion site. The nurse in C. Prone
D. Supine
from: 11.
which of the following observations should be reported immediately to the
B. Therapeutic procedure physician?
C. Poor hygiene A. Stoma is dark red to purple
D. Inadequate dietary patterns B. Stoma oozes a small amount of blood
4. C. Stoma is slightly edematous
bradykinesia when the client exhibits: D. Stoma does not expel stool
A. Intentional tremor 12.
B. Paralysis of limbs bed rest with bathroom privileges. What is the rationale for this activity restriction?
C. Muscle spasm A. Prevent injury
D. Lack of spontaneous movement B. Promote rest and comfort
5. A client who suffered from automobile accident complains of seeing frequent C. Reduce intestinal peristalsis
flashes of light. The nurse should expect: D. Conserve energy
A. Myopia 13. total
B. Detached retina parenteral nutrition (TPN) solution adequately by monitoring the client for which of
C. Glaucoma the following signs:
D. Scleroderma A. Hyperglycemia
6. Kate with severe head injury is being monitored by the nurse for increasing B. Hypoglycemia
intracranial pressure (ICP). Which finding should be most indicative sign of C. Hypertension
increasing intracranial pressure? D. Elevate blood urea nitrogen concentration
A. Intermittent tachycardia 14. A female client has acute pancreatitis. Which of the following signs and
B. Polydipsia symptoms would the nurse expect to see?
C. Tachypnea A. Constipation
D. Increased restlessness B. Hypertension
7. A hospitalized client had a tonic-clonic seizure while walking down the hall. C. Ascites
During the seizure the nurse priority should be: D. Jaundice
15. A client is suspected to develop tetany after a subtotal thyroidectomy. Which of
B. Place the client immediately on soft surface the following symptoms might indicate tetany?
A. Tingling in the fingers
D. Attempt to insert a B. Pain in hands and feet
8. A client has undergone right pneumonectomy. When turning the client, the nurse C. Tension on the suture lines
should plan to position the client either: D. Bleeding on the back of the dressing
A. Right side-lying position or supine 16. A 58-year-old woman has newly diagnosed with hypothyroidism. The nurse is
aware that the signs and symptoms of hypothyroidism include:
C. Right or left side lying position A. Diarrhea
B. Vomiting
9. Nurse Jenny should caution a female client who is sexually active in C. Tachycardia
taking Isoniazid (INH) because the drug has which of the following side effects? D. Weight gain
17. A client has undergone an ileal conduit, the nurse in charge should closely
monitor the client for occurrence of which of the following complications related to
pelvic surgery? 25.
A. Ascites of the following findings is indicative of infection?
B. Thrombophlebitis A. Edema
C. Inguinal hernia B. Weak distal pulse
D. Peritonitis C. Coolness of the skin
18. Dr. Marquez is about to defibrillate a client in ventricular fibrillation and says in
26. Nurse Rhia is performing an otoscopic examination on a female client with a
suspected diagnosis of mastoiditis. Nurse Rhia would expect to note which of the
B. Turn off the mechanical ventilator following if this disorder is present?
C. IV infusion A. Transparent tympanic membrane
D. Steps away from the bed and make sure all others have done the same B. Thick and immobile tympanic membrane
19. A client has been diagnosed with glomerulonephritis complains of thirst. The C. Pearly colored tympanic membrane
nurse should offer: D. Mobile tympanic membrane
A. Juice 27. Nurse Jocelyn is caring for a client with nasogastric tube that is attached to low
B. Ginger ale suction. Nurse Jocelyn assesses the client for symptoms of which acid-base disorder?
C. Milkshake A. Respiratory alkalosis
D. Hard candy B. Respiratory acidosis
20. A client with acute renal failure is aware that the most serious complication of C. Metabolic acidosis
this condition is: D. Metabolic alkalosis
A. Constipation 28. A male adult client has undergone a lumbar puncture to obtain cerebrospinal
B. Anemia fluid (CSF) for analysis. Which of the following values should be negative if the CSF is
C. Infection normal?
D. Platelet dysfunction A. Red blood cells
21. Nurse Karen is caring for clients in the OR. The nurse is aware that the last B. White blood cells
physiologic function that the client loss during the induction of anesthesia is: C. Insulin
D. Protein
A. Consciousness 29. A client is suspected of developing diabetes insipidus. Which of the following is
B. Gag reflex the most effective assessment?
C. Respiratory movement A. Taking vital signs every 4 hours
D. Corneal reflex B. Monitoring blood glucose
22. The nurse is assessing a client with pleural effusion. The nurse expects to find: C. Assessing ABG values every other day
A. Deviation of the trachea towards the involved side D. Measuring urine output hourly
B. Reduced or absent of breath sounds at the base of the lung 30. A 58-year-old client is suffering from acute phase of rheumatoid arthritis. Which
C. Moist crackles at the posterior of the lungs of the following would the nurse in charge identify as the lowest priority of the plan
D. Increased resonance with percussion of the involved area of care?
23. A clie A. Prevent joint deformity
following would the nurse expect the client to report? B. Maintaining usual ways of accomplishing task
A. Lymph node pain C. Relieving pain
B. Weight gain D. Preserving joint function
C. Night sweats 31. Among the following, which client is autotransfusion possible?
D. Headache A. Client with AIDS
24. A client has suffered from fall and sustained a leg injury. Which appropriate B. Client with ruptured bowel
question would the nurse ask the client to help determine if the injury C. Client who is in danger of cardiac arrest
caused fracture? D. Client with wound infection
32. Which of the following is not a sign of thromboembolism?
A. Edema
B. Swelling
C. Redness C. Exercise twice a day
D. Coolness D. Place hand on the abdomen and feel it rise
33. Nurse Becky is caring for client who begins to experience seizure while in bed. 41. Louie, with burns over 35% of the body, complains of chilling. In promoting the
Which action should the nurse implement to prevent aspiration?
A. Position the client on the side with head flexed forward A. Maintain room humidity below 40%
B. Elevate the head B. Place top sheet on the client
C. Use tongue depressor between teeth C. Limit the occurrence of drafts
D. Loosen restrictive clothing D. Keep room temperature at 80 degrees
34. A client has undergone bone biopsy. Which nursing action should the nurse 42. Nurse Trish is aware that temporary heterograft (pig skin) is used to
provide after the procedure? treat burns because this graft will:
A. Administer analgesics via IM A. Relieve pain and promote rapid epithelialization
B. Monitor vital signs B. Be sutured in place for better adherence
C. Monitor the site for bleeding, swelling and hematoma formation C. Debride necrotic epithelium
D. Keep area in neutral position D. Concurrently used with topical antimicrobials
35. A client is suffering from low back pain. Which of the following exercises will 43. Mark has multiple abrasions and a laceration to the trunk and all four
strengthen the lower back muscle of the client?
A. Tennis be eaten first should be:
B. Basketball A. Meatloaf and coffee
C. Diving B. Meatloaf and strawberries
D. Swimming C. Tomato soup and apple pie
36. A client with peptic ulcer is being assessed by the nurse for gastrointestinal D. Tomato soup and buttered bread
perforation. The nurse should monitor for: 44. Tony returns from surgery with permanent colostomy. During the first 24 hours,
A. (+) guaiac stool test the colostomy does not drain. The nurse should be aware that:
B. Slow, strong pulse A. Proper functioning of nasogastric suction
C. Sudden, severe abdominal pain B. Presurgical decrease in fluid intake
D. Increased bowel sounds C. Absence of gastrointestinal motility
37. A client has undergone surgery for retinal detachment. Which of the following D. Intestinal edema following surgery
goal should be prioritized? 45. When teaching a client about the signs of colorectal cancer, Nurse Trish stresses
A. Prevent an increase intraocular pressure that the most common complaint of persons with colorectal cancer is:
B. Alleviate pain A. Abdominal pain
C. Maintain darkened room B. Hemorrhoids
D. Promote low-sodium diet C. Change in caliber of stools
38. A Client with glaucoma has been prescribed with miotics. The nurse is aware that D. Change in bowel habits
miotics is for: 46. Louis develops peritonitis and sepsis after surgical repair of ruptured
A. Constricting pupil diverticulum. The nurse in charge should expect an assessment of the client to
B. Relaxing ciliary muscle reveal:
C. Constricting intraocular vessel A. Tachycardia
D. Paralyzing ciliary muscle B. Abdominal rigidity
39. When suctioning an unconscious client, which nursing intervention should the C. Bradycardia
nurse prioritize in maintaining cerebral perfusion? D. Increased bowel sounds
A. Administer diuretics 47. Immediately after liver biopsy, the client is placed on the right side, the nurse is
B. Administer analgesics aware that this position should be maintained because it will:
C. Provide hygiene A. Help stop bleeding if any occurs
D. Hyperoxygenate before and after suctioning B. Reduce the fluid trapped in the biliary ducts
40. When discussing breathing exercises with a postoperative client, Nurse Hazel C. Position with greatest comfort
should include which of the following teaching? D. Promote circulating blood volume
A. Short frequent breaths 48. Tony was diagnosed with hepatitis A. The information from the health history
B. Exhale with mouth open that is most likely linked to hepatitis A is:
A. Exposed with arsenic compounds at work Option C: Isoniazid (INH) interferes in the effectiveness of oral contraceptives and
B. Working as local plumber clients of childbearing age should be counseled to use an alternative form of birth
C. Working at hemodialysis clinic control while taking this drug.
D. Dishwasher in restaurants 10. Answer: B.
49. Nurse Trish is aware that the laboratory test result that most likely would Option B: A client who has had abdominal surgery is best placed in a
indicate acute pancreatitis is an elevated: low position. This relaxes abdominal muscles and provides maximum
A. Serum bilirubin level respiratory and cardiovascular function.
B. Serum amylase level 11. Answer: A. Stoma is dark red to purple
C. Potassium level Option A: Dark red to purple stoma indicates inadequate blood supply.
D. Sodium level 12. Answer: C. Reduce intestinal peristalsis
50. Dr. Marquez orders serum electrolytes. To determine the effect of persistent Option C: The rationale for activity restriction is to help reduce the hypermotility
vomiting, Nurse Trish should be most concerned with monitoring the: of the colon.
A. Chloride and sodium levels 13. Answer: A. Hyperglycemia
B. Phosphate and calcium levels Option A: During Total Parenteral Nutrition (TPN) administration, the client
C. Protein and magnesium levels should be monitored regularly for hyperglycemia.
D. Sulfate and bicarbonate levels 14. Answer: D. Jaundice
Answers and Rationale Option D: Jaundice may be present in acute pancreatitis owing to obstruction of
the biliary duct.
Here are the answers and rationale for this exam. Counter check your answers to those 15. Answer: A. Tingling in the fingers
below and tell us your scores. If you have any disputes or need more clarification to a
Option A: Tetany may occur after thyroidectomy if the parathyroid glands are
certain question, please direct them to the comments section. accidentally injured or removed.
1. Answer: B. Warfarin Sodium 16. Answer: D. Weight gain
Option B: In preoperative period, the nurse should consult with the physician Option D: Typical signs of hypothyroidism include weight gain, fatigue, decreased
about withholding Warfarin Sodium to avoid occurrence of hemorrhage. energy, apathy, brittle nails, dry skin, cold intolerance, constipation, and
2. Answer: D. Wisp of cotton numbness.
Option D: A client who is unconscious is at greater risk for corneal abrasion. For 17. Answer: B. Thrombophlebitis
this reason, the safest way to test the corneal reflex is by touching the cornea Option B: After a pelvic surgery, there is an increased chance of thrombophlebitis
lightly with a wisp of cotton. owing to the pelvic manipulation that can interfere with circulation and promote
3. Answer: B. Therapeutic procedure venous stasis.
Option B: Iatrogenic infection is caused by the health care provider or is induced 18. Answer: D. Steps away from the bed and make sure all others have done the same
inadvertently by medical treatment or procedures. Option D: For the safety of all personnel, if the defibrillator paddles are being
4. Answer: D. Lack of spontaneous movement discharged, all personnel must stand back and be clear of all the contact with the
Option D: Bradykinesia is slowing down from the initiation and execution of
movement.
19. Answer: D. Hard candy
5. Answer: B. Detached retina Option D: Hard candy will relieve thirst and increase carbohydrates but does not
Option B: This symptom is caused by stimulation of retinal cells by ocular supply extra fluid.
movement.
20. Answer: C. Infection
6. Answer: D. Increased restlessness Option C: Infection is responsible for one-third of the traumatic or surgically
Option D: Restlessness indicates a lack of oxygen to the brain stem which impairs induced death of clients with renal failure as well as medical induced acute renal
the reticular activating system. failure (ARF)
7. Answer: C. Protect 21. Answer: C. Respiratory movement
Option D: Rhythmic contraction and relaxation associated with tonic-clonic Option C: There is no respiratory movement in stage 4 of anesthesia, prior to this
seizure can cause repeated banging of head. stage, respiration is depressed but present.
8. Answer: A. Right side-lying position or supine 22. Answer: B. Reduced or absent of breath sounds at the base of the lung
Option A: Right side-lying position or supine position permits ventilation of the Option B: Compression of the lung by fluid that accumulates at the base of the
remaining lung and prevent fluid from draining into sutured bronchial stump.
lungs reduces expansion and air exchange.
9. Answer: C. Decreases the effectiveness of oral contraceptives 23. Answer: C. Night sweats
Option C:
enlarged, painless lymph node, fever, malaise and night sweats.
24. Answer: A. Option D: It is a priority to hyperoxygenate the client before and after suctioning
Option A: Fractured pain is generally described as sharp, continuous, and to prevent hypoxia and to maintain cerebral perfusion.
increasing in frequency. 40. Answer: D. Place hand on the abdomen and feel it rise
25. Answer: D. Option D: Abdominal breathing improves lungs expansion
Option D: Signs and symptoms of infection under a casted area include odor or 41. Answer: C. Limit the occurrence of drafts
Option C: A Client with burns is very sensitive to temperature changes because
are warmer than the others. heat is lost in the burn areas.
26. Answer: B. Thick and immobile tympanic membrane 42. Answer: A. Relieve pain and promote rapid epithelialization
Option B: Otoscopic examination in a client with mastoiditis reveals a dull, red, Option A: The graft covers the nerve endings, which reduces pain and provides
thick and immobile tympanic membrane with or without perforation. framework for granulation
27. Answer: D. Metabolic alkalosis 43. Answer: B. Meatloaf and strawberries
Option D: Loss of gastric fluid via nasogastric suction or vomiting causes Option B: Meat provides proteins and the fruit proteins vitamin C that both
metabolic alkalosis because of the loss of hydrochloric acid which is a potent acid promote wound healing.
in the body. 44. Answer: C. Absence of gastrointestinal motility
28. Answer: A. Red blood cells Option C: This is primarily caused by the trauma of intestinal manipulation and
Option A: The adult with normal cerebrospinal fluid has no red blood cells. the depressive effects anesthetics and analgesics.
29. Answer: D. Measuring urine output hourly 45. Answer: D. Change in bowel habits
Option D: Measuring the urine output to detect excess amount and checking the Option D: Constipation, diarrhea, and/or constipation alternating
specific gravity of urine samples to determine urine concentration are appropriate with diarrhea are the most common symptoms of colorectal cancer.
measures to determine the onset of diabetes insipidus. 46. Answer: B. Abdominal rigidity
30. Answer: B. Maintaining usual ways of accomplishing task Option B: With increased intraabdominal pressure, the abdominal wall will
Option B: The nurse should focus more on developing less stressful ways of become tender and rigid.
accomplishing routine task. 47. Answer: A. Help stop bleeding if any occurs
31. Answer: C. Client who is in danger of cardiac arrest Option A: Pressure applied in the puncture site indicates that a biliary vessel was
Option C: Autotransfusion is acceptable for the client who is in danger of cardiac puncture which is a common complication after liver biopsy.
arrest. 48. Answer: B. Working as local plumber
32. Answer: D. Coolness Option B: Hepatitis A is primarily spread via fecal-oral route. Sewage polluted
Option D: The client with thromboembolism does not have coolness. water may harbor the virus.
33. Answer: A. Position the client on the side with head flexed forward 49. Answer: B. Serum amylase level
Option A: Positioning the client on one side with head flexed forward allows the Option B: Amylase concentration is high in the pancreas and is elevated in the
tongue to fall forward and facilitates drainage secretions, therefore, prevents serum when the pancreas becomes acutely inflamed and also it distinguishes
aspiration. pancreatitis from other acute abdominal problems.
34. Answer: C. Monitor the site for bleeding, swelling and hematoma formation 50. Answer: A. Chloride and sodium levels
Option C: Nursing care after bone biopsy includes close monitoring of the Option A: Sodium, which is concerned with the regulation of extracellular fluid
punctured site for bleeding, swelling and hematoma formation. volume, it is lost with vomiting. Chloride, which balances cations in the
35. Answer: D. Swimming extracellular compartments, is also lost with vomiting, because sodium and
Option D: Walking and swimming are very helpful in strengthening back muscles chloride are parallel electrolytes, hyponatremia will accompany.
for the client suffering from lower back pain. In Text Mode: All questions and answers are given for reading and answering at your own
36. Answer: C. Sudden, severe abdominal pain pace. You can also copy this exam and make a printout.
Option C: Sudden, severe abdominal pain is the most indicative sign of Mr. Duffy is admitted to the CCU with a diagnosis of R/O MI. He presented in the ER
perforation. When perforation of an ulcer occurs, the nurse maybe unable to hear with a typical description of pain associated with an MI, and is now cold and clammy,
bowel sounds at all. pale and dyspneic. He has an IV of D5W running, and is complaining of chest pain.
37. Answer: A. Prevent an increased intraocular pressure Oxygen therapy has not been started, and he is not on the monitor. He is frightened.
Option A: After surgery to correct a detached retina, prevention of increased 1. The nurse is aware of several important tasks that should all be done immediately
intraocular pressure is the priority goal. in order to give Mr. Duffy the care he needs. Which of the following nursing
38. Answer: A. Constricting pupil interventions will relieve his current myocardial ischemia?
Option A: Miotic agent constricts the pupil and contracts ciliary muscle. These A. Stool softeners, rest
effects widen the filtration angle and permit increased outflow of aqueous humor. B. O2 therapy, analgesia
39. Answer: D. Hyperoxygenate before and after suctioning
C. Reassurance, cardiac monitoring C. A pterygium, which will interfere with vision.
D. Adequate fluid intake, low-fat diet D. Ciliary flush caused by congestion of the ciliary artery.
2. During the first three days that Mr. Duffy is in the CCU, a number of 9. You know that all but one of the following may eventually result in uremia. Which
diagnostic blood tests are obtained. Which of the following patterns of cardiac option is not implicated?
enzyme elevation are most common following an MI? A. glomerular disease
A. SGOT, CK, and LDH are all elevated immediately. B. uncontrolled hypertension
B. SGOT rises 4-6 hours after infarction with CK and LDH rising slowly 24 hours later. C. renal disease secondary to drugs, toxins, infections, or radiations
C. CK peaks first (12-24 hours), followed by the SGOT (peaks in 24-36 hours) and then the D. all of the above
LDH (peaks 3-4 days). 10. You did the initial assessment on Mr. Kaplan when he came to your unit. What
D. CK peaks first and remains elevated for 1 to 2 weeks. classical signs and symptoms did you note?
3. On his second day in CCU, Mr. Duffy suffers a life-threatening cardiac arrhythmia. A. fruity-smelling breath.
Considering his diagnosis, which is the most probable arrhythmia? B. Weakness, anorexia, pruritus
A. atrial tachycardia C. Polyuria, polydipsia, polyphagia
B. ventricular fibrillation D. Ruddy complexion
C. atrial fibrillation 11. Numerous drugs have been used on Mr. Kaplan in an attempt to stabilize him.
D. heart block Regarding his diagnosis and management of his drugs, you know that:
4. Mr. Duffy is placed on digitalis on discharge from the hospital. The nurse planning A. The half-life of many drugs is decreased in uremia; thus dosage may have to be increased
with him for his discharge should educate him as to the purpose and actions of his to be effective.
new medication. What should she or he teach Mr. Duffy to do at home to monitor his B. Drug toxicity is a major concern in uremia; individualization of therapy and often a
reaction to this medication? decrease in dose is essential.
A. take his blood pressure C. Drug therapy is not usually affected by this diagnosis
B. take his radial pulse for one minute D. Precautions should be taken with prescription drugs, but most OTC medications are safe
C. check his serum potassium (K) level for him to use.
D. weigh himself every day 12. The point of maximal impulse (PMI) is an important landmark in the cardiac
5. You decide to discuss glaucoma prevention. Which of the following diagnostic tests exam. Which statement best describes the location of the PMI in the healthy adult?
should these clients request from their care provider? A. Base of the heart, 5th intercostal space, 7-9 cm to the left of the midsternal line.
A. fluorescein stain B. Base of the heart, 7th intercostal space, 7-9 cm to the left of the midsternal line.
C. Apex of the heart, intercostal space, 7-9 cm to the left of the midsternal line.
C. tonometry D. Apex of the heart, intercostal space, 7-9 cm to the left of the midsternal line.
D. slit lamp 13. During the physical examination of the well adult client, the health care provider
6. You also explain common eye changes associated with aging. One of these is auscultates the heart. When the stethoscope is placed on the 5th intercostal space
presbyopia, which is: along the left sternal border, which valve closure is best evaluated?
A. Refractive error that prevents light rays from coming to a single focus on the retina. A. Tricuspid
B. Poor distant vision B. Pulmonic
C. Poor near vision C. Aortic
D. A gradual lessening of the power of accommodation D. Mitral
7. Some of the diabetic clients are interested in understanding what is visualized 14. The pulmonic component of which heart sound is best heard at the 2nd LICS at
during funduscopic examination. During your discussion, you describe the macular the LSB?
area as: A. S1
A. Head of the optic nerve, seen on the nasal side of the field, lighter in color than the retina. B. S2
B. The area of central vision, seen on the temporal side of the optic disc, which is quite C. S3
avascular. D. S4
C. Area where the central retinal artery and vein appear on the retina. 15. The coronary arteries furnish blood supply to the myocardium. Which of the
D. Reddish orange in color, sometimes stippled. following is a true statement relative to the coronary circulation?
8. One of the clients has noted a raised yellow plaque on the nasal side of the A. the right and left coronary arteries are the first of many branches off the ascending aorta
conjunctiva. You explain that this is called: B. blood enters the right and left coronary arteries during systole only
A. A pinguecula, which is normal slightly raised fatty structure under the conjunctiva that C. the right coronary artery forms almost a complete circle around the heart, yet supplies
may gradually increase with age. only the right ventricle
B. Icterus, which may be due to liver disease.
D. the left coronary artery has two main branches, the left anterior descending and left C. Decortication: removal of the ribs or sections of ribs
circumflex: both supply the left ventricle D. Thoracoplasty: removal of fibrous membrane that develops over visceral pleura as a
Sally Baker, a 40-year-old woman, is admitted to the hospital with an established result of emphysema
diagnosis of mitral stenosis. She is scheduled for surgery to repair her mitral valve. Mr. Liberatore, age 76, is admitted to your unit. He has a past medical history of
16. Ms. Baker has decided to have surgical correction of her stenosed valve at this hypertension, DM, hyperlipidemia. Recently he has had several episodes where he
time because her subjective complaints of dyspnea, hemoptysis, orthopnea, and stops talking mid-sentence and stares into space. Today the episode lasted for 15
paroxysmal nocturnal dyspnea have become unmanageable. These complaints are minutes. The admission diagnosis is impending CVA.
probably due to: 23. The episodes Mr. Liberatore has been experiencing are probably:
A. thickening of the pericardium A. small cerebral hemorrhages
B. right heart failure
C. pulmonary hypertension C. Secondary to hypoglycemia
D. left ventricular hypertrophy D. Secondary to hyperglycemia
17. On physical exam of Ms. Baker, several abnormal findings can be observed. 24. Mr. Liberatore suffers a left-sided CVA. He is right-handed. The nurse should
Which of the following is not one of the usual objective findings associated with expect:
mitral stenosis? A. left-sided paralysis
A. low-pitched rumbling diastolic murmur, precordial thrill, and parasternal lift B. visual loss
B. small crepitant rales at the bases of the lungs C. no alterations in speech
C. weak, irregular pulse, and peripheral and facial cyanosis in severe disease D. no impairment of bladder function
D. chest x-ray shows left ventricular hypertrophy 25. Upper motor neuron disease may be manifested in which of the following clinical
18. You are seeing more clients with diagnoses of mitral valve prolapse. You know signs?
those mitral valve prolapse is usually a benign cardiac condition, but may be A. spastic paralysis, hyperreflexia, presence of Babinski reflex
associated with atypical chest pain. This chest pain is probably caused by: B. flaccid paralysis, hyporeflexia
A. ventricular ischemia C. muscle atrophy, fasciculations
B. dysfunction of the left ventricle D. decreased or absent voluntary movement
C. papillary muscle ischemia and dysfunction 26. During your assessment of Julie, she tells you all visual symptoms are gone but
D. cardiac arrhythmias that she now has a severe pounding headache over her left eye. You suspect Julie
19. The most common lethal cancer in males between their fifth and seventh decades may have:
is: A. a tension headache
A. cancer of the prostate B. the aura and headache of migraine
B. cancer of the lung C. a brain tumor
C. cancer of the pancreas D. a conversion reaction
D. cancer of the bowel 27. You explain to Julie and her mother that migraine headaches are caused by:
20. Of the four basic cell types of lung cancer listed below, which is always associated A. an allergic response triggered by stress
with smoking? B. dilation of cerebral arteries
A. adenocarcinoma C. persistent contraction of the muscles of the head, neck, and face
B. squamous cell carcinoma (epidermoid) D. increased intracranial pressure
C. undifferentiated carcinoma 28. A thorough history reveals that hormonal changes associated
D. bronchoalveolar carcinoma with menstruation
21. Chemotherapy may be used in combination with surgery in the treatment of lung history what factors would be least significant in migraine?
cancer. Special nursing considerations with chemotherapy include all but which of A. seasonal allergies
the following? B. trigger foods such as alcohol, MSG, chocolate
A. Helping the client deal with depression secondary to the diagnosis and its treatment C. family history of migraine
B. Explaining that the reactions to chemotherapy are minimal D. warning sign of onset, or aura
C. Careful observation of the IV site of the administration of the drugs 29. A client with muscle contraction headache will exhibit a pattern different for
D. Careful attention to blood count results
22. Which of the following operative procedures of the thorax is paired with the A. severe aching pain behind both eyes
correct definition? B. headache worse when bending over
A. Pneumonectomy: removal of the entire lung C. a bandlike burning around the neck
B. Wedge resection: removal of one or more lobes of a lung D. feeling of tightness bitemporally, occipitally, or in the neck
Mr. Snyder is admitted to your unit with a brain tumor. The type of tumor he has is C. because she is probably overweight and will be less willing to breathe, cough, and move
currently unknown. You begin to think about the way brain tumors are classified. postoperatively
30. Glioma is an intracranial tumor. Which of the following statements about gliomas
do you know to be false? pain in her right scapular area and thinks she slept in poor position. While doing
A. 50% of all intracranial tumors are gliomas the pre-op checklist, you note that on her routine CB report, her WBC is 15,000. Your
B. gliomas are usually benign responsibility at this point is:
C. they grow rapidly and often cannot be totally excised from the surrounding tissue A. to notify the surgeon at once; this is an elevated WBC indicating an inflammatory
D. most glioma victims die within a year after diagnosis reaction
31. Acoustic neuromas produce symptoms of progressive nerve deafness, tinnitus, B. to record this finding in a prominent place on the pre-op checklist and in your preop
and vertigo due to pressure and eventual destruction of: notes
A. CN5 C. to call the laboratory for a STAT repeat WBC
B. CN7 D. None. This is not an unusual finding
C. CN8 38. Mrs. Hogan is scheduled for surgery 2 days later and is to be given atropine 0.3
D. The ossicles mg IM and Demerol 50 mg IM one hour preoperatively. Which nursing actions follow
the giving of the pre op medication?
increased intracranial pressure. Signs and symptoms of increasing intracranial A. have her void soon after receiving the medication
pressure may include all of the following except: B. allow her family to be with her before the medication takes effect
A. headache, nausea, and vomiting C. bring her valuables to the nursing station
B. papilledema, dizziness, mental status changes D. reinforce pre op teaching
C. obvious motor deficits 39. Mrs. Hogan is transported to the recovery room following her cholecystectomy.
D. increased pulse rate, drop in blood pressure
33. Mr. Snyder is scheduled for surgery in the morning, and you are surprised to find status: her BP is gradually dropping and her pulse rate is increasing. Your most
out that there is no order for an enema. You assess the situation and conclude that appropriate nursing action is to:
the reason for this is: A. order whole blood for Mrs. Hogan from the lab
A. Mr. Snyder has had some mental changes due to the tumor and would find an enema B. increase IV fluid rate of infusion and place in trendelenburg position
terribly traumatic C. immediately report signs of shock to the head nurse and/or surgeon and monitor VS
B. Straining to evacuate the enema might increase the intracranial pressure closely
C. Mr. Snyder had been on clear liquids and then was NPO for several days, so an enema is D. place in lateral sims position to facilitate breathing
not necessary 40. Mrs. Hogan returns to your clinical unit following discharge from the recovery
D. An oversight and you call the physician to obtain the order room. Her vital signs are stable and her family is with her. Postoperative leg
34. Postoperatively Mr. Snyder needs vigilant nursing care including all of the exercises should be initiated:
following except: A. after the physician writes the order
A. Keeping his head flat B. after the family leaves
B. Assessments q ½ hour of LOC, VS, pupillary responses, and mental status C. if Mrs. Hogan will not be ambulated early
C. Helping him avoid straining at stool, vomiting, or coughing D. stat
D. Providing a caring, supportive atmosphere for him and his family 41. An oropharyngeal airway may:
35. Potential post intracranial surgery problems include all but which of the A. Not be used in a conscious patient.
following? B. Cause airway obstruction.
A. increased ICP C. Prevent a patient from biting and occluding an ET tube.
B. extracranial hemorrhage mouth opening and then rotated into the proper
C. seizures orientation as it is advanced into the mouth.
D. leakage of cerebrospinal fluid E. All of the above.
Mrs. Hogan, a 43-year-old woman, is admitted to your unit for cholecystectomy. 42. Endotracheal intubation:
36. You are responsible for teaching Mrs. Hogan deep breathing and coughing A. Can be attempted for up to 2 minutes before you need to stop and ventilate the patient.
exercises. Why are these exercises especially important for Mrs. Hogan? B. Reduces the risk of aspiration of gastric contents.
A. they prevent postoperative atelectasis and pneumonia C. Should be performed with the neck flexed forward making the chin touch the chest.
B. the incision in gallbladder surgery is in the subcostal area, which makes the client D. Should be performed after a patient is found to be not breathing and two breaths have
reluctant to take a deep breath and cough been given but before checking for a pulse.
43. When giving bag-valve mask ventilations:
A. Rapid and forceful ventilations are desirable so that adequate ventilation will be assured 2. Answer: C. CK peaks first (12-24 hours), followed by the SGOT (peaks in 24-36
B. Effective ventilations can always be given by one person. hours) and then the LDH (peaks 3-4 days).
C. Cricoid pressure may prevent gastric inflation during ventilations. Option C: Although the timing of initial elevation, peak elevation, and duration of
D. Tidal volumes will always be larger than when giving mouth to pocket mask ventilations. elevation vary with sources, current literature favors option letter c.
44. If breath sounds are only heard on the right side after intubation: 3. Answer: B. ventricular fibrillation
A. Extubate, ventilate for 30 seconds then try again. Option B: Ventricular irritability is common in the early post-MI period, which
B. The patient probably only has one lung, the right. predisposes the client to ventricular arrhythmias.
C. You have intubated the stomach. Options C and D: Heart block and atrial arrhythmias may also be seen post-MI but
D. Pull the tube back and listen again. ventricular arrhythmias are more common.
45. An esophageal obturator airway (EOA): 4. Answer: B. take his radial pulse for one minute
A. Can be inserted by any person trained in ACLS. Option B: All options have some validity. However, option B relates best to the
B. Requires visualization of the trachea before insertion. action of digitalis. If the pulse rate drops below 60 or is markedly irregular, the
C. Never causes regurgitation. digitalis should be held and the physician consulted.
D. Should not be used with a conscious person, pediatric patients, or patients who have Option A: Blood pressure measurement is also helpful; providing the client has
swallowed caustic substances. the right size cuff and he or she and/or significant other understand the technique
46. During an acute myocardial infarct (MI): and can interpret the results meaningfully.
A. A patient may have a normal appearing ECG. Option C: Serum potassium levels should be monitored periodically in clients on
B. Chest pain will always be present. digitalis and diuretics, as potassium balance is essential for prevention of
C. A targeted history is rarely useful in making the diagnosis of MI. arrhythmias. However, the client cannot do this at home.
D. The chest pain is rarely described as crushing, pressing, or heavy. Option D: Daily weights may make the client alert to fluid accumulation, an early
47. The most common lethal arrhythmia in the first hour of an MI is: sign of CHF.
A. Pulseless Ventricular Tachycardia 5. Answer: C. tonometry
B. Asystole Option A: This is most often used to detect corneal lesions;
C. Ventricular fibrillation Option B: This is a test for visual acuity;
D. First-degree heart block. Option D: This is used to focus on layers of the cornea and lens looking for
48. Which of the following is true about verapamil? opacities and inflammation.
A. It is used for wide-complex tachycardia. 6. Answer: D. A gradual lessening of the power of accommodation
B. It may cause a drop in blood pressure. Option A: This defines astigmatism.
C. It is a first line drug for Pulseless Electrical Activity. Option B: This defines myopia.
D. It is useful for treatment of severe hypotension. Option C: This defines hyperopia.
49. Atropine: 7. Answer: B. The area of central vision, seen on the temporal side of the optic disc,
A. Is always given for a heart rate less than 60 bpm. which is quite avascular.
B. Cannot be given via ET tube. Options A and C: These refer to the optic disc.
C. Has a maximum total dosage of 0.03-0.04 mg/kg IV in the setting of cardiac arrest. Option D: This describes the color of the retina.
D. When given IV, should always be given slowly. 8. Answer: A. A pinguecula, which is normal slightly raised fatty structure under the
conjunctiva that may gradually increase with age.
A. True Option A: Correct by definition.
B. False 9. Answer: D. all of the above
C. Partially False Options A, B and C: These are potential causes of renal damage and eventually
D. Partially True renal failure. Individuals can live very well with only one healthy kidney.
Answers and Rationale 10. Answer: B. Weakness, anorexia, pruritus
Option B: Weakness and anorexia are due to progressive renal damage; pruritus
Here are the answers and rationale for this exam. Counter check your answers to those is secondary to presence of urea in the perspiration.
below and tell us your scores. If you have any disputes or need more clarification on a Option A: Fruity-smelling breath is found in diabetic ketoacidosis.
certain question, please direct them to the comments section. Option C: Polyuria, polydipsia, polyphagia are signs of DM and early diabetic
1. Answer: B. O2 therapy, analgesia
ketoacidosis. Oliguria is seen in chronic renal failure.
Option B: All the nursing interventions listed are important in the care of Mr. Option D: The skin is more sallow or brown as renal failure continues.
Duffy. However, relief of his pain will be best achieved by increasing the O2
11. Answer: B. Drug toxicity is a major concern in uremia; individualization of
content of the blood to his heart and relieving the spasm of coronary vessels. therapy and often a decrease in dose is essential.
 Option B: Metabolic changes and alterations in excretion put the client with Option B: Wedge resection is the removal of part of a segment of the lung.
uremia at risk for development of toxicity to any drug. Thus alteration in drug Option C: Decortication is the removal of a fibrous membrane that develops over
schedule and dosage is necessary for safe care. the visceral pleura.
12. Answer: C. Apex of the heart, intercostal space, 7-9 cm to the left of the Option D: Thoracoplasty is the removal of ribs or sections of ribs.
midsternal line. 23. Answer:
Option C: The PMI is the impulse at the apex of the heart caused by the beginning Option B: A TIA is a temporary reduction in blood flow to the brain, manifesting
of ventricular systole. It is generally located in the 5th left ICS, 7-9 cm from the itself in symptoms like those Mr. Liberatore experiences.
MSL or at, or just medial to, the MCL. Options C and D: Although hypoglycemia and hyperglycemia can cause some
13. Answer: A. Tricuspid drowsiness and/or disorientation, the episodes Mr. Liberatore experiences fit the
Option A: The sound created by closure of the tricuspid valve is heard at the 5th pattern of TIA because of his quick recovery with no sequelae and no treatment.
LICS at the LSB. 24. Answer: B. visual loss
Option B: Pulmonic closure is best heard at the 2nd LICS, LSB. Option B: Visual field loss is a common side effect of CVA. In right-handed persons
Option C: Aortic closure is best heard at the 2nd RICS, RSB.
Option D: Mitral valve closure is best heard at the PMI landmark (apex) Option A: Because of the crossover of the motor fibers, a CVA in the left brain will
14. Answer: B. S2 produce a right-sided hemiplegia.
Option A: S1 is caused by mitral and tricuspid valve closure; Option C: Thus, Mr. Liberatore will probably have some speech disturbance and
Option B: S2 is caused by the aortic and pulmonic valve closure; right-sided paralysis.
Options C and D: S3 and S4 are generally considered abnormal heart sounds in Option D: Often bladder control is diminished following CVA.
adults and are best heard at the apex. 25. Answer: A. spastic paralysis, hyperreflexia, presence of babinski reflex
15. Answer: D. the left coronary artery has two main branches, the left anterior Options B, C, and D: These describe lower motor neuron disease.
descending and left circumflex: both supply the left ventricle 26. Answer: B. the aura and headache of migraine
Option D: The right and left coronary arteries are the only branches off the Option B: The warning sign or aura is associated with migraine although not
ascending aorta; blood enters these arteries mainly during diastole; the right everyone with migrane has an aura. Migraine is usually unilateral and described as
coronary artery also often supplies a small portion of the left ventricle.
16. Answer: C. pulmonary hypertension 27. Answer: B. dilation of cerebral arteries
Option C: Pulmonary congestion secondary to left atrial hypertrophy causes these Option B: The vascular theory best explains migraine and often diagnosis is
symptoms. confirmed through a trial of ergotamine, which constricts the dilated, pulsating
Option D: The left ventricle does not hypertrophy in mitral stenosis. vessels.
Option B: Right heart failure would cause abdominal discomfort and peripheral 28. Answer: A. seasonal allergies
edema. Option A: Sinus headache often accompanies seasonal allergies.
Option A: Pericardial thickening does not occur. Option C: Many factors may contribute to migraine. Usually the client comes from
17. Answer: D. chest x-ray showed left ventricular hypertrophy
Option D: Evidence of left atrial enlargement may be seen on chest x-ray and ECG. accompanying nausea and vomiting.
Options A, B, and C: The other objective findings may be seen in chronic mitral Option D: Often there is an aura.
stenosis with episodes of atrial fibrillation and right heart failure. Option B: Stress, diet, hormonal changes, and fatigue may all be implicated in
18. Answer: C. papillary muscle ischemia and dysfunction migraine.
Option A: Ventricular ischemia does not occur with prolapsed mitral valve. 29. Answer: D. feeling of tightness bitemporally, occipitally, or in the neck
Options B and D: These are not painful conditions in themselves. Options A and B: These describe sinus headache; option A may also be
19. Answer: B. cancer of the lung compatible with headache secondary to eyestrain; option B is also compatible with
Option B: The incidence of lung cancer is also rapidly rising in women. migraine.
20. Answer: B. squamous cell carcinoma (epidermoid) Option C:
Option B: Textbooks of medicine and nursing classify primary pulmonary
carcinoma somewhat differently. However most agree that squamous cell or 30. Answer: B. gliomas are usually benign
epidermoid carcinoma is always associated with cigarette smoking. Option B: Gliomas are malignant tumors.
21. Answer: B. Explaining that the reactions to chemotherapy are minimal 31. Answer: C. CN8
Option B: There are numerous severe reactions to chemotherapy such as Option C: CN8, the acoustic nerve or vestibulocochlear nerve, is the most
stomatitis, alopecia, bone marrow depression, nausea and vomiting. commonly affected CN in acoustic neuroma.
Options A, C, and D: These are important nursing considerations. Options A and B: As the tumor progresses, CN5 and CN7 can be affected.
22. Answer: A. Pneumonectomy: removal of the entire lung 32. Answer: D. increased pulse rate, drop in blood pressure
 Option D: As ICP increases, the pulse rate decreases and the BP rise. However, as Option E: An oropharyngeal airway should be used in an unconscious patient. In a
ICP continues to rise, vital signs may vary considerably. conscious or semiconscious patient, its use may cause laryngospasm or vomiting.
33. Answer: B. Straining to evacuate the enema might increase the intracranial An oropharyngeal airway that is too long may push the epiglottis into a position
pressure that obstructs the airway. It is often used with an ETT to prevent biting and
Option B: Any activity that increases ICP could possibly cause brain herniation. occlusion. It is usually inserted upside down and then rotated into the correct
Straining to expel an enema is one example of how the increased ICP can be orientation as it approaches full insertion.
further aggravated. 42. Answer: B. Reduces the risk of aspiration of gastric contents.
34. Answer: A. Keeping his head flat Option A: This is wrong because an attempt should not last longer than 30
Option A: Postoperatively clients who have undergone craniotomy usually have seconds.
their heads elevated to decrease local edema and also decrease ICP. Option C: Unless the injury is suspected the neck should be slightly flexed and the
35. Answer: B. extracranial hemorrhage
Option B: Hemorrhage is predominantly intracranial, although there may be some Option D: After securing an airway and successfully ventilating the patient with
bloody drainage on external dressings. two breaths you should then check for a pulse. If there is no pulse begin chest
Option A: Increased ICP may result from hemorrhage or edema. compressions. Intubation is part of the
Option D: CSF leakage may result in meningitis. 43. Answer: C. Cricoid pressure may prevent gastric inflation during ventilations.
Option C: Seizures are another postoperative concern. Option C: Cricoid pressure may prevent gastric inflation during ventilations and
36. Answer: B. the incision in gallbladder surgery is in the subcostal area, which may also prevent regurgitation by compressing the esophagus.
makes the client reluctant to take a deep breath and cough Option A: This may cause gastric insufflation thus increasing the risk for
Option A: This is true: the rationale for deep breathing and coughing is to prevent regurgitation and aspiration. With adults, breaths should be delivered slowly and
postoperative pulmonary complications such as pneumonia and atelectasis. steadily over 2 seconds.
Option B: The risk of pulmonary problems is somewhat increased in clients with Option B: Effective ventilation using bag-valve mask usually requires at least two
biliary tract surgery because of their high abdominal incisions. well-trained rescuers.
Option C: This assumes the stereotype of the person with gallbladder disease Option D: A frequent problem with bag-valve mask ventilations is the inability to
fair, fat and forty which is not necessarily the case. Splinting the incision with the provide adequate tidal volumes.
hands or a pillow is very helpful in controlling the pain during coughing. 44. Answer: D. Pull the tube back and listen again.
37. Answer: A. to notify the surgeon at once; this is an elevated WBC indicating an Option D: Most likely you have a right mainstem bronchus intubation. Pulling the
inflammatory reaction tube back a few centimeters may be all you need to do.
Option A: A WBC count of 15,000 probably indicates acute cholecystitis, especially 45. Answer: D. Should not be used with a conscious person, pediatric patients, or
patients who have swallowed caustic substances.
treat the acute attack medically and delay the surgery for several days, weeks, or Option A: EOA insertion should only be attempted by persons highly proficient in
months. their use.
38. Answer: B. allow her family to be with her before the medication takes effect Option B: Moreover, since visualization is not required the EOA may be very
Options A, C, and D: These should all take place prior to administration of the
drugs. The family may also be involved earlier but certainly should have that time Option C: Vomiting and aspiration are possible complications of insertion and
immediately after the medication is given and before it takes full effect to be with removal of an EOA.
their loved ones. Good planning of nursing care can facilitate this. 46. Answer: A. A patient may have a normal appearing ECG.
39. Answer: C. immediately report signs of shock to the head nurse and/or surgeon Option A: Which is why a normal ECG alone cannot be relied upon to rule out an
and monitor VS closely MI.
Option C: These are signs of impending shock, which may be true shock or a Option B: Chest pain does not always accompany an MI. This is especially true of
reaction to anesthesia. Your most appropriate action is to report your findings patients with diabetes.
quickly and accurately and to continue to monitor Mrs. Hogan carefully. Option C: A targeted history is often crucial in making the diagnosis of acute MI.
40. Answer: D. stat Option D: The chest pain associated with an acute MI is often described as heavy,
Option D: Leg exercises, deep breathing and coughing, moving, and turning should
condition is stable. 47. Answer: C. Ventricular fibrillation
Option B: The family can be extremely helpful in encouraging the client to do Option C: Moreover, ventricular fibrillation is 15 times more likely to occur during
them, in supporting the incision, etc. the first hour of an acute MI than the following twelve hours which is why it is vital
Option A: this is a nursing responsibility. to decrease the delay between onset of chest pain and arrival at a medical facility.
41. Answer: E. All of the above. First-degree heart block is not a lethal arrhythmia.
48. Answer: B. It may cause a drop in blood pressure.
 Option B: Verapamil usually decreases blood pressure, which is why it is sleep
sometimes used as an antihypertensive agent.
Option A: Verapamil may be lethal if given to a patient with V-tach, therefore it 5. The nurse is planning care for a client during the acute phase of a sickle cell vaso-
should not be given to a tachycardic patient with a wide complex QRS. occlusive crisis. Which of the following actions would be most appropriate?
Option C: Verapamil is a calcium channel blocker and may actually cause PEA if A. Fluid restriction 1000cc per day
given too fast intravenously or if given in excessive amounts. The specific antidote B. Ambulate in hallway 4 times a day
for overdose from verapamil, or any other calcium channel blocker, is calcium. C. Administer analgesic therapy as ordered
Option D: Verapamil may cause hypotension. D. Encourage increased caloric intake
49. Answer: C. Has a maximum total dosage of 0.03-0.04 mg/kg IV in the setting of 6. While working with an obese adolescent, it is important for the nurse to recognize
cardiac arrest. that obesity in adolescents is most often associated with what other behavior?
Option A: Only give atropine for symptomatic bradycardias. Many physically fit A. Sexual promiscuity
people have resting heart rates less than 60 bpm. B. Poor body image
Option B: Atropine may be given via an endotracheal tube. C. Dropping out of school
Option D: Administering atropine slowly may cause paradoxical bradycardia. D. Drug experimentation
50. Answer: A. True ogress toward understanding
Option A: Asystole is not amenable to correction by defibrillation. But there is a his behavior under stress. This is typical of which phase in the therapeutic
school of thought that holds that asystole should be treated like V-fib, i.e., relationship?
defibrillate it. The thinking is that human error or equipment malfunction may A. Pre-interaction
result in misidentifying V-fib as asystole. Missing V-fib can have deadly B. Orientation
consequences for the patient because V-fib is highly amenable to correction by C. Working
defibrillation. D. Termination
In Text Mode: All questions and answers are given for reading and answering at your own 8. A nurse is eating in the hospital cafeteria when a toddler at a nearby table chokes
pace. You can also copy this exam and make a printout. on a piece of food and appears slightly blue. The appropriate initial action should be
1. The nursing care plan for a toddler diagnosed with Kawasaki to
Disease (mucocutaneous lymph node syndrome) should be based on the high risk for A. Begin mouth to mouth resuscitation
development of which problem? B. Give the child water to help in swallowing
A. Chronic vessel plaque formation C. Perform 5 abdominal thrusts
B. Pulmonary embolism D. Call for the emergency response team
C. Occlusions at the vessel bifurcations 9. The emergency room nurse admits a child who experienced a seizure at school.
D. Coronary artery aneurysms The father comments that this is the first occurrence, and denies any family history
2. A nurse has just received a medication order which is not legible. Which statement of epilepsy. What is the best response by the nurse?
best reflects assertive communication? Epilepsy

-
10. A nurse admits a 3 week-old infant to the special care nursery with a diagnosis
attempting to read your of bronchopulmonary dysplasia. As the nurse reviews the birth history, which data
would be most consistent with this diagnosis?
3. The nurse is discussing negativism with the parents of a 30 month-old child. How A. Gestational age assessment suggested growth retardation
should the nurse tell the parents to best respond to this behavior? B. Meconium was cleared from the airway at delivery
A. Reprimand the child and give a 15- C. Phototherapy was used to treat Rh incompatibility
B. Maintain a permissive attitude for this behavior D. The infant received mechanical ventilation for 2 weeks
C. Use patience and a sense of humor to deal with this behavior 11. Parents of a 6 month-old breastfed baby ask the nurse about increasing the
D. Assert authority over the child through limit setting
4. An ambulatory client reports edema during the day in his feet and an ankle that A. Cereal
disappears while sleeping at night. What is the most appropriate follow-up question B. Eggs
for the nurse to ask? C. Meat
heart attack D. Juice
 re better, I would not have been A. Neurotoxicity
B. Hepatomegaly
A. Fear C. Nephrotoxicity
B. Helplessness D. Ototoxicity
C. Self-blame 20. A newborn is having difficulty maintaining a temperature above 98 degrees
D. Rejection Fahrenheit and has been placed in a warming isolette. Which action is a nursing
13. The nurse is assessing the mental status of a client admitted with possible priority?
organic brain disorder. Which of these questions will best assess the function of the A. Protect the eyes of the neonate from the heat lamp
temperature
fter each question) C. Warm all medications and liquids before giving
D. Avoid touching the neonate with cold hands
21. At a senior citizens meeting a nurse talks with a client who has diabetes
mellitus Type 1. Which statement by the client during the conversation is most
predictive of a potential for impaired skin integrity?
insulin
14. Which oxygen delivery system would the nurse apply that would provide the
highest concentrations of oxygen to the client? glucose
A. Venturi mask
B. Partial rebreather mask 22. A 4-year-old hospitalized child begins to have a seizure while playing with hard
C. Non-rebreather mask plastic toys in the hallway. Of the following nursing actions, which one should the
D. Simple face mask nurse do first?
15. A nurse is caring for a client who had a closed reduction of a fractured right wrist A. Place the child in the nearest bed
followed by the application of a fiberglass cast 12 hours ago. Which finding requires B. Administer IV medication to slow down the seizure
attention?
A. Capillary refill of fingers on right hand is 3 seconds
B. Skin warm to touch and normally colored 23. The nurse is at the community center speaking with retired people. To which
C. Client reports prickling sensation in the right hand comment by one of the retirees during a discussion about glaucoma would the nurse
D. Slight swelling of fingers of right hand give a supportive comment to reinforce correct information?
16. Included in teaching the client with tuberculosis taking INH about follow-up
home care, the nurse should emphasize that a laboratory appointment for which of sinuses
the following lab tests is critical?
A. Liver function this eye
B. Kidney function D.
C. Blood sugar 24. The nurse is teaching a parent about side effects of routine immunizations.
D. Cardiac enzymes Which of the following must be reported immediately?
17. Which client is at highest risk of developing a pressure ulcer? A. Irritability
A. 23-year-old in traction for fractured femur B. Slight edema at site
B. 72-year-old with peripheral vascular disease, who is unable to walk without assistance C. Local tenderness
C. 75-year-old with left-sided paresthesia and is incontinent of urine and stool D. Temperature of 102.5 F
D. 30-year-old who is comatose following a ruptured aneurysm 25. A client is admitted with the diagnosis of pulmonary embolism. While taking a
18. Which contraindication should the nurse assess for prior to giving a child history, the client tells the nurse he was admitted for the same thing twice before,
immunization? the last time just 3 months ago. The nurse would anticipate the health care provider
A. Mild cold symptoms ordering
B. Chronic asthma A. Pulmonary embolectomy
C. Depressed immune system B. Vena caval interruption
D. Allergy to eggs C. Increasing the coumadin therapy to an INR of 3-4
19. The nurse is caring for a 2-year-old who is being treated with chelation therapy, D. Thrombolytic therapy
calcium disodium edetate, for lead poisoning. The nurse should be alert for which of 26. A woman in her third trimester complains of severe heartburn. What is
the following side effects? appropriate teaching by the nurse to help the woman alleviate these symptoms?
A. Drink small amounts of liquids frequently A. Use only cloth diapers that are rinsed with bleach
B. Eat the evening meal just before retiring B. Do not use occlusive ointments on the rash
C. Take sodium bicarbonate after each meal C. Use commercial baby wipes with each diaper change
D. Sleep with head propped on several pillows D. Discontinue a new fo
27. The nurse is teaching the mother of a 5 month-old about nutrition for her baby. 34. A 16-year-old client is admitted to a psychiatric unit with a diagnosis of
Which statement by the mother indicates the need for further teaching? attempted suicide. The nurse is aware that the most frequent cause of suicide in
adolescents is
A. Progressive failure to adapt
B. Feelings of anger or hostility
C. Reunion wish or fantasy
28. For a 6-year-old child hospitalized with moderate edema and D. Feelings of alienation or isolation
mild hypertension associated with acute glomerulonephritis (AGN), which one of the 35. A mother brings her 26-month-old to the well-child clinic. She expresses
following nursing interventions would be appropriate? to
A. Institute seizure precautions follow her directions. The nurse explains this is normal for his age, as negativism is
B. Weigh the child twice per shift attempting to meet which developmental need?
C. Encourage the child to eat protein-rich foods A. Trust
D. Relieve boredom through physical activity B. Initiative
29. Which statement by the client with chronic obstructive lung disease indicates an C. Independence
understanding of the major reason for the use of occasional pursed-lip breathing? D. Self-esteem
36. Following mitral valve replacement surgery
care provider orders a bolus of Lidocaine followed by a continuous Lidocaine
infusion at a rate of 2 mgm/minute. The IV solution contains 2 grams of Lidocaine in
D5W. The infusion pump delivers 60 microdrops/cc. What rate would
30. A 57-year-old male client has hemoglobin of 10 mg/dl and a hematocrit of 32%. deliver 4 mgm of Lidocaine/minute?
What would be the most appropriate follow-up by the home care nurse? A. 60 microdrops/minute
A. Ask the client if he has noticed any bleeding or dark stools B. 20 microdrops/minute
B. Tell the client to call 911 and go to the emergency department immediately C. 30 microdrops/minute
C. Schedule a repeat Hemoglobin and Hematocrit in 1 month D. 40 microdrops/minute
D. Tell the client to schedule an appointment with a hematologist 37. A couple asks the nurse about risks of several birth control methods. What is the
31. Which response by the nurse would best assist the chemically impaired client to most appropriate response by the nurse?
deal with issues of guilt? A. Norplant is safe and may be removed easily
B. Oral contraceptives should not be used by smokers
C. Depo-Provera is convenient with few side effects
about and what steps can you begin to D. The IUD gives protection from pregnancy and infection
38. The nurse is caring for a client in the late stages of Amyotrophic Lateral Sclerosis
(A.L.S.). Which finding would the nurse expect?
A. Confusion
pain to your family and close friends, so it will take time to B. Loss of half of visual field
C. Shallow respirations
32. An adolescent client comes to the clinic 3 weeks after the birth of her first baby. D. Tonic-clonic seizures
She tells the nurse she is concerned because she has not returned to her pre- 39. A client experiences postpartum hemorrhage eight hours after the birth of twins.
pregnant weight. Which action should the nurse perform first? Following administration of IV fluids and 500 ml of whole blood, her hemoglobin and
hematocrit are within normal limits. She asks the nurse whether she should
B. Ask the mother to record her diet for the last 24 hours continue to breastfeed the infants. Which of the following is based on sound
C. Encourage her to talk about her view of herself rationale?
D. Give her several pamphlets on postpartum nutrition
33. Which of the following measures would be appropriate for the nurse to teach the Breastfeeding
parent of a nine-month-old infant about diaper dermatitis?
40. A client complained of nausea, a metallic taste in her mouth, and fine hand A. A cerebral vascular accident
tremors 2 hours after her first dose of lithium carbonate (Lithane). What is the B. Postoperative meningitis
ion of these findings? C. Medication reaction
A. These side effects are common and should subside in a few days D. Metabolic alkalosis
B. The client is probably having an allergic reaction and should discontinue the drug 48. A client with schizophrenia is receiving Haloperidol (Haldol) 5 mg t.i.d.. The
C. Taking the lithium on an empty stomach should decrease these symptoms
D. Decreasing dietary intake of sodium and fluids should minimize the side effects nurse recognizes this as what type of side effect?
41. The nurse is caring for a post-surgical client at risk for developing deep vein A. Oculogyric crisis
thrombosis. Which intervention is an effective preventive measure? B. Tardive dyskinesia
A. Place pillows under the knees C. Nystagmus
B. Use elastic stockings continuously D. Dysphagia
C. Encourage range of motion and ambulation 49. A home health nurse is at the home of a client with diabetes and arthritis. The
D. Massage the legs twice daily client has difficulty drawing up insulin. It would be most appropriate for the nurse to
42. The parents of a newborn male with hypospadias want their child circumcised. refer the client to
The best response by the nurse is to inform them that A. A social worker from the local hospital
A. Circumcision is delayed so the foreskin can be used for the surgical repair B. An occupational therapist from the community center
B. This procedure is contraindicated because of the permanent defect C. A physical therapist from the rehabilitation agency
C. There is no medical indication for performing a circumcision on any child D. Another client with diabetes mellitus and takes insulin
D. The procedure should be performed as soon as the infant is stable 50. A client was admitted to the psychiatric unit after complaining to her friends and
43. The nurse is teaching parents about the treatment plan for a 2-week-old infant family that neighbors have bugged her home in order to hear all of her business. She
with Tetralogy of Fallot. While awaiting future surgery, the nurse instructs the remains aloof from other clients, paces the floor and believes that the hospital is a
parents to immediately report house of torture. Nursing interventions for the client should appropriately focus on
A. Loss of consciousness efforts to
B. Feeding problems A. Convince the client that the hospital staff is trying to help
C. Poor weight gain B. Help the client to enter into group recreational activities
D. Fatigue with crying C. Provide interactions to help the client learn to trust staff
44. An infant weighed 7 pounds 8 ounces at birth. If growth occurs at a normal rate,
what would be the expected weight at 6 months of age?
A. Double the birth weight
Answers & Rationale
B. Triple the birth weight Here are the answers and rationale for this exam. Counter check your answers to those
C. Gain 6 ounces each week below and tell us your scores. If you have any disputes or need more clarification on a
D. Add 2 pounds each month certain question, please direct them to the comments section.
45. The nurse is caring for a 13-year-old following spinal fusion for scoliosis. Which 1. Answer: D: Coronary artery aneurysms
Option D: Kawasaki Disease involves all the small and medium-sized blood
of the following interventions is appropriate in the immediate post-operative
period? vessels. There is progressive inflammation of the small vessels which progresses
A. Raise the head of the bed at least 30 degrees to the medium-sized muscular arteries, potentially damaging the walls and leading
to coronary artery aneurysms.
B. Encourage ambulation within 24 hours
C. Maintain in a flat position, logrolling as needed
D. Encourage leg contraction and relaxation after 48 hours
46. A client asks the nurse about including her 2 and 12-year-old sons in the care of Option B: Assertive communication respects the rights and responsibilities of
their newborn sister. Which of the following is an appropriate initial statement by both parties. This statement is an honest expression of concern for safe practice
the nurse? and a request for clarification without self-depreciation. It reflects the right of the
professional to give and receive information.
3. Answer: C. Use patience and a sense of humor to deal with this behavior
Option C: The nurse should help the parents see the negativism as a normal
growth of autonomy in the toddler. They can best handle the negative toddler by
47. A nurse is caring for a 2-year-old child after corrective surgery for Tetralogy of using patience and humor.
4. Answer: B.
Fallot. The mother reports that the child has suddenly begun seizing. The nurse
recognizes this problem is probably due to
 Option B: These are the symptoms of right-sided heart failure, which causes 17. Answer: C. 75-year-old with left-sided paresthesia and is incontinent of urine and
increased pressure in the systemic venous system. To equalize this pressure, the stool
fluid shifts into the interstitial spaces causing edema. Because of gravity, the lower Option C: Risk factors for pressure ulcers include: immobility, absence of
extremities are first affected in an ambulatory patient. This question would elicit sensation, decreased LOC, poor nutrition and hydration, skin
information to confirm the nursing diagnosis of activity intolerance and fluid moisture, incontinence, increased age, decreased immune response. This client has
volume excess both associated with right-sided heart failure. the greatest number of risk factors.
5. Answer: C. Administer analgesic therapy as ordered 18. Answer: C. Depressed immune system
Option C: The main general objectives in the treatment of a sickle cell crisis is bed Option C: Children who have a depressed immune system related
rest, hydration, electrolyte replacement, analgesics for pain, blood replacement to HIV or chemotherapy should not be given routine immunizations.
and antibiotics to treat any existing infection. 19. Answer: C. Nephrotoxicity
6. Answer: B. Poor body image Option C: Nephrotoxicity is a common side effect of calcium disodium edetate, in
Option B: As the adolescent gains weight, there is a lessening sense of self-esteem addition to lead poisoning in general.
and poor body image. 20. Answer: B.
7. Answer: C. Working Option B: When using a warming
Option C: During the working phase, alternative behaviors and techniques are continuously monitored for undesired elevations.
explored. The nurse and the client discuss the meaning behind the behavior. Option A: The use of heat lamps is not safe as there is no way to regulate their
8. Answer: C. Perform 5 abdominal thrusts temperature.
Option C: At this age, the most effective way to clear the airway of food is to Option C: Warming medications and fluids is not indicated.
perform abdominal thrusts. Option D: While touching with cold hands can startle the infant it does not pose a
9. safety risk.
Option B: There are many possible causes for a childhood seizure. These 21.
include fever, central nervous system conditions, trauma, metabolic alterations Option B: Peripheral neuropathy can lead to lack of sensation in the lower
and idiopathic (unknown). extremities. Clients do not feel pressure and/or pain and are at high risk for skin
10. Answer: D. The infant received mechanical ventilation for 2 weeks impairment.
Option D: Bronchopulmonary dysplasia is an iatrogenic disease caused by 22. Answer: D.
therapies such as use of positive-pressure ventilation used to treat lung disease. Option D: Nursing care for a child having a seizure includes maintaining airway
11. Answer: A. Cereal patency, ensuring safety, administering medications, and providing emotional
Option A: The guidelines of the American Academy of Pediatrics recommend that support.
one new food be introduced at a time, beginning with strained cereal. Options A and C: Since the seizure has already started, nothing should be forced
12. Answer: C. Self-blame
Option C: Domestic violence victims may be immobilized by a variety of affective priority would be for safety.
responses, one being self-blame. The victim believes that a change in their 23. Answer: D.
behavior will cause the abuser to become nonviolent, which is a myth.
13. Answer: C. Option D: Any activity that involves straining should be avoided in clients with
glaucoma. Such activities would increase intraocular pressure.
14. Answer: C. Non-rebreather mask 24. Answer: D. Temperature of 102.5 F
Option C: The non-rebreather mask has a one-way valve that prevents exhales air Option D: An adverse reaction of a fever should be reported immediately. Other
from entering the reservoir bag and one or more valves covering the air holes on reactions that should be reported include crying for > 3 hours, seizure activity, and
the face mask itself to prevent inhalation of room air but to allow exhalation of air. tender, swollen, reddened areas.
When a tight seal is achieved around the mask up to 100% of oxygen is available. 25. Answer: B. Vena caval interruption
15. Answer: C. Client reports prickling sensation in the right hand Option B: Clients with contraindications to heparin, recurrent PE or those with
Option C: Prickling sensation is an indication of compartment syndrome and complications related to the medical therapy may require vena caval interruption
requires immediate action by the nurse. The other findings are normal for a client by the placement of a filter device in the inferior vena cava. A filter can be placed
in this situation. transvenously to trap clots before they travel to the pulmonary circulation.
16. Answer: A. Liver function. 26. Answer: D. Sleep with head propped on several pillows
Option A: INH can cause hepatocellular injury and hepatitis. This side effect is age- Option D: Heartburn is a burning sensation caused by regurgitation of gastric
related and can be detected with regular assessment of liver enzymes, which are contents that is best relieved by sleeping position, eating small meals, and not
released into the blood from damaged liver cells. eating before bedtime.
27. Answer: C.
 Option C: Honey has been associated with infant botulism and should be avoided. 38. Answer: C. Shallow respirations
Older children and adults have digestive enzymes that kill the botulism spores. Option C: A.L.S. is a chronic progressive disease that involves degeneration of the
28. Answer: A. Institute seizure precautions anterior horn of the spinal cord as well as the corticospinal tracts. When
Option A: The severity of the acute phase of AGN is variable and unpredictable; the intercostal muscles and diaphragm become involved, the respirations become
therefore, a child with edema, hypertension, and gross hematuria may be subject shallow and coughing is ineffective.
to complications and anticipatory preparation such as seizure precautions are 39. will help contract the uterus and reduce your risk of
needed.
29. Answer: D. Option A: Stimulation of the breast during nursing releases oxytocin, which
lungs contracts the uterus. This contraction is especially important following
Option D: Clients with chronic obstructive pulmonary disease have difficulty hemorrhage.
exhaling fully as a result of the weak alveolar walls from the disease process. 40. Answer: A. These side effects are common and should subside in a few days
Alveolar collapse can be avoided with the use of pursed-lip breathing. This is the Option A: Nausea, metallic taste, and fine hand tremors are common side effects
major reason to use it. that usually subside within days.
Options A, B, and C: The other options are secondary effects of pursed-lip 41. Answer: C. Encourage range of motion and ambulation
breathing. Option C: Mobility reduces the risk of deep vein thrombosis in the post-surgical
30. Answer: A. Ask the client if he has noticed any bleeding or dark stools client and the adult at risk.
Option A: Normal hemoglobin for males is 13.0 18 g/100 ml. Normal hematocrit 42. Answer: A. Circumcision is delayed so the foreskin can be used for the surgical
for males is 42 52%. These values are below normal and indicate mild anemia. repair
The first thing the nurse should do is a Option A: Even if mild hypospadias is suspected, circumcision is not done in order
change in stools that could indicate bleeding from the GI tract. to save the foreskin for surgical repair, if needed.
31. 43. Answer: A. Loss of consciousness
Option A: While parents should report any of the observations, they need to call
Option B: This response encourages the client to get in touch with their feelings the healthcare provider immediately if the level of alertness changes. This
and utilize problem-solving steps to reduce guilt feelings. indicates anoxia, which may lead to death. The structural defects associated with
32. Answer: C. Encourage her to talk about her view of herself Tetralogy of Fallot include pulmonic stenosis, ventricular septal defect, right
Option C: To an adolescent, body image is very important. The nurse must ventricular hypertrophy and overriding of the aorta. Surgery is often delayed or
acknowledge this before assessment and teaching. may be performed in stages.
33. Answer: D. Discontinue a new food that was added to the diet just prior to 44. Answer: A. Double the birth weight
the rash Option A: Although growth rates vary, infants normally double their birth weight
Option D: by 6 months.
dermatitis. 45. Answer: C. Maintain in a flat position, logrolling as needed
34. Answer: D. Feelings of alienation or isolation Option C: The bed should remain flat for at least the first 24 hours to prevent
Option D: The isolation may occur gradually resulting in a loss of all meaningful injury. Logrolling is the best way to turn for the client while on bed rest.
social contacts. Isolation can be self-imposed or can occur as a result of the 46.
inability to express feelings. At this stage of development, it is important to achieve Option A: In an expanded family, it is important for parents to reassure older
a sense of identity and peer acceptance. children that they are loved and as important as the newborn.
35. Answer: C. Independence 47. Answer: A. A cerebral vascular accident
Option C: theory of development, toddlers struggle to assert Option A: Polycythemia occurs as a physiological reaction to chronic hypoxemia
which commonly occurs in clients with Tetralogy of Fallot. Polycythemia and the
is called autonomy versus shame and doubt. resultant increased viscosity of the blood increase the risk of thromboembolic
36. Answer: A. 60 microdrops/minute events. Cerebrovascular accidents may occur. Signs and symptoms include sudden
2 gm=2000 mgm paralysis, altered speech, extreme irritability or fatigue, and seizures.
2000 mgm/500 cc = 4 mgm/x cc 48. Answer: A. Oculogyric crisis
2000x = 2000 Option A: This refers to involuntary muscles spasm of the eye.
x= 2000/2000 = 1 cc of IV solution/minute 49. Answer: B. An occupational therapist from the community center
CC x 60 microdrops = 60 microdrops/minute Option B: An occupational therapist can assist a client to improve the fine motor
37. Answer: B. Oral contraceptives should not be used by smokers skills needed to prepare an insulin injection.
Option B: The use of oral contraceptives in a pregnant woman who smokes 50. Answer: C. Provide interactions to help the client learn to trust staff
increases her risk of cardiovascular problems, such as thromboembolic disorders.
 Option C: This establishes trust, facilitates a therapeutic alliance between staff and 8. Following a diagnosis of acute glomerulonephritis (AGN) in their 6-year-old child,
client.
In Text Mode: All questions and answers are given for reading and answering at your own response is based on an understanding that
pace. You can also copy this exam and make a printout. A. AGN is a streptococcal infection that involves the kidney tubules
1. A client is scheduled for a percutaneous transluminal coronary angioplasty B. The disease is easily transmissible in schools and camps
(PTCA). The nurse knows that a PTCA is the C. The illness is usually associated with chronic respiratory infections
A. Surgical repair of a diseased coronary artery -hemolytic strep infection
B. Placement of an automatic internal cardiac defibrillator 9. The nurse is caring for a 20 lbs (9 kg) 6 month-old with a 3-day history of diarrhea,
C. Procedure that compresses plaque against the wall of the diseased coronary artery to occasional vomiting and fever. Peripheral intravenous therapy has been initiated,
improve blood flow with 5% dextrose in 0.33% normal saline with 20 mEq of potassium per liter
D. Non-invasive radiographic examination of the heart infusing at 35 ml/hr. Which finding should be reported to the healthcare provider
2. A newborn has been diagnosed with hypothyroidism. In discussing the condition immediately?
and treatment with the family, the nurse should emphasize A. 3 episodes of vomiting in 1 hour
A. They can expect the child will be mentally retarded B. Periodic crying and irritability
B. Administration of thyroid hormone will prevent problems C. Vigorous sucking on a pacifier
C. This rare problem is always hereditary D. No measurable voiding in 4 hours
D. Physical growth/development will be delayed 10. While caring for the client during the first hour after delivery, the nurse
3. A priority goal of involuntary hospitalization of the severely mentally ill client is determines that the uterus is boggy and there is vaginal bleeding. What should be
A. Re-orientation to reality
B. Elimination of symptoms A. Check vital signs
C. Protection from harm to self or others B. Massage the fundus
D. Return to independent functioning C. Offer a bedpan
4. A 19-year-old client is paralyzed in a car accident. Which statement used by the D. Check for perineal lacerations
client would indicate to the nurse that the client was using the mechanism of 11. The nurse is assessing an infant with developmental dysplasia of the hip. Which
suppression finding would the nurse anticipate?
A. Unequal leg length
B. Limited adduction
C. Diminished femoral pulses
D. Symmetrical gluteal folds
5. The nurse is caring for a woman 2 hours after a vaginal delivery. Documentation 12. To prevent a Valsalva maneuver in a client recovering from an acute myocardial
indicates that the membranes were ruptured for 36 hours prior to delivery. What infarction, the nurse would
are the priority nursing diagnoses at this time? A. Assist the client to use the bedside commode
A. Altered tissue perfusion B. Administer stool softeners every day as ordered
B. Risk for fluid volume deficit C. Administer antidysrhythmics prn as ordered
C. High risk for hemorrhage D. Maintain the client on strict bed rest
D. Risk for infection 13. On admission to the psychiatric unit, the client is trembling and appears fearful.
6. A 3-year-old had a hip spica cast applied 2 hours ago. In order to facilitate drying, tial response should be to
the nurse should A. Give the client orientation materials and review the unit rules and regulations
A. Expose the cast to air and turn the child frequently
B. Use a heat lamp to reduce the drying time C. Take the client to the day room and introduce her to the other clients
C. Handle the cast with the abductor bar D. As
D. Turn the child as little as possible 14. During the admission assessment on a client with chronic bilateral glaucoma,
7. A client is scheduled for an Intravenous Pyelogram (IVP). In order to prepare the which statement by the client would the nurse anticipate since it is associated with
client for this test, the nurse would: this problem?
A. Instruct the client to maintain a regular diet the day prior to the examination

C. Administer a laxative to the client the evening before the examination

D. Inform the client that only 1 x-ray of his abdomen is necessary
15. A client with asthma has low pitched wheezes present in the final half A. Nutrition
of exhalation. One hour later the client has high pitched wheezes extending B. Elimination
throughout exhalation. This change in assessment indicates to the nurse that the C. Activity
client D. Safety
A. Has increased airway obstruction 23. Which playroom activities should the nurse organize for a small group of 7-year-
B. Has improved airway obstruction old hospitalized children?
C. Needs to be suctioned A. Sports and games with rules
D. Exhibits hyperventilation B. Finger paints and water play
16. Which behavioral characteristic describes the domestic abuser? -
A. Alcoholic D. Chess and television programs
B. Overconfident 24. A client is discharged following hospitalization for congestive heart failure. The
C. High tolerance for frustrations nurse teaching the family suggests they encourage the client to rest frequently in
D. Low self-esteem which of the following positions?
17. The nurse is caring for a client with a long leg cast. During discharge teaching
about appropriate exercises for the affected extremity, the nurse should recommend B. Supine
A. Isometric C. Left lateral
B. Range of motion
C. Aerobic 25. The nurse is caring for a 10-year-old on admission to the burn unit. One
D. Isotonic assessment parameter that will indicate that the child has adequate
18. A client is in her third month of her first pregnancy. During the interview, she fluid replacement is
tells the nurse that she has several sex partners and is unsure of the identity of the A. Urinary output of 30 ml per hour
ions is a priority? B. No complaints of thirst
A. Counsel the woman to consent to HIV screening C. Increased hematocrit
B. Perform tests for sexually transmitted diseases D. Good skin turgor around burn
C. Discuss her high risk for cervical cancer
D. Refer the client to a family planning clinic
Answers & Rationale
19. A 16-month-old child has just been admitted to the hospital. As the nurse Here are the answers and rationale for this exam. Counter check your answers to those
assigned to this child enters the hospital room for the first time, the toddler runs to below and tell us your scores. If you have any disputes or need more clarification on a
the mother, clings to her and begins to cry. What would be the initial action by the certain question, please direct them to the comments section.
nurse? 1. Answer: C. Procedure that compresses plaque against the wall of the diseased
A. Arrange to change client care assignments coronary artery to improve blood flow
B. Explain that this behavior is expected Option C: PTCA is performed to improve coronary artery blood flow in a diseased
- artery. It is performed during a cardiac catheterization. Aorta coronary bypass
Graft is the surgical procedure to repair a diseased coronary artery.
D. Explain that the child needs extra attention
20. While planning care for a 2-year-old hospitalized child, which situation would 2. Answer: B. Administration of thyroid hormone will prevent problems
the nurse expect to most likely affect the behavior? Option B. Early identification and continued treatment with hormone
replacement correct this condition.
A. Strange bed and surroundings
B. Separation from parents 3. Answer: C. Protection from self-harm and harm to others
C. Presence of other toddlers Option C: Involuntary hospitalization may be required for persons considered
D. Unfamiliar toys and games dangerous to self or others or for individuals who are considered gravely disabled.
21. While explaining an illness to a 10-year-old, what should the nurse keep in mind 4.
about the cognitive development at this age? Option A: Suppression is willfully putting an unacceptable thought or feeling out
A. They are able to make simple association of ideas is generally used to
B. They are able to think logically in organizing facts -esteem.
C. Interpretation of events originate from their own perspective 5. Answer: D. Risk for infection
Option D: Membranes ruptured over 24 hours prior to birth greatly increases the
D. Conclusions are based on previous experiences
22. The nurse has just admitted a client with severe depression. From which focus risk of infection to both mother and the newborn.
6. Answer: A. Expose the cast to air and turn the child frequently
should the nurse identify a priority nursing diagnosis?
 Option A: The child should be turned every 2 hours, with surface exposed to the instructed to do active range of motion exercises for every joint that is not
air. immobilized at regular and frequent intervals.
7. Answer: C. Administer a laxative to the client the evening before the examination 18. Answer: A. Counsel the woman to consent to HIV screening
Option C: Bowel prep is important because it will allow greater visualization of Option A: irst
the bladder and ureters. step. If the woman is HIV positive, the earlier treatment begins, the better the
-hemolytic strep outcome.
infection 19. Answer: B. Explain that this behavior is expected
Option D: AGN is generally accepted as an immune-complex disease in relation to Option B: During normal development, fear of strangers becomes prominent
an antecedent streptococcal infection of 4 to 6 weeks prior and is considered as a beginning around age 6-8 months. Such behaviors include clinging to parent,
noninfectious renal disease. crying, and turning away from the stranger. These fears/behaviors extend into the
9. Answer: D. No measurable voiding in 4 hours toddler period and may persist into preschool.
Option D: The concern is possible hyperkalemia, which could occur with 20. Answer: B. Separation from parents
continued potassium administration and a decrease in urinary output since Option B: Separation anxiety if most evident from 6 months to 30 months of age.
potassium is excreted via the kidneys. It is the greatest stress imposed on a toddler by hospitalization. If separation is
10. Answer: B. Massage the fundus avoided, young children have a tremendous capacity to withstand other stress.
Option B: 21. Answer: B. They are able to think logically in organizing facts
as uterine atony is the primary cause of bleeding in the first hour after delivery. Option B: The child in the concrete operations stage, according to Piaget, is
11. Answer: A. Unequal leg length capable of mature thought when allowed to manipulate and organize objects.
Option A: Shortening of a leg is a sign of developmental dysplasia of the hip. 22. Answer: D. Safety
12. Answer: B. Administer stool softeners every day as ordered Option D: Safety is a priority of care for the depressed client. Precautions to
Option B: Administering stool softeners every day will prevent straining on prevent suicide must be a part of the plan.
defecation which causes the Valsalva maneuver. If constipation occurs then 23. Answer: A. Sports and games with rules
laxatives would be necessary to prevent straining. If straining on defecation Option A: The purpose of play for the 7-year-old is cooperation. Rules are very
produced the Valsalva maneuver and rhythm disturbances resulted then important. Logical reasoning and social skills are developed through play.
antidysrhythmics would be appropriate. 24.
13. Option A:
Option B: Anxiety the cardiac workload and facilitates breathing.
security. In response to anxiety in clients, the nurse should remain calm, minimize 25. Answer: A. Urinary output of 30 ml per hour
stimuli, and move the client to a calmer, more secure/safe setting. Option A: For a child of this age, this is adequate output, yet does not suggest
14. overload.
Option C: Intraocular pressure becomes elevated which slowly produces a In Text Mode: All questions and answers are given for reading and answering at your own
progressive loss of the peripheral visual field in the affected eye along with pace. You can also copy this exam and make a printout.
rainbow halos around lights. Intraocular pressure becomes elevated from the 1. What is the priority nursing diagnosis for a patient experiencing a
microscopic obstruction of the trabecular meshwork. If left untreated or migraine headache dd?
undetected blindness results in the affected eye. A. Acute pain related to biologic and chemical factors
15. Answer: A. Has increased airway obstruction B. Anxiety related to change in or threat to health status
Option A: The higher pitched a sound is, the more narrow the airway. Therefore, C. Hopelessness related to deteriorating physiological condition
the obstruction has increased or worsened. With no evidence of secretions no D. Risk for Side effects related to medical therapy
support exists to indicate the need for suctioning. 2. You are creating a teaching plan for a patient with newly diagnosed migraine
16. Answer: D. Low self-esteem headaches. Which key items should be included in the teaching plan? (Choose all that
Option D: Batterers are usually physically or psychologically abused as children apply).
or have had experiences of parental violence. Batterers are also manipulative, A. Avoid foods that contain tyramine, such as alcohol and aged cheese.
have a low self-esteem, and have a great need to exercise control or power-over B. Avoid drugs such as Tagamet, nitroglycerin and Nifedipine.
partner. C. Abortive therapy is aimed at eliminating the pain during the aura.
17. Answer: A. Isometric D. A potential side effect of medications is rebound headache.
Option A: The nurse should instruct the client on isometric exercises for the E. Complementary therapies such as relaxation may be helpful.
muscles of the casted extremity, i.e., instruct the client to alternately contract and F. Continue taking estrogen as prescribed by your physician.
relax muscles without moving the affected part. The client should also be 3. The patient with migraine headaches has a seizure. After the seizure, which action
can you delegate to the nursing assistant?
A. Document the seizure. 11. You are pulled from the ED to the neurologic floor. Which action should you
B. Perform neurologic checks. delegate to the nursing assistant when providing nursing care for a patient with SCI?
A. Assess patien
D. Restrain the patient for protection.
4. You are preparing to admit a patient with a seizure disorder. Which of the C. Monitor nutritional status including calorie counts.
following actions can you delegate to LPN/LVN? D. Have patient turn, cough, and deep breathe every 3 hours.
A. Complete admission assessment. 12. You are helping the patient with an SCI to establish a bladder-retraining
B. Set up oxygen and suction equipment. program. What strategies may stimulate the patient to void? (Choose all that apply).
C. Place a padded tongue blade at bedside. A. Stroke
D. Pad the side rails before patient arrives. hair.
5. A nursing student is teaching a patient and family about epilepsy prior to the C. Initiate intermittent straight catheterization.
D. Pour warm water over the perineum.
E. Tap the bladder to stimulate detrusor muscle.
13. The patient with a cervical SCI has been placed in fixed skeletal traction with a
halo fixation device. When caring for this patient the nurse may delegate which
-the- action (s) to the LPN/LVN? (Choose all that apply).
Impaired Physical
Mobility related to neuromuscular impairment. You observe a nursing assistant
performing all of these actions. For which action must you intervene? C. Observe the halo insertion sites for signs of infection.
A. The NA assists the patient to ambulate to the bathroom and back to bed. D. Clean the halo insertion sites with hydrogen peroxide.
B. The NA reminds the patient not to look at his feet when he is walking. 14. You are preparing a nursing care plan for the patient with SCI including the
nursing diagnosis Impaired Physical Mobility and Self-Care Deficit. The patient tells

7. The nurse is preparing to discharge a patient with chronic low back pain. Which diagnosis takes priority based on this statement?
statement by the patient indicates that additional teaching is necessary? A. Risk for Injury related to altered mobility
B. Imbalanced Nutrition, Less Than Body Requirements
C. Impaired Adjustment to Spinal Cord Injury
- D. Poor Body Image related to immobilization
15. Which patient should be assigned to the traveling nurse, new to neurologic
8. A patient with a spinal cord injury (SCI) complains about a severe throbbing nursing care, who has been on the neurologic unit for 1 week?
headache that suddenly started a short time ago. Assessment of the patient reveals A. A 34-year-old patient newly diagnosed with multiple sclerosis (MS)
increased blood pressure (168/94) and decreased heart rate (48/minute), B. A 68-year-old patient with chronic amyotrophic lateral sclerosis (ALS)
diaphoresis, and flushing of the face and neck. What action should you take first? C. A 56-year-old patient with Guillain-Barre syndrome (GBS) in respiratory distress
A. Administer the ordered acetaminophen (Tylenol). D. A 25-year-old patient admitted with CA level spinal cord injury (SCI)
B. Check the Foley tubing for kinks or obstruction. 16. The patient with multiple sclerosis tells the nursing assistant that after physical
C. Adjust the tempe therapy she is too tired to take a bath. What is your priority nursing diagnosis at this
D. Notify the physician about the change in status. time?
9. Which patient should you, as charge nurse, assign to a new graduate RN who is A. Fatigue related to disease state
orienting to the neurologic unit? B. Activity Intolerance due to generalized weakness
A. A 28-year-old newly admitted patient with spinal cord injury C. Impaired Physical Mobility related to neuromuscular impairment
B. A 67-year-old patient with stroke 3 days ago and left-sided weakness D. Self-care Deficit related to fatigue and neuromuscular weakness
C. An 85-year-old dementia patient to be transferred to long-term care today 17. The LPN/LVN, under your supervision, is providing nursing care for a patient
D. A 54-year- with GBS. What observation would you instruct the LPN/LVN to report immediately?
10. A patient with a spinal cord injury at level C3-4 is being cared for in the ED. What A. Complaints of numbness and tingling
is the priority assessment? B. Facial weakness and difficulty speaking
A. Determine the level at which the patient has intact sensation. C. Rapid heart rate of 102 beats per minute
B. Assess the level at which the patient has retained mobility. D. Shallow respirations and decreased breath sounds
C. Check blood pressure and pulse for signs of spinal shock. 18. The nursing assistant reports to you, the RN, that the patient with myasthenia
D. Monitor respiratory effort and oxygen saturation level. gravis (MG) has an elevated temperature (102.20 F), heart rate of 120/minute, rise
in blood pressure (158/94), and was incontinent off urine and stool. What is your C. The student gives the patient a warm blanket when he says he feels cold.
best first action at this time? pupil response to light every 30 minutes.
A. Administer an acetaminophen suppository. 25. A 23-year-old patient with a recent history of encephalitis is admitted to the
B. Notify the physician immediately. medical unit with new onset generalized tonic-clonic seizures. Which nursing
C. Recheck vital signs in 1 hour. activities included in the patien
you are supervising? (Choose all that apply).
19. You are providing care for a patient with an acute hemorrhage stroke. The A. Document the onset time, nature of seizure activity, and postictal behaviors for all
seizures.
receive alteplase. What is your best response? B. Administer phenytoin (Dilantin) 200 mg PO daily.
C. Teach patient about the need for good oral hygiene.
heart attack D. Develop a discharge plan, including physician visits and referral to
bleeding the Epilepsy Foundation.
surgery just 6 months ago and this prevents the use of 26. While working in the ICU, you are assigned to care for a patient with a seizure
disorder. Which of these nursing actions will you implement first if the patient has a
20. You are supervising a senior nursing student who is caring for a patient with a seizure?
right hemisphere stroke. Which action by the student nurse requires that you A. Place the patient on a non-rebreather mask will the oxygen at 15 L/minute.
intervene? B. Administer lorazepam (Ativan) 1 mg IV.
C. Turn the patient to the side and protect airway.
expression. D. Assess level of consciousness during and immediately after the seizure.
-bed tray. 27. A patient recently started on phenytoin (Dilantin) to control simple complex
C. The student assists the patient with passive range-of-motion (ROM) exercises. seizures is seen in the outpatient clinic. Which information obtained during his chart
review and assessment will be of greatest concern?
right side. A. The gums appear enlarged and inflamed.
21. Which action (s) should you delegate to the experienced nursing assistant when B. The white blood cell count is 2300/mm3.
caring for a patient with a thrombotic stroke with residual left-sided weakness? C. Patient occasionally forgets to take the phenytoin until after lunch.
(Choose all that apply).
A. Assist patient to reposition every 2 hours. 28. After receiving a change-of-shift report at 7:00 AM, which of these patients will
B. Reapply pneumatic compression boots. you assess first?
C. Remind patient to perform active ROM. A. A 23-year-old with a migraine headache who is complaining of severe nausea associated
D. Check extremities for redness and edema. with retching
22. The patient who had a stroke needs to be fed. What instruction should you give to B. A 45-year-old who is scheduled for a craniotomy in 30 minutes and needs preoperative
the nursing assistant who will feed the patient? teaching
A. Position the patient sitting up in bed before you feed her. C. A 59-year-
B breakfast
C. Feed the patient quickly because there are three more waiting. D. A 63-year-old with multiple sclerosis who has an oral temperature of 101.80 F and flank
pain
23. You have just admitted a patient with bacterial meningitis to the medical-surgical 29. All of these nursing activities are included in the care plan for a 78-year-old man
unit. The patient complains of a severe headache with photophobia and has a
temperature of 102.60 F orally. Which collaborative intervention must be ones will you delegate to a nursing assistant (NA)? (Choose all that apply).
accomplished first? A. Check for orthostatic changes in pulse and blood pressure.
A. Administer codeine B. Monitor for improvement in tremor after levodopa (L-dopa) is given.
B. Infuse ceftriaxone (Rocephin) 2000 mg IV to treat the infection. C. Remind the patient to allow adequate time for meals.
C. Give acetaminophen (Tylenol) 650 mg orally to reduce the fever. D. Monitor for abnormal involuntary jerky movements of extremities.
D. Give furosemide (Lasix) 40 mg IV to decrease intracranial pressure. E. Assist the patient with prescribed strengthening exercises.
24. You are mentoring a student nurse in the intensive care unit (ICU) while caring on.
for a patient with meningococcal meningitis. Which action by the student requires 30. As the manager in a long-term-care (LTC) facility, you are in charge of developing
that you intervene immediately?
A. The student enters the room without putting on a mask and gown. nursing tasks is best to delegate to the LPN team leaders working in the facility?
B. The student instructs the family that visits are restricted to 10 minutes.
A. Check for improvement in resident memory after medication therapy is initiated. Options B, C, and D: All of the other nursing diagnoses are accurate, but none of
B. Use the Mini-Mental State Examination to assess residents every 6 months. them is as urgent as the issue of pain, which is often incapacitating. Focus:
C. Assist residents to toilet every 2 hours to decrease risk for urinary intolerance. Prioritization
D. Develop individualized activity plans after consulting with residents and family. 2. Answers: A, B, C, D, and E
31. A patient who has been admitted to the medical unit with new-onset angina also Option F: Medications such as estrogen supplements may actually trigger a
migraine headache attack.
sleep because he needs to be sure she does not wander during the night. Options A, B, C, D, and E: All of the other statements are accurate. Focus:
He insists on checking each of the medications you give her to be sure they are the Prioritization
same as the ones she takes at home. Based on this information, which nursing 3. Answer: C.
diagnosis is most appropriate for this patient? Option C: Taking vital signs is within the education and scope of practice for a
A. Decreased Cardiac Output related to poor myocardial contractility nursing assistant. The nurse should perform neurologic checks and document the
B. Caregiver Role Strain related to continuous need for providing care seizure. Patients with seizures should not be restrained; however, the nurse may
C. Ineffective Therapeutic Regimen Management related to poor patient memory ments as necessary. Focus: Delegation/supervision
D. Risk for Falls related to patient wandering behavior during the night 4. Answer: B. Set up oxygen and suction equipment.
32. You are caring for a patient with a recurrent glioblastoma who is Option B: The LPN/LVN can set up the equipment for oxygen and suctioning.
receiving dexamethasone (Decadron) 4 mg IV every 6 hours to relieve symptoms of Option A: The RN should perform the complete initial assessment.
right arm weakness and headache. Which assessment information concerns you the Option C: Padded side rails are controversial in terms of whether they actually
most? provide safety and ay embarrass the patient and family. Tongue blades should not
A. The patient does not recognize family members. mouth after a
B. The blood glucose level is 234 mg/dL. seizure begins. Focus: Delegation/supervision.
C. The patient complains of a continued headache. 5. Answer: D. -the-
D. The daily weight has increased 1 kg. Option D: A patient with a seizure disorder should not take over-the-counter
33. A 70-year-old alcoholic patient with acute lethargy, confusion, medications without consulting with the physician first.
and incontinence is admitted to the hospital ED. His wife tells you that he fell down Options A, B, and C: The other three statements are appropriate teaching points
for patients with seizures disorders and their families. Focus:
he has become gradually less active and sleepier over the last 10 days or so. Which of Delegation/supervision
the following collaborative interventions will you implement first? 6. Answer: C. oral care.
A. Place on the hospital alcohol withdrawal protocol. Option C: The nursing assistant should assist the patient with morning care as
B. Transfer to radiology for a CT scan. needed, but the goal is to keep this patient as independent and mobile as possible.
C. Insert a retention catheter to straight drainage. Options A, B, and D: Assisting the patient to ambulate, reminding the patient not
D. Give phenytoin (Dilantin) 100 mg PO. to look at his feet (to prevent falls), and encouraging the patient to feed himself are
34. Which of these patients in the neurologic ICU will be best to assign to an RN who all appropriate to goal of maintaining independence. Focus:
has floated from the medical unit? Delegation/supervision
A. A 26-year-old patient with a basilar skull structure who has clear drainage coming out of 7. Answer: A.
the nose Option A: Exercises are used to strengthen the back, relieve pressure on
B. A 42-year-old patient admitted several hours ago with a headache and diagnosed with a compressed nerves and protect the back from re-injury.
ruptured berry aneurysm. Options B and D: Ice, heat, and firm mattresses are appropriate interventions for
C. A 46-year-old patient who was admitted 48 hours ago with bacterial meningitis and has back pain.
an antibiotic dose due Option C: People with chronic back pain should avoid wearing high-heeled shoes
D. A 65-year-old patient with an astrocytoma who has just returned to the unit after having at all times. Focus: Prioritization
a craniotomy 8. Answer: B. Check the Foley tubing for kinks or obstruction.
Answers and Rationales Option B: These signs and symptoms are characteristic of autonomic dysreflexia,
a neurologic emergency that must be promptly treated to prevent a hypertensive
Here are the answers and rationale for this exam. Counter check your answers to those stroke. The cause of this syndrome is noxious stimuli, most often a distended
below and tell us your scores. If you have any disputes or need more clarification to a bladder or constipation, so checking for poor catheter drainage, bladder
certain question, please direct them to the comments section.
distention, or fecal impaction is the first action that should be taken.
1. Answer: A. Acute pain related to biologic and chemical factors Option C: Adjusting the room temperature may be helpful, since too cool a
Option A: The priority for interdisciplinary care for the patient experiencing a
temperature in the room may contribute to the problem.
migraine headache is pain management.
 Option A: Tylenol will not decrease the autonomic dysreflexia that is causing the diagnosed patient will need to be transferred to the ICU. The patient with C4 SCI is
at risk for respiratory arrest.
Option D: Notification of the physician may be necessary if nursing actions do not Options A, C, and D: All three of these patients should be assigned to nurses
resolve symptoms. Focus: Prioritization experienced in neurologic nursing care. Focus: Assignment
9. Answer: B. A 67-year-old patient with stroke 3 days ago and left-sided weakness 16. Answer: D. Self-care Deficit related to fatigue and neuromuscular weakness
Option B: The new graduate RN who is oriented to the unit should be assigned Option D: -Care
stable, non-complex patients, such as the patient with stroke. Deficit related to fatigue after physical therapy.
Option D: Options A, B, and C: The other three nursing diagnoses are appropriate to a
which is best delegated to the nursing assistant.
Option A: The patient being transferred to the nursing home and the newly Prioritization
admitted SCI should be assigned to experienced nurses. Focus: Assignment 17. Answer: D. Shallow respirations and decreased breath sounds
10. Answer: D. Monitor respiratory effort and oxygen saturation level. Option D: The priority interventions for the patient with GBS are aimed at
Option D: The first priority for the patient with an SCI is assessing respiratory maintaining adequate respiratory function. These patients are risk for respiratory
patterns and ensuring an adequate airway. The patient with a high cervical injury failure, which is urgent.
is at risk for respiratory compromise because the spinal nerves (C3 5) innervate Options A, B, and C: The other findings are important and should be reported to
the phrenic nerve, which controls the diaphragm. the nurse, but they are not life-threatening. Focus: Prioritization,
Options A, B, and C: The other assessments are also necessary, but not as high delegation/supervision
priority. Focus: Prioritization 18. Answer: B. Notify the physician immediately.
11. Answer: B. Take Option B: The changes that the nursing assistant is reporting are characteristics of
Option B: myasthenia crisis, which often follows some type of infection. The patient is at risk
for inadequate respiratory function. In addition to notifying the physician, the
Option D: The nursing assistant may assist with turning and repositioning the
patient and may remind the patient to cough and deep breathe but does not teach need intubation and mechanical ventilation.
the patient how to perform these actions. Option A: The nurse would notify the physician before giving the suppository
Options A and C: Assessing and monitoring patients require additional education because there may be orders for cultures before giving acetaminophen.
and are appropriate to the scope of practice for professional nurses. Focus: Option C: -checked sooner than 1 hour.
Delegation/supervision Option D: Rescheduling the physical therapy can be delegated to the unit clerk
12. Answers: A, B, D, and E and is not urgent. Focus: Prioritization
Options A, B, D, and E: All of the strategies, except straight catheterization, may 19. Answer: C. may cause more bleeding into your
stimulate voiding in patients with SCI.
Option C: Intermittent bladder catheterization can be used to empty the patient Option C: Alteplase is a clot buster. With patient who has experienced
bladder, but it will not stimulate voiding. Focus: Prioritization hemorrhagic stroke, there is already bleeding into the brain. A drug like alteplase
13. Answers: A, C, and D can worsen the bleeding.
Options A, C, and D: Checking and observing for signs of pressure or infection are Options A, B, and D: The other statements are also accurate about use of
within the scope of practice of the LPN/LVN. The LPN/LVN also has the
appropriate skills for cleaning the halo insertion sites with hydrogen peroxide. Prioritization
Option B: Neurologic examination requires additional education and skill 20. Answer: A. The student instructs the patient to sit up straight, resulting in the
appropriate to the professional RN. Focus: Delegation/supervision
14. Answer: C. Impaired Adjustment to Spinal Cord Injury Option A: Patients with right cerebral hemisphere stroke often present
Option C: with neglect syndrome. They lean to the left and when asked, respond that they
limitations of the injury and indicates the need for additional counseling, teaching, believe they are sitting up straight. They often neglect the left side of their bodies
and support. and ignore food on the left side of their food trays. The nurse would need to
Options A, B, and D: The other three nursing diagnoses may be appropriate to the remind the student of this phenomenon and discuss the appropriate interventions.
patient w Focus: Delegation/supervision
Prioritization 21. Answer: A, B, and C
15. Answer: B. A 68-year-old patient with chronic amyotrophic lateral sclerosis (ALS) Options A, B, and C: The experienced nursing assistant would know how to
Option B: The traveling is relatively new to neurologic nursing and should be reposition the patient and how to reapply compression boots, and would remind
assigned patients whose conditions are stable and not complex. The newly the patient to perform activities he has been taught to perform.
 Option D: Assessing for redness and swelling (signs of deep Option B: Leukopenia is a serious adverse effect of phenytoin and would require
venous thrombosis {DVT}) requires additional education and still appropriate to discontinuation of the medication.
the professional nurse. Focus: Delegation/supervision Options A, C, and D: The other data indicate a need for further assessment and/or
22. Answer: A. Position the patient sitting up in bed before you feed her. patient teaching, but will not require a change in medical treatment for the
Option A: Positioning the patient in a sitting position decreases the risk seizures. Focus: Prioritization
of aspiration. 28. Answer: D. A 63-year-old with multiple sclerosis who has an oral temperature of
Option B: The nursing assistant is not trained to assess gag or swallowing 101.80 F and flank pain
reflexes. Option D: Urinary tract infections are a frequent complication in patient with
Option C: The patient should not be rushed during feeding. multiple sclerosis because of the effect on bladder function. The elevated
Option D: A patient who needs to be suctioned between bites of food is not temperature and decreased breath sounds suggest that this patient may
handling secretions and is at risk for aspiration. This patient should be assessed have pyelonephritis. The physician should be notified immediately so that
further before feeding. Focus: Delegation/supervision antibiotic therapy can be started quickly.
23. Answer: B. Infuse ceftriaxone (Rocephin) 2000 mg IV to treat the infection. Options A, B, and C: The other patients should be assessed soon, but do not have
Option B: Untreated bacterial meningitis has a mortality rate approaching 100%, needs as urgent and this patient. Focus: Prioritization
so rapid antibiotic treatment is essential. 29. Answer: A, C, and E
Options A, C, and D: The other interventions will help reduce CNS stimulation and Options A, C, and E: NA education and scope of practice includes taking pulse and
irritation and should be implemented as soon as possible. Focus: Prioritization blood pressure measurements. In addition, NAs can reinforce previous teaching or
24. Answer: A. The student enters the room without putting on a mask and gown. skills taught by the RN or other disciplines, such as speech or physical therapists.
Option A: Meningococcal meningitis is spread through contact with respiratory Evaluation of patient response to medication and development and individualizing
secretions so use of a mask and gown is required to prevent spread of the infection the plan of care require RN-level education and scope of practice. Focus:
to staff members or other patients. The other actions may not be appropriate but Delegation
they do not require intervention as rapidly. 30. Answer: A. Check for improvement in resident memory after medication therapy
Option B: The presence of a family member at the bedside may decrease patient is initiated.
confusion and agitation. Option A: LPN education and team leader responsibilities include checking for the
Option C: Patients with hyperthermia frequently complain of feeling chilled, but
warming the patient is not an appropriate intervention. would be communicated to the RN supervisor, who is responsible for overseeing
Option D: Checking the pupil response to light is appropriate, but it is not needed the plan of care for each resident.
every 30 minutes and is uncomfortable for a patient with photophobia. Focus: Options B and D: Assessment for changes on the Mini-Mental State Examination
Prioritization and developing the plan of care are RN responsibilities.
25. Answer: B. Administer phenytoin (Dilantin) 200 mg PO daily. Option C: Assisting residents with personal care and hygiene would be delegated
Option B: Administration of medications is included in LPN education and scope to nursing assistants working the LTC facility. Focus: Delegation
of practice. Collection of data about the seizure activity may be accomplished by an 31. Answer: B. Caregiver Role Strain related to continuous need for providing care
LPN/LVN who observes initial seizure activity. An LPN/LVN would know to call Option B: of sleep and anxiety over whether
the supervising RN immediately if a patient started to seize. the patient is receiving the correct medications are behaviors that support this
Options A, C, and D: Documentation of the seizure, patient teaching, and planning diagnosis.
of care are complex activities that require RN level education and scope of Option A: There is no e
practice. Focus: Delegation
26. Answer: C. Turn the patient to the side and protect airway. with medication administration indicate that the Risk for
Option C: The priority action during a generalized tonic-clonic seizure is to Options C and D: Ineffective Therapeutic Regimen Management and falls are not
protect the airway. priorities at this time. Focus: Prioritization
Option B: Administration of lorazepam should be the next action, since it will act 32. Answer: A. The patient does not recognize family members.
rapidly to control the seizure. Option A: The inability to recognize a family member is a new neurologic deficit
Option A: Although oxygen may be useful during the postictal phase, the for this patient, and indicates a possible increase in intracranial pressure (ICP).
hypoxemia during tonic-clonic seizures is caused by apnea. This change should be communicated to the physician immediately so that
Option D: Checking the level of consciousness is not appropriate during the treatment can be initiated.
seizure, because generalized tonic-clonic seizures are associated with a loss of Option C: The continued headache also indicates that the ICP may be elevated, but
consciousness. Focus: Prioritization it is not a new problem.
27. Answer: B. The white blood cell count is 2300/mm3.
 Options B and D: The glucose elevation and weight gain are common adverse C. Give two sharp thumps to the precordium, and check the pulse.
effects of dexamethasone that may require treatment, but they are not D. Administer two quick blows.
emergencies. Focus: Prioritization 6. Nurse Monett is caring for a client recovering from gastrointestinal bleeding. The
33. Answer: B. Transfer to radiology for a CT scan. nurse should:
Option B: essment data indicate that he may have a A. Plan care so the client can receive 8 hours of uninterrupted sleep each night.
chronic subdural hematoma. The priority goal is to obtain a rapid diagnosis and B. Monitor vital signs every 2 hours.
send the patient to surgery to have the hematoma evacuated. C. Make sure that the client takes food and medications at prescribed intervals.
Options A, C, and D: The other interventions also should be implemented as soon D. Provide milk every 2 to 3 hours.
as possible, but the initial nursing activities should be directed toward treatment 7. A male client was on warfarin (Coumadin) before admission and has been
of any intracranial lesion. Focus: Prioritization receiving heparin I.V. for 2 days. The partial thromboplastin time (PTT) is 68
34. Answer: C. C. A 46-year-old patient who was admitted 48 hours ago with bacterial seconds. What should Nurse Carla do?
meningitis and has an antibiotic dose due A. Stop the I.V. infusion of heparin and notify the physician.
Option C: This patient is the most stable of the patients listed. An RN from the B. Continue treatment as ordered.
medical unit would be familiar with administration of IV antibiotics. C. Expect the warfarin to increase the PTT.
Options A, B, and D: The other patients require assessments and care from D. Increase the dosage, because the level is lower than normal.
RNs more experienced in caring for patients with neurologic diagnoses. Focus: 8. A client underwent ileostomy, when should the drainage appliance be applied to
Assignment. the stoma?
In Text Mode: All questions and answers are given for reading and answering at your own A. 24 hours later, when edema has subsided.
pace. You can also copy this exam and make a printout. B. In the operating room.
1. Nurse Michelle should know that the drainage is normal four (4) days after a C. After the ileostomy begins to function.
sigmoid colostomy when the stool is: D. When the client is able to begin self-care procedures.
A. Green liquid 9. A client has undergone spinal anesthetic, it will be important that the nurse
B. Solid formed immediately position the client in:
C. Loose, bloody A. On the side, to prevent obstruction of airway by tongue.
D. Semiformed B. Flat on back.
2. Where would nurse Kristine place the call light for a male client with a right-sided C. On the back, with knees flexed 15 degrees.
brain attack and left homonymous hemianopsia? D. Flat on the stomach, with the head turned to the side.
10. While monitoring a male client several hours after a motor vehicle accident,
which assessment data suggest increasing intracranial pressure?
C. Directly in front of the client A. Blood pressure is decreased from 160/90 to 110/70.
D. Where the client like B. Pulse is increased from 87 to 95, with an occasional skipped beat.
3. A male client is admitted to the emergency department following an accident. C. The client is oriented when aroused from sleep and goes back to sleep immediately.
What are the first nursing actions of the nurse? D. The client refuses dinner because of anorexia.
A. Check respiration, circulation, neurological response. 11. Mrs. Cruz, 80 years old is diagnosed with pneumonia. Which of the following
B. Align the spine, check pupils, and check for hemorrhage. symptoms may appear first?
C. Check respirations, stabilize spine, and check circulation. A. Altered mental status and dehydration
D. Assess level of consciousness and circulation. B. Fever and chills
4. In evaluating the effect of nitroglycerin, Nurse Arthur should know that it reduces C. Hemoptysis and Dyspnea
preload and relieves angina by: D. Pleuritic chest pain and cough
A. Increasing contractility and slowing heart rate. 12. A male client has active tuberculosis (TB). Which of the following symptoms will
B. Increasing AV conduction and heart rate. be exhibited?
C. Decreasing contractility and oxygen consumption. A. Chest and lower back pain
D. Decreasing venous return through vasodilation. B. Chills, fever, night sweats, and hemoptysis
5. Nurse Patricia finds a female client who is post-myocardial infarction (MI) C. Fever of more than 104°F (40°C) and nausea
slumped on the side rails of the bed and unresponsive to shaking or shouting. Which D. Headache and photophobia
is the nurse next action? 13. Mark, a 7-year-
A. Call for help and note the time. tachypneic and afebrile and has a respiratory rate of 36 breaths/minute and has a
B. Clear the airway nonproductive cough. He recently had a cold. Form this history; the client may have
which of the following conditions?
A. Acute asthma 21. When caring for a female client who is being treated for hyperthyroidism, it is
B. Bronchial pneumonia important to:
C. Chronic obstructive pulmonary disease (COPD) A. Provide extra blankets and clothing to keep the client warm.
D. Emphysema B. Monitor the client for signs of restlessness, sweating, and excessive weight loss during
14. Marichu was given morphine sulfate for pain. She is sleeping and her respiratory thyroid replacement therapy.
which of the
following reactions? D. Encourage the client to be active to prevent constipation.
A. Asthma attack 22. Nurse Kris is teaching a client with history of atherosclerosis. To decrease the
B. Respiratory arrest risk of atherosclerosis, the nurse should encourage the client to:
C. Seizure A. Avoid focusing on his weight.
D. Wake up on his own B. Increase his activity level.
15. A 77-year-old male client is admitted for elective knee surgery. Physical C. Follow a regular diet.
examination reveals shallow respirations but no sign of respiratory distress. Which D. Continue leading a high-stress lifestyle.
of the following is a normal physiologic change related to aging? 23. Nurse Greta is working on a surgical floor. Nurse Greta must logroll a client
A. Increased elastic recoil of the lungs following a:
B. Increased number of functional capillaries in the alveoli A. Laminectomy
C. Decreased residual volume B. Thoracotomy
D. Decreased vital capacity C. Hemorrhoidectomy
16. Nurse John is caring for a male client receiving lidocaine I.V. Which factor is the D. Cystectomy
most relevant to administration of this medication? 24. A 55-year old client underwent cataract removal with intraocular lens implant.
A. Decrease in arterial oxygen saturation (SaO2) when measured with a pulse oximeter. Nurse Oliver is giving the client discharge instructions. These instructions should
B. Increase in systemic blood pressure. include which of the following?
C. Presence of premature ventricular contractions (PVCs) on a cardiac monitor. A. Avoid lifting objects weighing more than 5 lb (2.25 kg).
D. Increase in intracranial pressure (ICP). B. Lie on your abdomen when in bed.
17. Nurse Ron is caring for a male client taking an anticoagulant. The nurse should C. Keep rooms brightly lit.
teach the client to: D. Avoiding straining during bowel movement or bending at the waist.
A. Report incidents of diarrhea. 25. George should be taught about testicular examinations during:
B. Avoid foods high in vitamin K A. when sexual activity starts
C. Use a straight razor when shaving. B. After age 69
D. Take aspirin for pain relief. C. After age 40
18. Nurse Lynette is preparing a site for the insertion of an I.V. catheter. The nurse D. Before age 20
should treat excess hair at the site by: 26. A male client has undergone a colon resection. While turning him, wound
A. Leaving the hair intact dehiscence with evisceration occurs. Nurse Trish first response is to:
B. Shaving the area A. Call the physician.
C. Clipping the hair in the area B. Place a saline-soaked sterile dressing on the wound.
D. Removing the hair with a depilatory. C. Take a blood pressure and pulse.
19. Nurse Michelle is caring for an elderly female with osteoporosis. When teaching D. Pull the dehiscence closed.
the client, the nurse should include information about which major complication: 27. Nurse Audrey is caring for a client who has suffered a severe cerebrovascular
A. Bone fracture accident. During routine assessment, the nurse notices Cheyne- Stokes respirations.
B. Loss of estrogen Cheyne-stokes respirations are:
C. Negative calcium balance A. A progressively deeper breath followed by shallower breaths with apneic periods.
B. Rapid, deep breathing with abrupt pauses between each breath.
20. Nurse Len is teaching a group of women to perform BSE. The nurse should C. Rapid, deep breathing and irregular breathing without pauses.
explain that the purpose of performing the examination is to discover: D. Shallow breathing with an increased respiratory rate.
A. Cancerous lumps 28. Nurse Bea is assessing a male client with heart failure. The breath sounds
B. Areas of thickness or fullness commonly auscultated in clients with heart failure are:
C. Changes from previous examinations. A. Tracheal
D. Fibrocystic masses B. Fine crackles
C. Coarse crackles 36. Nurse Oliver is working in a outpatient clinic. He has been alerted that there is an
D. Friction rubs outbreak of tuberculosis (TB). Which of the following clients entering the clinic
29. The nurse is caring for Kenneth experiencing an acute asthma attack. The client today most likely to have TB?
change is that: A. A 16-year-old female high school student
A. The attack is over. B. A 33-year-old daycare worker
B. The airways are so swollen that no air cannot get through. C. A 43-year-old homeless man with a history of alcoholism
C. The swelling has decreased. D. A 54-year-old businessman
D. Crackles have replaced wheezes. 37. Virgie with a positive Mantoux test result will be sent for a chest X-ray. The nurse
30. Mike with epilepsy is having a seizure. During the active seizure phase, the nurse is aware that which of the following reasons this is done?
should: A. To confirm the diagnosis
A. Place the client on his back remove dangerous objects, and insert a bite block. B. To determine if a repeat skin test is needed
B. Place the client on his side, remove dangerous objects, and insert a bite block. C. To determine the extent of lesions
C. Place the client o his back, remove dangerous objects, and hold down his arms. D. To determine if this is a primary or secondary infection
D. Place the client on his side, remove dangerous objects, and protect his head. 38. Kennedy with acute asthma showing inspiratory and expiratory wheezes and a
31. After insertion of a chest tube for a pneumothorax, a client becomes hypotensive decreased forced expiratory volume should be treated with which of the following
with neck vein distention, tracheal shift, absent breath sounds, and diaphoresis. classes of medication right away?
Nurse Amanda suspects a tension pneumothorax has occurred. What cause of A. Beta-adrenergic blockers
tension pneumothorax should the nurse check for? B. Bronchodilators
A. Infection of the lung C. Inhaled steroids
B. Kinked or obstructed chest tube D. Oral steroids
C. Excessive water in the water-seal chamber 39. Mr. Vasquez 56-year-old client with a 40-year history of smoking one to two
D. Excessive chest tube drainage packs of cigarettes per day has a chronic cough producing thick sputum, peripheral
32. Nurse Maureen is talking to a male client, the client begins choking on his lunch. edema, and cyanotic nail beds. Based on this information, he most likely has which of
the following conditions?
A. Stand him up and perform the abdominal thrust maneuver from behind. A. Adult respiratory distress syndrome (ARDS)
B. Lay him down, straddle him, and perform the abdominal thrust maneuver. B. Asthma
C. Leave him to get assistance. C. Chronic obstructive bronchitis
D. Stay with him but not intervene at this time. D. Emphysema
33. Nurse Ron is taking a health history of an 84-year-old client. Which information Situation: Francis, age 46 is admitted to the hospital with diagnosis of Chronic
will be most useful to the nurse for planning care? Lymphocytic Leukemia.
A. General health for the last 10 years. 40. The treatment for patients with leukemia is bone marrow transplantation. Which
B. Current health promotion activities. statement about bone marrow transplantation is not correct?
C. Family history of diseases. A. The patient is under local anesthesia during the procedure
D. Marital status. B. The aspirated bone marrow is mixed with heparin.
34. When performing oral care on a comatose client, Nurse Krina should: C. The aspiration site is the posterior or anterior iliac crest.
D. The recipient receives cyclophosphamide (Cytoxan) for 4 consecutive days before the
B. Brush the teeth with client lying supine. procedure.
C. Place the client in a side-lying position, with the head of the bed lowered. 41. After several days of admission, Francis becomes disoriented and complains of
mouth with hydrogen peroxide. frequent headaches. The nurse in-charge first action would be:
35. A 77-year-old male client is admitted with a diagnosis of dehydration and change A. Call the physician.
B. Document the
signs, she notes he has a fever of 103°F (39.4°C) a cough producing yellow sputum C. Prepare oxygen treatment.
and pleuritic chest pain. The nurse suspects this client may have which of the D. Raise the side rails.
following conditions?
A. Adult respiratory distress syndrome (ARDS) -charge best
B. Myocardial infarction (MI) response would be that the increased number of white blood cells (WBC) is:
C. Pneumonia A. crowded red blood cells
D. Tuberculosis B. is not responsible for the anemia.
C. uses nutrients from other cells C. Radiation
D. have an abnormally short lifespan of cells. D. Immunotherapy
43. Diagnostic assessment of Francis would probably not reveal: 49. Cristina undergoes a biopsy of a suspicious lesion. The biopsy report classifies
A. Predominance of lymphoblasts the lesion according to the TNM staging system as follows: TIS, N0, M0. What does
B. Leukocytosis this classification mean?
C. Abnormal blast cells in the bone marrow A. No evidence of primary tumor, no abnormal regional lymph nodes, and no evidence of
D. Elevated thrombocyte counts distant metastasis
44. Robert, a 57-year-old client with acute arterial occlusion of the left leg undergoes B. Carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant
an emergency embol metastasis
his left foot using Doppler ultrasound. The nurse immediately notifies the physician
D. Carcinoma in situ, no demonstrable metastasis of the regional lymph nodes, and
to prepare him, he ascending degrees of distant metastasis
following is the best initial response by the nurse? 50. Lydia undergoes a laryngectomy to treat laryngeal cancer. When teaching the
A. Explain the risks of not having the surgery client how to care for the neck stoma, the nurse should include which instruction?
B. Notifying the physician immediately
C. Notifying the nursing supervisor

45. During the endorsement, which of the following clients should the on-duty nurse
assess first?
A. The 58-year-old client who was admitted 2 days ago with heart failure, blood pressure of
Answers & Rationale
126/76 mm Hg, and a respiratory rate of 22 breaths/minute Gauge your performance by counter checking your answers to the answers below. Learn
B. The 89-year-old client with end-stage right-sided heart failure, blood pressure of 78/50 more about the question by reading the rationale. If you have any disputes or questions,
please direct them to the comments section.
C. The 62-year-old client who was admitted 1 day ago with thrombophlebitis and is 1. Answer: C. Loose, bloody
receiving L.V. heparin Option C: Normal bowel function and soft-formed stool usually do not occur until
D. The 75-year-old client who was admitted 1 hour ago with new-onset atrial fibrillation around the seventh day following surgery. The stool consistency is related to how
and is receiving L.V. diltiazem (Cardizem) much water is being absorbed.
46. Honey, a 23-year old client complains of substernal chest pain and states that her 2. Answer: A. On
heart feels Option A: The client has left visual field blindness. The client will see only from
disorders. The nurse attaches her to a cardiac monitor and notes sinus tachycardia the right side.
with a rate of 136beats/minutes. Breath sounds are clear and the respiratory rate is 3. Answer: C. Check respirations, stabilize spine, and check circulation
26 breaths/minutes. Which of the following drugs should the nurse question the Option C: Checking the airway would be the priority, and a neck injury should be
client about using? suspected.
4. Answer: D. Decreasing venous return through vasodilation.
A. Barbiturates
B. Opioids Option D: The significant effect of nitroglycerin is vasodilation and decreased
C. Cocaine venous return, so the heart does not have to work hard.
5. Answer: A. Call for help and note the time.
D. Benzodiazepines
47. A 51-year-old female client tells the nurse-in-charge that she has found a painless Option A: Having established, by stimulating the client, that the client is
lump in her right breast during her monthly self-examination. Which assessment unconscious rather than sleep, the nurse should immediately call for help. This
finding would strongly sugges giving the
A. Eversion of the right nipple and mobile mass
B. Nonmobile mass with irregular edges the phone is not available, by pulling the emergency call button. Noting the time is
C. Mobile mass that is soft and easily delineated important baseline information for cardiac arrest procedure.
D. Nonpalpable right axillary lymph nodes 6. Answer: C. Make sure that the client takes food and medications at prescribed
48. A 35-year-old client with vaginal cancer intervals.
Option C: Food and drug therapy will prevent the accumulation of hydrochloric
A. Surgery acid, or will neutralize and buffer the acid that does accumulate.
7. Answer: B. Continue treatment as ordered.
B. Chemotherapy
 Option B: The effects of heparin are monitored by the PTT is normally 30 to 45 Options A, B, and D: SaO2, blood pressure, and ICP are important factors but
seconds; the therapeutic level is 1.5 to 2 times the normal level. PVCs in the situation.
8. Answer: B. In the operating room. 17. Answer: B. Avoid foods high in vitamin K
Option B: The stoma drainage bag is applied in the operating room. Drainage from Option B: The client should avoid consuming large amounts of vitamin K because
the ileostomy contains secretions that are rich in digestive enzymes and highly vitamin K can interfere with anticoagulation.
irritating to the skin. Protection of the skin from the effects of these enzymes is Option A: The client may need to report diarrhea
begun at once. Skin exposed to these enzymes even for a short time becomes anticoagulant.
reddened, painful, and excoriated. Option C: An electric razor-not a straight razor-should be used to prevent cuts
9. Answer: B. Flat on back. that cause bleeding.
Option B: To avoid the complication of a painful spinal headache that can last for Option D: Aspirin may increase the risk of bleeding; acetaminophen should be
several days, the client is kept in flat in a supine position for approximately 4 to 12 used for pain relief.
hours postoperatively. Headaches are believed to be caused by the seepage 18. Answer: C. Clipping the hair in the area
of cerebrospinal fluid from the puncture site. By keeping the client flat, cerebral Option C: Hair can be a source of infection and should be removed by clipping.
spinal fluid pressures are equalized, which avoids trauma to the neurons. Option B: Shaving the area can cause skin abrasions and depilatories can irritate
10. Answer: C. The client is oriented when aroused from sleep and goes back to sleep the skin.
immediately. 19. Answer: A. Bone fracture
Option C: This finding suggests that the level of consciousness is decreasing. Option A: Bone fracture is a major complication of osteoporosis that results when
11. Answer: A. Altered mental status and dehydration loss of calcium and phosphate increased the fragility of bones.
Options B, C, and D: Fever, chills, hemoptysis, dyspnea, cough, and pleuritic chest Option B: Estrogen deficiencies result from menopause and not osteoporosis.
pain are the common symptoms of pneumonia. Option C: Calcium and vitamin D supplements may be used to support normal
Option A: Elderly clients may first appear with only an altered mental status and
dehydration due to a blunted immune response. osteoporosis.
12. Answer: B. Chills, fever, night sweats, and hemoptysis Option D:
Option B: Typical signs and symptoms are chills, fever, night sweats, and repeated vertebral fractures increase spinal curvature.
hemoptysis. 20. Answer: C. Changes from previous examinations.
Option A: Option C: Women are instructed to examine themselves to discover changes that
Option C: Clients with TB typically have low-grade fevers, not higher than 102°F have occurred in the breast.
(38.9°C). Options A, B, and D: Only a physician can diagnose lumps that are cancerous,
Option D: areas of thickness or fullness that signal the presence of a malignancy, or masses
13. Answer: A. Acute asthma that are fibrocystic as opposed to malignant.
Option A:
likely diagnosis. Option C: A client with hyperthyroidism needs to be encouraged to balance
Options B, C, and D: periods of activity and rest. Many clients with hyperthyroidism are hyperactive
and complain of feeling very warm.
emphysema. 22. Answer: B. Increase his activity level.
14. Answer: B. Respiratory arrest Option B: The client should be encouraged to increase his activity level.
Option B: Narcotics can cause respiratory arrest if given in large quantities. Options A, C, and D: Maintaining an ideal weight; following a low-cholesterol, low
Options A, C, and D: t will have asthma attack or a seizure or sodium diet; and avoiding stress are all important factors in decreasing the risk of
wake up on his own. atherosclerosis.
15. Answer: D. Decreased vital capacity 23. Answer: A. Laminectomy
Option D: Reduction in vital capacity is a normal physiologic changes include Option A: The client who has had spinal surgery, such as laminectomy, must be
decreased elastic recoil of the lungs, fewer functional capillaries in the alveoli, and log rolled to keep the spinal column straight when turning.
an increased in residual volume. Options B and D: Thoracotomy and cystectomy may turn themselves or may be
16. Answer: C. Presence of premature ventricular contractions (PVCs) on a cardiac assisted into a comfortable position.
monitor. Option C: Under normal circumstances, hemorrhoidectomy is an outpatient
Option C: Lidocaine drips are commonly used to treat clients whose arrhythmias procedure, and the client may resume normal activities immediately after surgery.
24. Answer: D. Avoiding straining during bowel movement or bending at the waist.
visible on the cardiac monitor. Option D: The client should avoid straining, lifting heavy objects, and coughing
harshly because these activities increase intraocular pressure.
 Option A: Typically, the client is instructed to avoid lifting objects weighing more Option D: If the client is coughing, he should be able to dislodge the object or
than 15 lb (7kg) not 5lb. cause a complete obstruction. If complete obstruction occurs, the nurse should
Option B: Instruct the client when lying in bed to lie on either the side or back. perform the abdominal thrust maneuver with the client standing.
Option C: The client should avoid bright light by wearing sunglasses. Option B: If the client is unconscious, she should lay him down.
25. Answer: D. Before age 20. Option C: A nurse should never leave a choking client alone.
Option D: Testicular cancer commonly occurs in men between ages 20 and 30. A 33. Answer: B. Current health promotion activities
male client should be taught how to perform testicular self-examination before age Option B:
20, preferably when he enters his teens. Option A: General health in the previous 10 years is important, however, the
26. Answer: B. Place a saline-soaked sterile dressing on the wound. current activities of an 84-year-old client are most significant in planning care.
Option B: The nurse should first place saline-soaked sterile dressings on the open Option C: Family history of disease for a client in later years is of minor
wound to prevent tissue drying and possible infection. significance.
Options A and C: Option D: Marital status information may be important for discharge planning but
vital signs. is not as significant for addressing the immediate medical problem.
Option D: The dehiscence needs to be surgically closed, so the nurse should never 34. Answer: C. Place the client in a side-lying position, with the head of the bed
try to close it. lowered.
27. Answer: A. A progressively deeper breaths followed by shallower breaths with Option C: The client should be positioned in a side-lying position with the head of
apneic periods. the bed lowered to prevent aspiration. A small amount of toothpaste should be
Option A: Cheyne-Stokes respirations are breaths that become progressively used and the mouth swabbed or suctioned to remove pooled secretions.
deeper followed by shallower respirations with apneas periods. Option A: Lemon glycerin can be drying if used for extended periods.
Option B: Option B: Brushing the teeth with the client lying supine may lead to aspiration.
between each breath, and equal depth between each breath. Option D: Hydrogen peroxide is caustic to tissues and should not be used.
Option C: 35. Answer: C. Pneumonia
Option D: Tachypnea is shallow breathing with increased respiratory rate. Option C: Fever productive cough and pleuritic chest pain are common signs and
28. Answer: B. Fine crackles symptoms of pneumonia.
Option B: Fine crackles are caused by fluid in the alveoli and commonly occur in Option A: The client with ARDS has dyspnea and hypoxia with worsening hypoxia
clients with heart failure. over time, if not treated aggressively.
Option A: Tracheal breath sounds are auscultated over the trachea. Option B: Pleuritic chest pain varies with respiration, unlike the constant chest
Option C: Coarse crackles are caused by secretion accumulation in the airways.
Option D: Friction rubs occur with pleural inflammation. Option D: The client with TB typically has a cough producing blood-tinged
29. Answer: B. The airways are so swollen that no air cannot get through
Option B: During an acute attack, wheezing may stop and breath sounds become 36. Answer: C. A 43-year-old homeless man with a history of alcoholism
Option C: Clients who are economically disadvantaged, malnourished, and have
Options A and C: If the attack is over and swelling has decreased, there would be reduced immunity, such as a client with a history of alcoholism, are at extremely
no more wheezing and less emergent concern. high risk for developing TB.
Option D: Crackles do not replace wheezes during an acute asthma attack. Options A, B, and D: A high school student, daycare worker, and businessman
30. Answer: D. Place the client on his side, remove dangerous objects, and protect his probably have a much low risk of contracting TB.
head. 37. Answer: C. To determine the extent of lesions
Option D: During the active seizure phase, initiate precautions by placing the Option C: If the lesions are large enough, the chest X-ray will show their presence
client on his side, removing dangerous objects, and protecting his head from in the lungs.
injury. Option A: Sputum culture confirms the diagnosis.
Options A and B: A bite block should never be inserted during the active seizure Option B: There can be false-positive and false-negative skin test results.
phase. Insertion can break the teeth and lead to aspiration. Option D: A chest X-
31. Answer: B. Kinked or obstructed chest tube 38. Answer: B. Bronchodilators
Option B: Kinking and blockage of the chest tube is a common cause of a tension Option B: Bronchodilators are the first line of treatment for asthma because
pneumothorax. broncho-constriction is the cause of reduced airflow.
Option A: Infec Option A: Beta-
Option C bronchoconstriction.
32. Answer: D. Stay with him but not intervene at this time. Options C and D: Inhaled oral steroids may be given to reduce the inflammation
39. Answer: C. Chronic obstructive bronchitis Option B: Breast cancer tumors are fixed, hard, and poorly delineated with
Option C: Because of this extensive smoking history and symptoms, the client irregular edges.
most likely has chronic obstructive bronchitis. Option C: A mobile mass that is soft and easily delineated is most often a fluid-
Option A: Client with ARDS have acute symptoms of hypoxia and typically need filled benign cyst.
large amounts of oxygen. Option D: Axillary lymph nodes may or may not be palpable on initial detection of
Options B and D: Clients with asthma and emphysema tend not to have chronic a cancerous mass.
cough or peripheral edema. Option A: Nipple retraction not eversion may be a sign of cancer.
40. Answer: A. The patient is under local anesthesia during the procedure 48. Answer: C. Radiation
Option A: Before the procedure, the patient is administered with drugs that would Option C: The usual treatment for vaginal cancer is external or intravaginal
help to prevent infection and rejection of the transplanted cells such as antibiotics, radiation therapy.
cytotoxic, and corticosteroids. During the transplant, the patient is placed under Option A: Less often, surgery is performed.
general anesthesia. Option B: Chemotherapy typically is prescribed only if vaginal cancer is diagnosed
41. Answer: D. Raise the side rails in an early stage, which is rare.
Option D: A patient who is disoriented is at risk of falling out of bed. The initial Option D: t vaginal cancer.
action of the nurse should be raising the side rails to ensure patients safety. 49. Answer: B. Carcinoma in situ, no abnormal regional lymph nodes, and no
42. Answer: A. Crowd red blood cells evidence of distant metastasis
Option A: The excessive production of white blood cells crowd out red blood cells Option B: TIS, N0, M0 denotes carcinoma in situ, no abnormal regional lymph
production which causes anemia to occur. nodes, and no evidence of distant metastasis.
43. Answer: B. Leukocytosis Option A: No evidence of primary tumor, no abnormal regional lymph nodes, and
Option B: Chronic Lymphocytic leukemia (CLL) is characterized by increased no evidence of distant metastasis is classified as T0, N0, M0.
production of leukocytes and lymphocytes resulting in leukocytosis, and Option C:
proliferation of these cells within the bone marrow, spleen and liver. evidence of metastasis exists, the lesion is classified as TX, NX, M0.
44. Answer: A. Explain the risks of not having the surgery Option D: A progressive increase in tumor size, no demonstrable metastases of
Option A: The best initial response is to explain the risks of not having the the regional lymph nodes, and ascending degrees of distant metastasis is classified
surgery. as T1, T2, T3, or T4; N0; and M1, M2, or M3.
Options B, C, and D: If the client understands the risks but still refuses the nurse
Option D: The nurse should instruct the client to keep the stoma moist, such as by
applying a thin layer of petroleum jelly around the edges, because a dry stoma may
45. Answer: D. The 75-year-old client who was admitted 1 hour ago with new-onset become irritated.
atrial fibrillation and is receiving L.V. diltiazem (Cardizem) Option A: The nurse should recommend placing a stoma bib over the stoma to
Option D: The client with atrial fibrillation has the greatest potential to become filter and warm air before it enters the stoma.
unstable and is on L.V. medication that requires close monitoring. Option C: The client should begin performing stoma care without assistance as
Options C and A: After assessing this client, the nurse should assess the client soon as possible to gain independence in self-care activities.
with thrombophlebitis who is receiving a heparin infusion, and then the 58- year- In Text Mode: All questions and answers are given for reading and answering at your own
old client admitted 2 days ago with heart failure (his signs and symptoms are pace. You can also copy this exam and make a printout.
1. A 37-year-old client with uterine cancer asks the nurse
Option B: The lowest priority is the 89-year-old with end-stage right-sided heart breast cancer. Which
failure, who requires time-consuming supportive measures. type of cancer causes the most deaths in women?
46. Answer: C. Cocaine A. Breast cancer
Option C: B. Lung cancer
should question her about cocaine use. Cocaine increases myocardial oxygen C. Brain cancer
consumption and can cause coronary artery spasm, leading to tachycardia, D. Colon and rectal cancer
ventricular fibrillation, myocardial ischemia, and myocardial infarction. 2. Antonio tumor invades
Option A: Barbiturate overdose may trigger respiratory depression and slow the ribs and affects the sympathetic nerve ganglia. When assessing for signs and
pulse. symptoms of this syndrome, the nurse should note:
Options B and D: Opioids can cause marked respiratory depression, while A. miosis, partial eyelid ptosis, and anhidrosis on the affected side of the face.
benzodiazepines can cause drowsiness and confusion. B. chest pain, dyspnea, cough, weight loss, and fever.
47. Answer: B. Nonmobile mass with irregular edges C. arm and shoulder pain and atrophy of arm and hand muscles, both on the affected side.
D. hoarseness and dysphagia.
3. Vic asks the nurse what PSA is. The nurse should reply that it stands for: C. Joint flexion of less than 50%
A. prostate-specific antigen, which is used to screen for prostate cancer. D. Joint stiffness
B. protein serum antigen, which is used to determine protein levels. 11. Mr. Rodriguez is admitted with severe pain in the knees. Which form
C. pneumococcal strep antigen, which is a bacteria that causes pneumonia. of arthritis is characterized by urate deposits and joint pain, usually in the feet and
D. Papanicolaou-specific antigen, which is used to screen for cervical cancer. legs, and occurs primarily in men over age 30?
4. What is the most important postoperative instruction that nurse Kate must give a A. Septic arthritis
client who has just returned from the operating room after receiving a subarachnoid B. Traumatic arthritis
block? C. Intermittent arthritis
gag reflex D. Gouty arthritis
12. A heparin infusion at 1,500 unit/hour is ordered for a 64-year-old client
blood in your urine with stroke in evolution. The infusion contains 25,000 units of heparin in 500 ml of
supine saline solution. How many milliliters per hour should be given?
5. A male client suspected of having colorectal cancer will require which diagnostic A. 15 ml/hour
study to confirm the diagnosis? B. 30 ml/hour
A. Stool Hematest C. 45 ml/hour
B. Carcinoembryonic antigen (CEA) D. 50 ml/hour
C. Sigmoidoscopy 13. A 76-year-old male client had a thromboembolic right stroke; his left arm is
D. Abdominal computed tomography (CT) scan swollen. Which of the following conditions may cause swelling after a stroke?
6. During a breast examination, which finding most strongly suggests that the Luz A. Elbow contracture secondary to spasticity
has breast cancer? B. Loss of muscle contraction decreasing venous return
A. Slight asymmetry of the breasts. C. Deep vein thrombosis (DVT) due to immobility of the ipsilateral side
B. A fixed nodular mass with dimpling of the overlying skin D. Hypoalbuminemia due to protein escaping from an inflamed glomerulus
C. Bloody discharge from the nipple osteoarthritis. Which of the following
D. Multiple firm, round, freely movable masses that change with the menstrual cycle statement is correct about this deformity?
7. A female client with cancer is being evaluated for possible metastasis. Which of the A. It appears only in men
following is one of the most common metastasis sites for cancer cells? B. It appears on the distal interphalangeal joint
A. Liver C. It appears on the proximal interphalangeal joint
B. Colon D. It appears on the dorsolateral aspect of the interphalangeal joint.
C. Reproductive tract 15. Which of the following statements explains the main difference
D. White blood cells (WBCs) between rheumatoid arthritis and osteoarthritis?
8. Nurse Mandy is preparing a client for magnetic resonance imaging (MRI) to A. Osteoarthritis is gender-specific, rheumatoid arthritis
confirm or rule out a spinal cord lesion. During the MRI scan, which of the following B. Osteoarthritis is a localized disease rheumatoid arthritis is systemic
would pose a threat to the client? C. Osteoarthritis is a systemic disease, rheumatoid arthritis is localized
A. The client lies still.
B. The client asks questions. 16. Mrs. Cruz uses a cane for assistance in walking. Which of the following
C. The client hears thumping sounds. statements is true about a cane or other assistive devices?
D. The client wears a watch and wedding band. A. A walker is a better choice than a cane.
9. Nurse Cecile is teaching a female client about preventing osteoporosis. Which of B. The cane should be used on the affected side
the following teaching points is correct? C. The cane should be used on the unaffected side
A. Obtaining an X-ray of the bones every 3 years is recommended to detect bone loss. D. A client with osteoarthritis should be encouraged to ambulate without the cane
B. To avoid fractures, the client should avoid strenuous exercise. 17. A male client with type 1 diabetes is scheduled to receive 30 U of 70/30 insulin.
C. The recommended daily allowance of calcium may be found in a wide variety of foods. There is no 70/30 insulin available. As a substitution, the nurse may give the client:
D. Obtaining the recommended daily allowance of calcium requires taking a calcium A. 9 U regular insulin and 21 U neutral protamine Hagedorn (NPH).
supplement. B. 21 U regular insulin and 9 U NPH.
10. Before Jacob undergoes arthroscopy, the nurse reviews the assessment findings C. 10 U regular insulin and 20 U NPH.
for contraindications for this procedure. Which finding is a contraindication? D. 20 U regular insulin and 10 U NPH.
A. Joint pain 18. Nurse Len should expect to administer which medication to a client with gout?
B. Joint deformity A. aspirin
B. furosemide (Lasix)
C. colchicines reports numbness and tingling of the mouth and fingertips. Suspecting a life-
D. calcium gluconate (Kalcinate) threatening electrolyte disturbance, the nurse notifies the surgeon immediately.
19. Mr. Domingo with a history of hypertension is diagnosed with primary Which electrolyte disturbance most commonly follows thyroid surgery?
hypertension is caused A. Hypocalcemia
by excessive hormone secretion from which of the following glands? B. Hyponatremia
A. Adrenal cortex C. Hyperkalemia
B. Pancreas D. Hypermagnesemia
C. Adrenal medulla
D. Parathyroid a general indicator of cancer?
20. For a diabetic male client with a foot ulcer, the doctor orders bed rest, a wetto- A. Acid phosphatase level
dry dressing change every shift, and blood glucose monitoring before meals and B. Serum calcitonin level
bedtime. Why are wet-to-dry dressings used for this client? C. Alkaline phosphatase level
A. They contain exudate and provide a moist wound environment. D. Carcinoembryonic antigen level
B. They protect the wound from mechanical trauma and promote healing. 28. Francis with anemia has been admitted to the medical-surgical unit. Which
C. They debride the wound and promote healing by secondary intention. assessment findings are characteristic of iron-deficiency anemia?
D. They prevent the entrance of microorganisms and minimize wound discomfort. A. Nights sweats, weight loss, and diarrhea
21. Nurse Zeny is caring for a client in acute addisonian crisis. Which laboratory data B. Dyspnea, tachycardia, and pallor
would the nurse expect to find? C. Nausea, vomiting, and anorexia
A. Hyperkalemia D. Itching, rash, and jaundice
B. Reduced blood urea nitrogen (BUN) 29. In teaching a female client who is HIV-positive about pregnancy, the nurse would
C. Hypernatremia know more teaching is necessary when the client says:
D. Hyperglycemia A. The baby can get the virus from my placenta
22. A client is admitted for treatment of the syndrome of inappropriate antidiuretic
hormone (SIADH). Which nursing intervention is appropriate?
A. Infusing I.V. fluids rapidly as ordered -
B. Encouraging increased oral intake 30. When preparing Judy with acquired immunodeficiency syndrome (AIDS) for
C. Restricting fluids discharge to the home, the nurse should be sure to include which instruction?
D. Administering glucose-containing I.V. fluids as ordered
23. A female client tells nurse Nikki that she has been working hard for the last 3
months to control her type 2 diabetes mellitus with diet and exercise. To determine

A. urine glucose level. 31. Nurse Marie is caring for a 32-year-old client admitted with pernicious anemia.
B. fasting blood glucose level. Which set of findings should the nurse expect when assessing the client?
C. serum fructosamine level. A. Pallor, bradycardia, and reduced pulse pressure
D. glycosylated hemoglobin level. B. Pallor, tachycardia, and a sore tongue
24. Nurse Trinity administered neutral protamine Hagedorn (NPH) insulin to a C. Sore tongue, dyspnea, and weight gain
diabetic client at 7 a.m. At what time would the nurse expect the client to be most at D. Angina, double vision, and anorexia
risk for a hypoglycemic reaction? 32. After receiving a dose of penicillin, a client develops dyspnea and hypotension.
A. 10:00 am Nurse Celestina suspects the client is experiencing anaphylactic shock. What should
B. Noon the nurse do first?
C. 4:00 pm A. Page an anesthesiologist immediately and prepare to intubate the client.
D. 10:00 pm B. Administer epinephrine, as prescribed, and prepare to intubate the client if necessary.
25. The adrenal cortex is responsible for producing which substances?
A. Glucocorticoids and androgens vital signs.
B. Catecholamines and epinephrine D. Insert an indwelling urinary catheter and begin to infuse I.V. fluids as ordered.
C. Mineralocorticoids and catecholamines 33. Mr. Marquez with rheumatoid arthritis is about to begin aspirin therapy to
D. Norepinephrine and epinephrine reduce inflammation. When teaching the client about aspirin, the nurse discusses
26. On the third day after a partial thyroidectomy, Proserfina exhibits muscle adverse reactions to prolonged aspirin therapy. These include:
twitching and hyperirritability of the nervous system. When questioned, the client
A. weight gain. C. Orange
B. fine motor tremors. D. Strawberries
C. respiratory acidosis. 41. Nurse John is caring for clients in the outpatient clinic. Which of the following
D. bilateral hearing loss. phone calls should the nurse return first?
34. A 23-year-old client is diagnosed with human immunodeficiency virus (HIV). A. A c
After recovering from the initial shock of the diagnosis, the client expresses a desire
to learn as much as possible about HIV and acquired immunodeficiency syndrome
(AIDS). When teaching the client about the immune system, the nurse states that D.
adaptive immunity is provided by which type of white blood cell? 42. Nurse Sarah is caring for clients on the surgical floor and has just received report
A. Neutrophil from the previous shift. Which of the following clients should the nurse see first?
B. Basophil A. A 35-year-old admitted three hours ago with a gunshot wound; 1.5 cm area of dark
C. Monocyte drainage noted on the dressing.
D. Lymphocyte B. A 43-year-old who had a mastectomy two days ago; 23 ml of serosanguinous fluid noted
syndrome, nursing care should focus on: in the Jackson-Pratt drain.
A. moisture replacement. C. A 59-year-old with a collapsed lung due to an accident; no drainage noted in the previous
B. electrolyte balance. eight hours.
C. nutritional supplementation. D. A 62-year-old who had an abdominal-perineal resection three days ago; client
D. arrhythmia management. complaints of chills.
36. During chemotherapy for lymphocytic leukemia, Mathew develops abdominal 43. Nurse Eve is caring for a client who had a thyroidectomy 12 hours ago for
diarrhea. It would be most important for the
nurse to advise the physician to order: following was observed?
A. enzyme-linked immunosuppressant assay (ELISA) test. A. Blood pressure 138/82, respirations 16, oral temperature 99 degrees Fahrenheit.
B. electrolyte panel and hemogram. B. The client supports his head and neck when turning his head to the right.
C. stool for Clostridium difficile test. C. The client spontaneously flexes his wrist when the blood pressure is obtained.
D. flat plate X-ray of the abdomen. D. The client is drowsy and complains of sore throat.
37. A male client seeks medical evaluation for fatigue, night sweats, and a 20-lb 44. Julius is admitted with complaints of severe pain in the lower right quadrant of
weight loss in 6 weeks. To confirm that the client has been infected with the human the abdomen. To assist with pain relief, the nurse should take which of the following
immunodeficiency virus (HIV), the nurse expects the physician to order: actions?
A. E-rosette immunofluorescence. A. Encourage the client to change positions frequently in bed.
B. Quantification of T-lymphocytes. B. Administer Demerol 50 mg IM q 4 hours and PRN.
C. Enzyme-linked immunosorbent assay (ELISA). C. Apply warmth to the abdomen with a heating pad.
D. Western blot test with ELISA. D. Use comfort measures and pillows to position the client.
38. A complete blood count is commonly performed before a Joe goes into surgery. 45. Nurse Tina prepares a client for peritoneal dialysis. Which of the following
What does this test seek to identify? actions should the nurse take first?
A. Potential hepatic dysfunction indicated by decreased blood urea nitrogen (BUN) and A. Assess for a bruit and a thrill.
creatinine levels B. Warm the dialysate solution.
B. Low levels of urine constituents normally excreted in the urine C. Position the client on the left side.
C. Abnormally low hematocrit (HCT) and hemoglobin (Hb) levels D. Insert a Foley catheter
D. Electrolyte imbalance ate properly 46. Nurse Jannah teaches an elderly client with right-sided weakness how to use
39. While monitoring a client for the development of disseminated intravascular cane. Which of the following behaviors, if demonstrated by the client to the nurse,
coagulation (DIC), the nurse should take note of what assessment parameters? indicates that the teaching was effective?
A. Platelet count, prothrombin time, and partial thromboplastin time A. The client holds the cane with his right hand, moves the can forward followed by the
B. Platelet count, blood glucose levels, and white blood cell (WBC) count right leg, and then moves the left leg.
C. Thrombin time, calcium levels, and potassium levels B. The client holds the cane with his right hand, moves the cane forward followed by his left
D. Fibrinogen level, WBC, and platelet count leg, and then moves the right leg.
40. When taking a dietary history from a newly admitted female client, Nurse Len C. The client holds the cane with his left hand, moves the cane forward followed by the
should remember that which of the following foods is a common allergen? right leg, and then moves the left leg.
A. Bread D. The client holds the cane with his left hand, moves the cane forward followed by his left
B. Carrots leg, and then moves the right leg.
47. An elderly client is admitted to the nursing home setting. The client is Option C: Arm and shoulder pain and atrophy of the arm and hand muscles on the
occasionally confused and her gait is often unsteady. Which of the following actions,
if taken by the nurse, is most appropriate? and eighth cervical nerves within the brachial plexus.
Option D: Hoarseness in a client with lung cancer suggests that the tumor has
B. Select a room with a bed by the door so the woman can look down the hall. extended to the recurrent laryngeal nerve; dysphagia suggests that the lung tumor
C. Suggest the woman eat her meals in the room with her roommate. is compressing the esophagus.
D. Encourage the woman to ambulate in the halls twice a day. 3. Answer: A. prostate-specific antigen, which is used to screen for prostate cancer.
48. Nurse Evangeline teaches an elderly client how to use a standard aluminum Option A: PSA stands for prostate-specific antigen, which is used to screen for
walker. Which of the following behaviors, if demonstrated by the client, indicates prostate cancer.
effective? Options B, C, and D: The other answers are incorrect.
A. The client slowly pushes the walker forward 12 inches, then takes small steps forward
while leaning on the walker. Option D: The nurse should instruct the client to remain supine for the time
B. The client lifts the walker, moves it forward 10 inches, and then takes several small steps specified by the physician.
forward. Option A: Local anesthetics the gag reflex.
C. The client supports his weight on the walker while advancing it forward, then takes Option B: No interactions between local anesthetics and food occur.
small steps while balancing on the walker. Option C: hematuria.
D. The client slides the walker 18 inches forward, then takes small steps while holding onto 5. Answer: C. Sigmoidoscopy
the walker for balance. Option C: Used to visualize the lower GI tract, sigmoidoscopy and proctoscopy aid
49. Nurse Derek is supervising a group of elderly clients in a residential home in the detection of two-thirds of all colorectal cancers.
setting. The nurse knows that the elderly are at greater risk of developing sensory Option A: Stool Hematest detects blood, which is a sign of colorectal cancer;
deprivation for what reason?
A. Increased sensitivity to the side effects of medications. Option B:
B. Decreased visual, auditory, and gustatory abilities. confirming test.
C. Isolation from their families and familiar surroundings. Option D: An abdominal CT scan is used to stage the presence of colorectal cancer.
D. Decrease musculoskeletal function and mobility. 6. Answer: B. A fixed nodular mass with dimpling of the overlying skin
50. A male client with emphysema becomes restless and confused. What step should Option B: A fixed nodular mass with dimpling of the overlying skin is common
nurse Jasmine take next? during late stages of breast cancer.
A. Encourage the client to perform pursed-lip breathing. Option A: Many women have slightly asymmetrical breasts.
Option C: Bloody nipple discharge is a sign of intraductal papilloma, a benign
condition.
Option D: Multiple firm, round, freely movable masses that change with the
Answers & Rationale menstrual cycle indicate fibrocystic breasts, a benign condition.
7. Answer: A. Liver
Gauge your performance by counter checking your answers to the answers below. Learn
Option A: The liver is one of the five most common cancer metastasis sites. The
more about the question by reading the rationale. If you have any disputes or questions, others are the lymph nodes, lung, bone, and brain.
please direct them to the comments section. Options B, C, and D: The colon, reproductive tract, and WBCs are occasional
1. Answer: B. Lung cancer
metastasis sites.
Option B: Lung cancer is the most deadly type of cancer in both women and men. 8. Answer: D. The client wears a watch and wedding band.
Options A, C, and D: Breast cancer ranks second in women, followed (in Option D: During an MRI, the client should wear no metal objects, such as jewelry,
descending order) by colon and rectal cancer, pancreatic cancer, ovarian cancer, because the strong magnetic field can pull on them, causing injury to the client and
uterine cancer, lymphoma, leukemia, liver cancer, brain cancer, stomach cancer, (if they fly off) to others.
and multiple myeloma. Options A and B: The client must lie still during the MRI but can talk to those
2. Answer: A. miosis, partial eyelid ptosis, and anhidrosis on the affected side of the performing the test by way of the microphone inside the scanner tunnel.
face. Option C: The client should hear thumping sounds, which are caused by the sound
Option A: waves thumping on the magnetic field.
and affects the sympathetic nerve ganglia, is characterized by miosis, partial eyelid
9. Answer: C. The recommended daily allowance of calcium may be found in a wide
ptosis, and anhidrosis on the affected side of the face. variety of foods.
Option B: Chest pain, dyspnea, cough, weight loss, and fever are associated with
pleural tumors.
 Option C: Premenopausal women require 1,000 mg of calcium per day. Option C: A cane should be used on the unaffected side. A client with
osteoarthritis should be encouraged to ambulate with a cane, walker, or other
possible to get the recommended daily requirement in the foods we eat. assistive device as needed; their use takes weight and stress off joints.
Option D: Supplements are available but not always necessary. 17. Answer: A. 9 U regular insulin and 21 U neutral protamine Hagedorn (NPH).
Option A: -rays until 30% of the bone Option A: A 70/30 insulin preparation is 70% NPH and 30% regular insulin.
loss has occurred. Bone densitometry can detect bone loss of 3% or less. This test Therefore, a correct substitution requires mixing 21 U of NPH and 9 U of regular
is sometimes recommended routinely for women over 35 who are at risk. insulin.
Option B: Options B, C, and D: The other choices are incorrect dosages for the prescribed
10. Answer: C. Joint flexion of less than 50% insulin.
Option C: Arthroscopy is contraindicated in clients with joint flexion of less than 18. Answer: C. colchicines
50% because of technical problems in inserting the instrument into the joint to see Option C: A disease characterized by joint inflammation (especially in the great
it clearly. Other contraindications for this procedure include skin and wound toe), gout is caused by urate crystal deposits in the joints. The physician prescribes
infections. colchicine to reduce these deposits and thus ease joint inflammation.
Option A: Joint pain may be an indication, not a contraindication, for arthroscopy. Option A: Although aspirin is used to reduce joint inflammation and pain in clients
Options B and D: Joint defo with
this procedure. has no effect on urate crystal formation.
11. Answer: D. Gouty arthritis Option B:
Option D: Gouty arthritis, a metabolic disease, is characterized by urate deposits Option D: Calcium gluconate is used to reverse a negative calcium balance and
and pain in the joints, especially those in the feet and legs. Urate de relieve muscle cramps, not to treat gout.
occur in septic or traumatic arthritis. 19. Answer: A. Adrenal cortex
Option A: Septic arthritis results from bacterial invasion of a joint and leads to Option A: Excessive secretion of aldosterone in the adrenal cortex is responsible
inflammation of the synovial lining. renal tubule, where it
Option B: Traumatic arthritis results from blunt trauma to a joint or ligament. promotes reabsorption of sodium and excretion of potassium and hydrogen ions.
Option C: Intermittent arthritis is a rare, benign condition marked by regular, Option B: The pancreas mainly secretes hormones involved in fuel metabolism.
recurrent joint effusions, especially in the knees. Option C: The adrenal medulla secretes the catecholamines epinephrine and
12. Answer: B. 30 ml/hour norepinephrine.
Option B: An infusion prepared with 25,000 units of heparin in 500 ml of saline Option D: The parathyroids secrete parathyroid hormone.
solution yields 50 units of heparin per milliliter of solution. The equation is set up 20. Answer: C. They debride the wound and promote healing by secondary intention
as 50 units times X (the unknown quantity) equals 1,500 units/hour, X equals 30 Option C: For this client, wet-to-dry dressings are most appropriate because they
ml/hour. clean the foot ulcer by debriding exudate and necrotic tissue, thus promoting
13. Answer: B. Loss of muscle contraction decreasing venous return healing by secondary intention.
Option B: In clients with hemiplegia or hemiparesis loss of muscle contraction Option A: Moist, transparent dressings contain exudate and provide a moist
decreases venous return and may cause swelling of the affected extremity. wound environment.
Option A: Contractures or bony calcifications Option D: Hydrocolloid dressings prevent the entrance of microorganisms and
appear with swelling. minimize wound discomfort.
Option C: DVT may develop in clients with a stroke but is more likely to occur in Option B: Dry sterile dressings protect the wound from mechanical trauma and
the lower extremities. promote healing.
Option D: 21. Answer: A. Hyperkalemia
14. Answer: B. It appears on the distal interphalangeal joint Option A: In adrenal insufficiency, the client has hyperkalemia due to reduced
Option B: aldosterone secretion.
men and women. Option B: BUN increases as the glomerular filtration rate is reduced.
Option D: Option C: Hyponatremia is caused by reduced aldosterone secretion.
interphalangeal joint. Option D: Reduced cortisol secretion leads to impaired gluconeogenesis and a
15. Answer: B. Osteoarthritis is a localized disease rheumatoid arthritis is systemic reduction of glycogen in the liver and muscle, causing hypoglycemia.
Option B: Osteoarthritis is a localized disease, rheumatoid arthritis is systemic. 22. Answer: C. Restricting fluids
Option A: -specific, but rheumatoid arthritis is. Option C: To reduce water retention in a client with the SIADH, the nurse should
Option D: Clients have dislocations and subluxations in both disorders. restrict fluids.
16. Answer: C. The cane should be used on the unaffected side Options A, B, and D: Administering fluids by any route would further increase the
23. Answer: D. glycosylated hemoglobin level. Option A: The human immunodeficiency virus (HIV) is transmitted from mother
Option D: Because some of the glucose in the bloodstream attaches to some of the to child via the transplacental route.
hemoglobin and stays attached during the 120-day lifespan of red blood cells, Option B: The use of birth control will prevent the conception of a child who
glycosylated hemoglobin levels provide information about blood glucose levels might have HIV.
during the previous 3 months. Option C:
Options A and B: Fasting blood glucose and urine glucose levels only give HIV negative.
information about glucose levels at the point in time when they were obtained.
Option C: Serum fructosamine levels provide information about blood glucose Option C: The human immunodeficiency virus (HIV), which causes AIDS, is most
control over the past 2 to 3 weeks. personal
24. Answer: C. 4:00 pm articles that may be blood-contaminated, such as toothbrushes and razors, with
Option C: NPH is an intermediate-acting insulin that peaks 8 to 12 hours after other family members.
administration. Because the nurse administered NPH insulin at 7 a.m., the client is Options A, B, and D:
at greatest risk for hypoglycemia from 3 p.m. to 7 p.m. utensils, or serving dishes used by a person with AIDS.
25. Answer: A. Glucocorticoids and androgens 31. Answer: B. Pallor, tachycardia, and a sore tongue
Option A: The adrenal glands have two divisions, the cortex and medulla. The Option B: Pallor, tachycardia, and a sore tongue are all characteristic findings in
cortex produces three types of hormones: glucocorticoids, mineralocorticoids, and pernicious anemia. Other clinical manifestations include anorexia; weight loss; a
androgens. smooth, beefy red tongue; a wide pulse pressure; palpitations; angina; weakness;
Options B and D: The medulla produces catecholamines epinephrine and fatigue; and paresthesia of the hands and feet.
norepinephrine. Options A, C, and D: Bradycardia, reduced pulse pressure, weight gain, and
26. Answer: A. Hypocalcemia
Option A: Hypocalcemia may follow thyroid surgery if the parathyroid 32. Answer: B. Administer epinephrine, as prescribed, and prepare to intubate the
glands were removed accidentally. Signs and symptoms of hypocalcemia may be client if necessary.
delayed for up to 7 days after surgery. Thyroid sur Option B: To reverse anaphylactic shock, the nurse first should administer
serum sodium, potassium, or magnesium abnormalities. epinephrine, a potent bronchodilator as prescribed.
Option B: Hyponatremia may occur if the client inadvertently received too much Option A: The physician is likely to order additional medications, such
fluid; however, this can happen to any surgical client receiving I.V. fluid therapy, as antihistamines
not just one recovering from thyroid surgery. respiratory compromise associated with anaphylaxis, the nurse should prepare to
Options C and D: Hyperkalemia and hypermagnesemia usually are associated intubate the client.
with reduced renal excretion of potassium and magnesium, not thyroid surgery. Option C: No antidote for penicillin exists; however, the nurse should continue to
27. Answer: D. Carcinoembryonic antigen level signs. A client who remains hypotensive may need fluid
Option D: In clients who smoke, the level of carcinoembryonic antigen is elevated. resuscitation and fluid intake and output monitoring; however, administering
There epinephrine is the first priority.
monitoring cancer treatment because the level usually falls to normal within 1 33. Answer: D. bilateral hearing loss.
month if treatment is successful. Option D: Prolonged use of aspirin and other salicylates sometimes causes
Option A: An elevated acid phosphatase level may indicate prostate cancer. bilateral hearing loss of 30 to 40 decibels. Usually, this adverse effect resolves
Option C: An elevated alkaline phosphatase level may reflect bone metastasis. within 2 weeks after the therapy is discontinued.
Option B: An elevated serum calcitonin level usually signals thyroid cancer. Options A and B:
28. Answer: B. Dyspnea, tachycardia, and pallor Option C: Large or toxic salicylate doses may cause respiratory alkalosis, not
Option B: Signs of iron-deficiency anemia include dyspnea, tachycardia, and pallor respiratory acidosis.
as well as fatigue, listlessness, irritability, and headache. 34. Answer: D. Lymphocyte
Option A: Night sweats, weight loss, and diarrhea may signal acquired Option D: The lymphocyte provides adaptive immunity recognition of a foreign
immunodeficiency syndrome (AIDS). antigen and formation of memory cells against the antigen. Adaptive immunity is
Option C: Nausea, vomiting, and anorexia may be signs of hepatitis B. mediated by B and T lymphocytes and can be acquired actively or passively.
Option D: Itching, rash, and jaundice may result from an allergic or hemolytic Option A: The neutrophil is crucial to phagocytosis.
reaction. Option B: The basophil plays an important role in the release of inflammatory
29. Answer: D. - mediators.
Option D: A Cesarean section - Option C: The monocyte functions in phagocytosis and monokine production.
positive. 35. Answer: A. moisture replacement.
 Option A:
loss of lubrication of the skin, GI tract, ears, nose, and vagina. Moisture
replacement is the mainstay of therapy. Option B: It may indicate neurovascular compromise, requires immediate
Options B and C: Though malnutrition and electrolyte imbalance may occur as a assessment.
42. Answer: D. A 62-year-old who had an abdominal-perineal resection three days
problem. ago; client complaints of chills.
Option D: Option D: The client is at risk for peritonitis; should be assessed for further
36. Answer: C. stool for Clostridium difficile test. symptoms and infection.
Option C: Immunosuppressed clients for example, clients 43. Answer: C. The client spontaneously flexes his wrist when the blood pressure is
receiving chemotherapy, are at risk for infection with C. difficile, which causes obtained.
Option C: Carpal spasms indicate hypocalcemia.
diagnosis, which includes a stool test. 44. Answer: D. Use comfort measures and pillows to position the client.
Option A: The ELISA test is diagnostic for human immunodeficiency virus (HIV) Option D: Using comfort measures and pillows to position the client is a non-
se. pharmacological methods of pain relief.
Option B: An electrolyte panel and hemogram may be useful in the overall 45. Answer: B. Warm the dialysate solution.
Option B: Cold dialysate increases discomfort. The solution should be warmed to
Option D: A flat plate of the abdomen may provide useful information about
46. Answer: C. The client holds the cane with his left hand, moves the cane forward
37. Answer: D. Western blot test with ELISA. followed by the right leg, and then moves the left leg.
Option D: HIV infection is detected by analyzing blood for antibodies to HIV, Option C: The cane acts as a support and aids in weight bearing for the weaker
which form approximately 2 to 12 weeks after exposure to HIV and denote right leg.
infection. The Western blot test electrophoresis of antibody proteins is more provide personal items such as photos or
than 98% accurate in detecting HIV antibodies when used in conjunction with the mementos.
Option A: Photos and mementos provide visual stimulation to reduce sensory
Option A: E-rosette immunofluorescence is used to detect viruses in general; it deprivation.
48. Answer: B. The client lifts the walker, moves it forward 10 inches, and then takes
Option B: Quantification of T- several small steps forward.
diagnostic for HIV. Option B: A walker needs to be picked up, placed down on all legs.
Option C: The ELISA test detects HIV antibody particles but may yield inaccurate 49. Answer: B. Decreased visual, auditory, and gustatory abilities.
results; a positive ELISA result must be confirmed by the Western blot test. Option B: Gradual loss of sight, hearing, and taste interferes with normal
38. Answer: C. Abnormally low hematocrit (HCT) and hemoglobin (Hb) levels functioning.
Option C: Low preoperative HCT and Hb levels indicate the client may require a 50. Answer: A. Encourage the client to perform pursed-lip breathing.
blood transfusion before surgery. If the HCT and Hb levels decrease during Option A: Pursed lip breathing prevents the collapse of lung unit and helps client
surgery because of blood loss, the potential need for a transfusion increases. control rate and depth of breathing.
Option A: Possible renal failure is indicated by elevated BUN or creatinine levels. In Text Mode: All questions and answers are given for reading and answering at your own
Option B: pace. You can also copy this exam and make a printout.
Option D: Coagulation is determined by the presence of 1. Randy has undergone kidney transplant, what assessment would
appropriate clotting factors, not electrolytes. prompt Nurse Katrina to suspect organ rejection?
39. Answer: A. Platelet count, prothrombin time, and partial thromboplastin time A. Sudden weight loss
Option A: The diagnosis of DIC is based on the results of laboratory studies of B. Polyuria
prothrombin time, platelet count, thrombin time, partial thromboplastin time, and C. Hypertension
fibrinogen level as well as client history and other assessment factors. D. Shock
Options B, C, and D: Blood glucose levels, WBC count, calcium levels, and 2. The immediate objective of nursing care for an overweight, mildly hypertensive
potas male client with ureteral colic and hematuria is to decrease:
40. Answer: D. Strawberries A. Pain
Option D: Common food allergens include berries, peanuts, Brazil nuts, cashews, B. Weight
shellfish, and eggs. C. Hematuria
Options A, B, and C: Bread, carrots, and oranges rarely cause allergic reactions. D. Hypertension
 iodine solution before a 10. Terence suffered from burn injury. Using the rule of nines, which has the largest
subtotal thyroidectomy is performed. The nurse is aware that this medication is percent of burns?
given to: A. Face and neck
A. Decrease the total basal metabolic rate. B. Right upper arm and penis
B. Maintain the function of the parathyroid glands. C. Right thigh and penis
C. Block the formation of thyroxine by the thyroid gland. D. Upper trunk
D. Decrease the size and vascularity of the thyroid gland. 11. Herbert, a 45-year-old construction engineer is brought to the hospital
4. Ricardo was diagnosed with type I diabetes. The nurse is aware that unconscious after falling from a 2-story building. When assessing the client, the
acute hypoglycemia also can develop in the client who is diagnosed with: nurse would be most concerned if the assessment revealed:
A. Liver disease A. Reactive pupils
B. Hypertension B. A depressed fontanel
C. Type 2 diabetes C. Bleeding from ears
D. Hyperthyroidism D. An elevated temperature
5. Tracy is receiving combination chemotherapy for treatment of metastatic 12. Nurse Sherry is teaching male client regarding his permanent
carcinoma. Nurse Ruby should monitor the client for the systemic side effect of: artificial pacemaker. Which information given by the nurse shows her knowledge
A. Ascites deficit about the artificial cardiac pacemaker?
B. Nystagmus A. Take the pulse rate once a day, in the morning upon awakening
C. Leukopenia B. May be allowed to use electrical appliances
D. Polycythemia C. Have regular follow up care
6. Norma, with recent colostomy, expresses concern about the inability to control the D. May engage in contact sports
passage of gas. Nurse Oliver should suggest that the client plan to: 13. The nurse is aware that the most relevant knowledge about oxygen
A. Eliminate foods high in cellulose. administration to a male client with COPD is
B. Decrease fluid intake at meal times. A. Oxygen at 1-2L/min is given to maintain the hypoxic stimulus for breathing.
C. Avoid foods that in the past caused flatus. B. Hypoxia stimulates the central chemoreceptors in the medulla that makes the client
D. Adhere to a bland diet prior to social events. breath.
7. Nurse Ron begins to teach a male client how to perform colostomy irrigations. The C. Oxygen is administered best using a non-rebreathing mask
nurse would evaluate that the instructions were understood when the client states, D. Blood gases are monitored using a pulse oximeter.
14. Tonny has undergoes a left thoracotomy and a partial pneumonectomy. Chest
tubes are inserted, and one-bottle water-seal drainage is instituted in the operating
B. Keep the irrigating container less than 18 inches above the stom tion on either
C. Instill a minimum of 1200 ml of irrigating solution to stimulate his right side or on his back. The nurse is aware that this position:
D. Insert the irrigating catheter deeper into the stoma if cramping occurs during the A. Reduce incisional pain.
B. Facilitate ventilation of the left lung.
8. Patrick is in the oliguric phase of acute tubular necrosis and is experiencing fluid C. Equalize pressure in the pleural space.
and electrolyte imbalances. The client is somewhat confused and complains D. Increase venous return
of nausea and muscle weakness. As part of the prescribed therapy to correct 15. Kristine is scheduled for a bronchoscopy. When teaching Kristine what to expect
this electrolyte imbalance, the nurse would expect to:
A. Administer Kayexalate A. Food and fluids will be withheld for at least 2 hours.
B. Restrict foods high in protein B. Warm saline gargles will be done q 2h.
C. Increase oral intake of cheese and milk. C. Coughing and deep-breathing exercises will be done q2h.
D. Administer large amounts of normal saline via I.V. D. Only ice chips and cold liquids will be allowed initially.
9. Mario has burn injury. After 48 hours, the physician orders for Mario 2 liters of IV 16. Nurse Tristan is caring for a male client in acute renal failure. The nurse should
fluid to be administered q12 h. The drop factor of the tubing is 10 gtt/ml. The nurse expect hypertonic glucose, insulin infusions, and sodium bicarbonate to be used to
should set the flow to provide: treat:
A. 18 gtt/min A. hypernatremia.
B. 28 gtt/min B. hypokalemia.
C. 32 gtt/min C. hyperkalemia.
D. 36 gtt/min D. hypercalcemia.
17. Ms. X has just been diagnosed with condylomata acuminata (genital warts). What A. Auscultate bowel sounds.
information is appropriate to tell this client? B. Palpate the abdomen.
A. This condition puts her at a higher risk for cervical cancer; therefore, she should have a
Papanicolaou (Pap) smear annually. D. Insert a rectal tube.
B. The most common treatment is metronidazole (Flagyl), which should eradicate the 24. Wilfredo with a recent history of rectal bleeding is being prepared for
problem within 7 to 10 days. a colonoscopy. How should the nurse Patricia position the client for this test
C. The potential for transmission to her sexual partner will be eliminated if condoms are initially?
used every time they have sexual intercourse. A. Lying on the right side with legs straight
B. Lying on the left side with knees bent
transmitted during oral sex. C. Prone with the torso elevated
18. Maritess was recently diagnosed with a genitourinary problem and is being D. Bent over with hands touching the floor
examined in the emergency department. When palpating her kidneys, the nurse 25. A male client with inflammatory bowel disease undergoes an ileostomy. On the
should keep which anatomical fact in mind?
A. The left kidney usually is slightly higher than the right one. should the nurse interpret this finding?
B. The kidneys are situated just above the adrenal glands. A. Blood supply to the stoma has been interrupted.
- B. This is a normal finding 1 day after surgery.
D. The kidneys lie between the 10th and 12th thoracic vertebrae. C. The ostomy bag should be adjusted.
19. Jestoni with chronic renal failure (CRF) is admitted to the urology unit. The nurse D. An intestinal obstruction has occurred.
is aware that the diagnostic test is consistent with CRF if the result is: 26. Anthony suffers burns on the legs, which nursing intervention helps prevent
A. Increased pH with decreased hydrogen ions. contractures?
B. Increased serum levels of potassium, magnesium, and calcium. A. Applying knee splints
C. Blood urea nitrogen (BUN) 100 mg/dl and serum creatinine 6.5 mg/ dl. B. Elevating the foot of the bed
D. Uric acid analysis 3.5 mg/dl and phenolsulfonphthalein (PSP) excretion 75%.
20. Katrina has an abnormal result on a Papanicolaou test. After admitting that she D. Performing shoulder range-of-motion exercises
read her chart while the nurse was out of the room, Katrina asks what dysplasia 27. Nurse Ron is assessing a client admitted with second- and third-degree burns on
means. Which definition should the nurse provide? the face, arms, and chest. Which finding indicates a potential problem?
A. Presence of completely undifferentiated tumor A. Partial pressure of arterial oxygen (PaO2) value of 80 mm Hg.
tissues of their origin. B. Urine output of 20 ml/hour.
B. Increase in the number of normal cells in a normal arrangement in a tissue or an organ. C. White pulmonary secretions.
C. Replacement of one type of fully differentiated cell by another in tissues where the D. Rectal temperature of 100.6° F (38° C).
28. Mr. Mendoza who has suffered a cerebrovascular accident (CVA) is too weak to
D. Alteration in the size, shape, and organization of differentiated cells. move on his own. To help the client avoid pressure ulcers, Nurse Celia should:
21. During a routine checkup, Nurse Marianne assesses a male client with acquired A. Turn him frequently.
immunodeficiency syndrome (AIDS) for signs and symptoms of cancer. What is the B. Perform passive range-of-motion (ROM) exercises.
most common AIDS-related cancer?
A. Squamous cell carcinoma D. Encourage the client to use a footboard.
B. Multiple myeloma 29. Nurse Maria plans to administer dexamethasone cream to a female client who
C. Leukemia has dermatitis over the anterior chest. How should the nurse apply this topical
ma agent?
22. Ricardo is scheduled for a prostatectomy, and the anesthesiologist plans to use a A. With a circular motion, to enhance absorption.
spinal (subarachnoid) block during surgery. In the operating room, the nurse B. With an upward motion, to increase blood supply to the affected area
C. In long, even, outward, and downward strokes in the direction of hair growth
client require special positioning for this type of anesthesia? D. In long, even, outward, and upward strokes in the direction opposite hair growth
A. To prevent confusion 30. Nurse Kate is aware that one of the following classes of medication protect the
B. To prevent seizures ischemic myocardium by blocking catecholamines and sympathetic nerve
C. To prevent cerebrospinal fluid (CSF) leakage stimulation is:
D. To prevent cardiac arrhythmias A. Beta-adrenergic blockers
23. A male client had a nephrectomy 2 days ago and is now complaining of B. Calcium channel blocker
abdominal pressure and nausea. The first nursing action should be to:
C. Narcotics 37. A female client arrives at the emergency department with chest and stomach
D. Nitrates pain and a report of black tarry stool for several months. Which of the following
31. A male client has jugular distention. On what position should the nurse place the order should the nurse Oliver anticipate?
head of the bed to obtain the most accurate reading of jugular vein distention? A. Cardiac monitor, oxygen, creatine kinase and lactate dehydrogenase levels
B. Prothrombin time, partial thromboplastin time, fibrinogen and fibrin split product
B. Raised 10 degrees values
C. Raised 30 degrees C. Electrocardiogram, complete blood count, testing for occult blood, comprehensive serum
D. Supine position metabolic panel
32. The nurse is aware that one of the following classes of medications maximizes D. Electroencephalogram, alkaline phosphatase, and aspartate aminotransferase levels,
cardiac performance in clients with heart failure by increasing ventricular basic serum metabolic panel
contractility? 38. Macario had coronary artery bypass graft (CABG) surgery 3 days ago. Which of
A. Beta-adrenergic blockers the following conditions is suspected by the nurse when a decrease in platelet count
B. Calcium channel blocker from 230,000 ul to 5,000 ul is noted?
C. Diuretics A. Pancytopenia
D. Inotropic agents B. Idiopathic thrombocytopenic purpura (ITP)
33. A male client has a reduced serum high-density lipoprotein (HDL) level and an C. Disseminated intravascular coagulation (DIC)
elevated low-density lipoprotein (LDL) level. Which of the following dietary D. Heparin-associated thrombosis and thrombocytopenia (HATT)
modifications is not appropriate for this client? 39. Which of the following drugs would be ordered by the physician to improve the
A. Fiber intake of 25 to 30 g daily platelet count in a male client with idiopathic thrombocytopenic purpura (ITP)?
B. Less than 30% of calories from fat A. Acetylsalicylic acid (ASA)
C. Cholesterol intake of less than 300 mg daily B. Corticosteroids
D. Less than 10% of calories from saturated fat C. Methotrexate
34. A 37-year-old male client was admitted to the coronary care unit (CCU) 2 days D. Vitamin K
ago with an acute myocardial infarction. Which of the following actions would 40. A female client is scheduled to receive a heart valve replacement with a porcine
breach the client confidentiality? valve. Which of the following types of transplant is this?
A. The CCU nurse gives a verbal report to the nurse on the telemetry unit before A. Allogeneic
transferring the client to that unit B. Autologous
B. The CCU nurse notifies the on-call physician about C. Syngeneic
C. The emergency department nurse calls up the latest electrocardiogram results to check D. Xenogeneic
41. Marco falls off his bicycle and injures his ankle. Which of the following actions
shows the initial response to the injury in the extrinsic pathway?
35. A male client arriving in the emergency department is receiving A. Release of Calcium
cardiopulmonary resuscitation from paramedics who are giving ventilations through B. Release of tissue thromboplastin
C. Conversion of factors XII to factor XIIa
compressions, the cardiac monitor shows narrow QRS complexes and a heart rate of D. Conversion of factor VIII to factor VIIIa
beats/minute with a palpable pulse. Which of the following actions should the nurse 42. Instructions for a client with systemic lupus erythematosus (SLE) would include
take first? information about which of the following blood dyscrasias?
A. Start an L.V. line and administer amiodarone (Cordarone), 300 mg L.V. over 10 minutes.
B. Check endotracheal tube placement. B. Polycythemia
C. Obtain an arterial blood gas (ABG) sample. C. Essential thrombocytopenia
D. Administer atropine, 1 mg L.V. disease
43. The nurse is aware that the following symptom is most commonly an early
Katrina determines that mean arterial pressure (MAP) is which of the following?
A. 46 mm Hg A. Pericarditis
B. 80 mm Hg B. Night sweat
C. 95 mm Hg C. Splenomegaly
D. 90 mm Hg D. Persistent hypothermia
44. Francis with leukemia has neutropenia. Which of the following functions must be
frequently assessed?
A. Blood pressure
B. Bowel sounds
Answers and Rationale
Gauge your performance by counter checking your answers to the answers below. Learn
C. Heart sounds
D. Breath sounds more about the question by reading the rationale. If you have any disputes or questions,
45. The nurse knows that neurologic complications of multiple myeloma (MM) please direct them to the comments section.
1. Answer: C. Hypertension
usually involve which of the following body system?
A. Brain Option C: Hypertension, along with fever, and tenderness over the grafted kidney,
B. Muscle spasm reflects acute rejection.
C. Renal dysfunction 2. Answer: A. Pain
D. Myocardial irritability Option A: Sharp, severe pain (renal colic) radiating toward the genitalia and thigh
46. Nurse Patricia is aware that the average length of time from human is caused by urethral distention and smooth muscle spasm; relief from pain is the
immunodeficiency virus (HIV) infection to the development of acquired priority.
immunodeficiency syndrome (AIDS)? 3. Answer: D. Decrease the size and vascularity of the thyroid gland.
A. Less than 5 years Option D:
the vascularity of the thyroid gland, which limits the risk of hemorrhage
B. 5 to 7 years
C. 10 years when surgery is performed.
4. Answer: A. Liver Disease
D. More than 10 years
47. An 18-year-old male client admitted with heat stroke begins to show signs of Option A: The client with liver disease has a decreased ability to metabolize
disseminated intravascular coagulation (DIC). Which of the following laboratory carbohydrates because of a decreased ability to form glycogen (glycogenesis) and
to form glucose from glycogen.
findings is most consistent with DIC?
A. Low platelet count 5. Answer: C. Leukopenia
B. Elevated fibrinogen levels Option C: Leukopenia, a reduction in WBCs, is a systemic effect of chemotherapy
C. Low levels of fibrin degradation products as a result of myelosuppression.
D. Reduced prothrombin time 6. Answer: C. Avoid foods that in the past caused flatus.
48. Mario comes to the clinic complaining of fever, drenching night sweats, and Option C: Foods that bothered a person preoperatively will continue to do so after
unexplained weight loss over the past 3 months. Physical examination reveals a a colostomy.
single enlarged supraclavicular lymph node. Which of the following is the most 7. Answer: B. Keep the irrigating container less than 18 inches above the
probable diagnosis? Option B: This height permits the solution to flow slowly with little force so that
A. Influenza excessive peristalsis is not immediately precipitated.
B. Sickle cell anemia 8. Answer: A. Administer Kayexalate
C. Leukemia Option A: Kayexalate, a potassium exchange resin, permits sodium to
be exchanged for potassium in the intestine, reducing the serum potassium level.
49. A male client with a gunshot wound requires an emergency blood transfusion. 9. Answer: B. 28 gtt/min
Option B: This is the correct flow rate; multiply the amount to be infused (2000
His blood type is AB negative. Which blood type would be the safest for him to
receive? ml) by the drop factor (10) and divide the result by the amount of time in minutes
A. AB Rh-positive (12 hours x 60 minutes)
10. Answer: D. Upper trunk
B. A Rh-positive
C. A Rh-negative Option D: The percentage designated for each burned part of the body using the
D. O Rh-positive rule of nines: Head and neck 9%; Right upper extremity 9%; Left upper extremity
Situation: Stacy is diagnosed with acute lymphoid leukemia (ALL) and beginning 9%; Anterior trunk 18%; Posterior trunk 18%; Right lower extremity 18%; Left
chemotherapy. lower extremity 18%; Perineum 1%.
50. Stacy is discharged from the hospital following her chemotherapy treatments. 11. Answer: C. Bleeding from ears
Which statement of Option C: The nurse needs to perform a thorough assessment that could indicate
contact the physician? alterations in cerebral function, increased intracranial pressures, fractures and
bleeding. Bleeding from the ears occurs only with basal skull fractures that can
easily contribute to increased intracranial pressure and brain herniation.
diarrhea
12. Answer: D. may engage in contact sports
Option D: The client should be advised by the nurse to avoid contact sports. This
will prevent trauma to the area of the pacemaker generator.
13. Answer: A. Oxygen at 1-2L/min is given to maintain the hypoxic stimulus for Option B: CRF also increases serum levels of potassium, magnesium, and
breathing. phosphorous, and decreases serum levels of calcium.
Option A: COPD causes a chronic CO2 retention that renders the medulla Option D: A uric acid analysis of 3.5 mg/dl falls within the normal range of 2.7 to
insensitive to the CO2 stimulation for breathing. The hypoxic state of the client 7.7 mg/dl; PSP excretion of 75% also falls with the normal range of 60% to 75%.
then becomes the stimulus for breathing. Giving the client oxygen in low 20. Answer: D. Alteration in the size, shape, and organization of differentiated cells
Option D: Dysplasia refers to an alteration in the size, shape, and organization of
14. Answer: B. Facilitate ventilation of the left lung. differentiated cells.
Option B: Since only a partial pneumonectomy is done, there is a need to promote Option A: The presence of completely
expansion of this remaining left lung by positioning the client on the opposite resemble cells of the tissues of their origin is called anaplasia.
unoperated side. Option B: An increase in the number of normal cells in a normal arrangement in a
15. Answer: A. Food and fluids will be withheld for at least 2 hours. tissue or an organ is called hyperplasia.
Option A: Prior to bronchoscopy, the doctors spray the back of the throat with Option C: Replacement of one type of fully differentiated cell by another in
anesthetic to minimize the gag reflex and thus facilitate the insertion of the tissues
bronchoscope. Giving the client food and drink after the procedure without
checking on the return of the gag reflex can cause the client to aspirate. The gag Option D: AIDS.
reflex usually returns after two hours. Options A, B, and C: Squamous cell carcinoma, multiple myeloma, and leukemia
16. Answer: C. hyperkalemia. may
Option C: Hyperkalemia is a common complication of acute renal failure. - 22. Answer: C. To prevent cerebrospinal fluid (CSF) leakage
administration of Option C: The client receiving a subarachnoid block requires special positioning to
glucose and regular insulin, with sodium bicarbonate, if necessary, can prevent CSF leakage and headache and to ensure proper anesthetic distribution.
temporarily prevent cardiac arrest by moving potassium into the cells and Options A, B, and D: seizures,
temporarily reducing serum potassium levels. or cardiac arrhythmias.
Options A, B, and D: Hypernatremia, hypokalemi 23. Answer: A. Auscultate bowel sounds.
usually occur with Option A: If abdominal distention is accompanied by nausea, the nurse must first
sodium bicarbonate. auscultate bowel sounds. If bowel sounds are absent, the nurse should suspect
17. Answer: A. This condition puts her at a higher risk for cervical cancer; therefore, gastric or small intestine dilation and these findings must be reported to the
she should have a Papanicolaou (Pap) smear annually. physician.
Option A: Women with condylomata acuminata are at risk for cancer of the cervix Option B: Palpation should be avoided postoperatively with abdominal distention.
and vulva. Yearly Pap smears are very important for early detection. Because Options C and D: If peristalsis is absent, changing positions and inserting a rectal
condylomata acuminata is a virus, there is no permanent cure.
Option C: Because condylomata acuminata can occur on the vulva, a condom 24. Answer: B. Lying on the left side with knees bent
Option B: For a colonoscopy, the nurse initially should position the client on the
Option D: HPV can be transmitted to other parts of the body, such as the mouth, left side with knees bent.
oropharynx, and larynx. Option A, C, and D: Placing the client on the right side with legs straight, prone
18. Answer: A. The left kidney usually is slightly higher than the right one. with the torso elevated, or bent over with hands
Option A: The left kidney usually is slightly higher than the right one. An adrenal proper visualization of the large intestine.
gland lies atop each kidney. 25. Answer: A. Blood supply to the stoma has been interrupted
Option C: The average kidney measures approximately 11 cm (4- Option A: An ileostomy stoma forms as the ileum is brought through
the abdominal wall to the surface skin, creating an artificial opening for
Option B: The kidneys are located retroperitoneally, in the posterior aspect of the waste elimination. The stoma should appear cherry red, indicating
abdomen, on either side of the vertebral column. adequate arterial perfusion. A dusky stoma suggests decreased perfusion,
Option D: They lie between the 12th thoracic and 3rd lumbar vertebrae. which
19. Answer: C. Blood urea nitrogen (BUN) 100 mg/dl and serum creatinine 6.5 mg/dl. to tissue damage or necrosis.
Option C: The normal BUN level ranges 8 to 23 mg/dl; the normal Option B:
serum creatinine level ranges from 0.7 to 1.5 mg/dl. The test results in option Option C: Adjusting or, which depends
C to on blood supply to the area.
remove nonprotein nitrogen waste from the blood. Option D: color.
Option A: CRF causes decreased pH and increased hydrogen ions not vice 26. Answer: A. Applying knee splints
versa.
 Option A: Applying knee splints prevents leg contractures by holding the joints in Option C: Jugular venous pressure is measured with a centimeter ruler to obtain
a position of function. the vertical distance between the sternal angle and the point of highest pulsation
Option B: contractures because this with the head of the bed inclined between 15 to 30 degrees.
function. Options B and D:
Option C: Hyperextending a body part for an extended time is or when the head of the bed is raised 10 degrees because the point that marks the
inappropriate because it can cause contractures. pressure level is above the jaw (therefore, not visible).
Option D: Performing shoulder range-of-motion exercises can prevent Option A: In high the veins would be barely discernible above
contractures in the shoulders, but not in the legs. the clavicle.
27. Answer: B. Urine output of 20 ml/hour. 32. Answer: D. Inotropic agents
Option B: A urine output of less than 40 ml/hour in a client with burns indicates Option D: Inotropic agents are administered to increase the force of the
a fluid volume deficit. contractions, thereby increasing ventricular contractility and ultimately increasing
Option A: normal range (80 to 100 mm cardiac output.
Hg). Options A and B: Beta-adrenergic blockers and calcium channel blockers
Option C: White pulmonary secretions also are normal. decrease the heart rate and ultimately decreased the workload of the heart.
Option D: probably Option C: Diuretics are administered to decrease the overall vascular volume, also
results from the fluid volume deficit. decreasing the workload of the heart.
28. Answer: A. Turn him frequently. 33. Answer: B. Less than 30% of calories from fat
Option A: The most important intervention to prevent pressure ulcers is frequent Option B: A client with low serum HDL and high serum LDL levels should get less
position changes, which relieve pressure on the skin and underlying tissues. If than 30% of daily calories from fat.
reducing circulation and Options A, C, and D: The other modifications are appropriate for this client.
oxygenation of the tissues and resulting in cell death and ulcer formation. 34. Answer: C. The emergency department nurse calls up the
Option B: During passive ROM exercises, the nurse moves each joint through its latest
range of movement, which improves joint mobility and circulation to the affected Option C: The emergency department nurse is no longer directly involved with
ulcers. legal right to information about his present
Option C: Adequate hydration is necessary to maintain healthy skin and ensure condition. Anyone directly involved in his care (such as the telemetry nurse and
tissue repair. the on-call physician) has the right to information about his condition. Because the
Option D: A footboard prevents plantar flexion and footdrop by maintaining the client requested that the nurse update his wi
foot in a dorsiflexed position. breach confidentiality.
29. Answer: C. In long, even, outward, and downward strokes in the direction of hair 35. Answer: B. Check endotracheal tube placement.
growth Option B: ET tube placement should be confirmed as soon as the client arrives in
Option C: When applying a topical agent, the nurse should begin at the midline the emergency department. Once the airways is secured, oxygenation and
and use long, even, outward, and downward strokes in the direction of hair ventilation should be confirmed using an end-tidal carbon dioxide monitor and
growth. This application pattern reduces the risk of follicle irritation and skin pulse oximetry.
inflammation. Option A: Next, the nurse should make sure L.V. access is established.
30. Answer: A. Beta-adrenergic blockers Option D: If the client experiences symptomatic bradycardia, atropine is
Option A: Beta-adrenergic blockers work by blocking beta receptors in the administered as ordered 0.5 to 1 mg every 3 to 5 minutes to a total of 3 mg.
myocardium, reducing the response to catecholamines and sympathetic nerve Option C: Then the nurse should try to find the cause of
stimulation. They protect the myocardium, helping to reduce the risk of another obtaining an ABG sample. Amiodarone is indicated for ventricular tachycardia,
infraction by decreasing myocardial oxygen demand. ventricular fibrillation, and atrial flutter not symptomatic bradycardia.
Option B: Calcium channel blockers reduce the workload of the heart 36. Answer: C. 95 mm Hg
by decreasing the heart rate. Option C: Use the following formula to calculate MAP
Option C: Narcotics reduce myocardial oxygen demand, promote vasodilation, and MAP = systolic + 2 (diastolic)
decrease anxiety. MAP = 126 mm Hg + 2 (80 mm Hg)
Option D: Nitrates reduce myocardial oxygen consumption but decrease left MAP = 286 mm Hg
ventricular end-diastolic pressure (preload) and systemic vascular resistance MAP = 95 mm Hg
(afterload). 37. Answer: C. Electrocardiogram, complete blood count, testing for occult blood,
31. Answer: C. Raised 30 degrees comprehensive serum metabolic panel.
 Option C: An electrocardiogram evaluates the complaints of chest pain, laboratory Option D: Persistent hypothermia is associated with
tests determine anemia, and the stool test for occult blood determines blood in the sign of the disease.
stool. 44. Answer: D. Breath sounds
Option A: Cardiac monitoring, oxygen, and creatine kinase and lactate Option D: Pneumonia, both viral and fungal, is a common cause of death in clients
dehydrogenase levels are appropriate for a cardiac primary problem. A basic with neutropenia, so frequent assessment of respiratory rate and breath sounds is
metabolic panel and alkaline phosphatase and aspartate aminotransferase levels required.
assess liver function. Options A, B, and C: Although assessing blood pressure, bowel sounds, and heart
Option B: Prothrombin time, partial thromboplastin time, fibrinogen and fibrin pneumonia.
split products are measured to verify bleeding dyscrasias. 45. Answer: B. Muscle spasm
Option D: An electroencephalogram evaluates brain electrical activity. Option B: Back pain or paresthesia in the lower extremities may
38. Answer: D. Heparin-associated thrombosis and thrombocytopenia (HATT) indicate impending spinal cord compression from a spinal tumor. This should
Option D: HATT may occur after CABG surgery due to heparin use during surgery. be recognized and treated promptly as progression of the tumor may result
Options B and C: Although DIC and ITP cause platelet aggregation and bleeding, in paraplegia.
neither is common in a client after revascularization surgery. Options A, C, and D: The other options, which reflect parts of the nervous
Option A: Pancytopenia is a reduction in all blood cells. system,
39. Answer: B. Corticosteroids 46. Answer: C. 10 years
Option B: Corticosteroid therapy can decrease antibody production Option C: Epidemiologic studies show the average time from initial contact
and phagocytosis of the antibody-coated platelets, retaining more with HIV to the development of AIDS is 10 years.
functioning platelets. 47. Answer: A. Low platelet count
Option C: Methotrexate can cause thrombocytopenia. Option A: In DIC, platelets and clotting factors are consumed, resulting
Options A and D: Vitamin K is used to treat an excessive anticoagulate state in microthrombi and excessive bleeding. As clots form, fibrinogen levels decrease
from warfarin overload, and ASA decreases platelet aggregation. and the prothrombin time increases. Fibrin degradation products increase as
40. Answer: D. Xenogeneic fibrinolysis takes places.
Option D: A xenogeneic transplant is between is between human and another
species. Option D: Ho loss, and
Options A, B, and C: A syngeneic transplant is between identical twins, allogeneic lymph node enlargement.
transplant is between two humans, and autologous is a transplant from the same Option A:
individual. Option B: Clients with sickle cell anemia manifest signs and symptoms of
41. Answer: B. Release of tissue thromboplastin chronic anemia with pallor of the mucous membrane, fatigue, and
Option B: Tissue thromboplastin is released when damaged tissue comes in decreased
contact with clotting factors. or lymph node enlargement.
Option A: Calcium is released to assist the conversion of factors X to Xa. Option C: enlargement.
Options C and D: Conversion of factors XII to XIIa and VIII to VIII a are part of the 49. Answer: C. A Rh-negative
intrinsic pathway. Option C: Human blood can sometimes contain an inherited D antigen. Persons
42. Answer: C. Essential thrombocytopenia with the D antigen have Rh-positive blood type; those lacking the antigen have Rh-
Option C: Essential thrombocytopenia is linked to immunologic disorders, such as -negative blood receives Rh-
SLE and human immunodeficiency virus. negative blood. If Rh-positive blood is administered to an Rh-negative person, the
Option D: The disorder known as recipient develops anti-Rh agglutinins, and subsequent transfusions with Rh-
of hemophilia positive blood may cause serious reactions with clumping and hemolysis of red
Option B: Moderate to severe anemia is associated with SLE, not polycythemia. blood cells.
Option A: ctor if Stacy has persistent vomiting and diarrhea
infarction Option B: Persistent (more than 24 hours) vomiting, anorexia, and diarrhea are
43. Answer: B. Night sweat signs of toxicity and the patient should stop the medication and notify the
Option B: In stage 1, symptoms include a single enlarged lymph node (usually), healthcare provider.
unexplained fever, night sweats, malaise, and generalized pruritus. Options A, C, and D: The other manifestations are expected side effects of
Option C: Although splenomegaly may be present in some clients, night sweats are chemotherapy
generally more prevalent. In Text Mode: All questions and answers are given for reading and answering at your own
Option A: thermia. pace. You can also copy this exam and make a printout.
Moreover, splenomegaly and
 nurse that it is hard to see Stacy with no hair. The best has a decreased level of consciousness. These signs indicate which of the following
response for the nurse is: conditions?
A. Asthma attack
B. Pulmonary embolism
ings when you are with her or else she C. Respiratory failure
D. Rheumatoid arthritis
-grow new hair in 3-6 months but may be different Situation: Mr. Gonzales was admitted to the hospital with ascites and jaundice. To
rule out cirrhosis of the liver:
2. Stacy has beginning stomatitis. To promote oral hygiene and comfort, the nurse- 9. Which laboratory test indicates liver cirrhosis?
in-charge should: A. Decreased red blood cell count
A. Provide frequent mouthwash with normal saline. B. Decreased serum acid phosphatase level
B. Apply viscous Lidocaine to oral ulcers as needed. C. Elevated white blood cell count
C. Use lemon glycerine swabs every 2 hours. D. Elevated serum aminotransferase
D. Rinse mouth with Hydrogen Peroxide. 10. The biopsy of Mr. Gonzales confirms the diagnosis of cirrhosis. Mr. Gonzales is at
3. During the administration of chemotherapy agents, Nurse Oliver observed that the increased risk for excessive bleeding primarily because of:
IV site is red and swollen when the IV is touched Stacy shouts in pain. The first A. Impaired clotting mechanism
nursing action to take is: B. Varix formation
A. Notify the physician C. Inadequate nutrition
B. Flush the IV line with saline solution D. Trauma of invasive procedure
C. Immediately discontinue the infusion 11. Mr. Gonzales develops hepatic encephalopathy. Which clinical manifestation is
D. Apply an ice pack to the site, followed by warm compress. most common with this condition?
A. Increased urine output
A. Adult respiratory distress syndrome (ARDS) B. Altered level of consciousness
B. Asthma C. Decreased tendon reflex
C. Chronic obstructive bronchitis D. Hypotension
D. Emphysema 12. When Mr. Gonzales regained consciousness, the physician orders 50 ml of
Lactulose p.o. every 2 hours. Mr. Gonzales develops diarrhea. The nurse best action
conditions? would be:
A. Adult respiratory distress syndrome (ARDS)
B. Asthma
C. Chronic obstructive bronchitis dosage
D. Emphysema
6. Jose is in danger of respiratory arrest following the administration of a narcotic 13. Which of the following groups of symptoms indicates a ruptured
analgesic. An arterial blood gas value is obtained. Nurse Oliver would expect the abdominal aortic aneurysm?
paco2 to be which of the following values? A. Lower back pain, increased blood pressure, decreased red blood cell (RBC) count,
A. 15 mm Hg increased white blood (WBC) count.
B. 30 mm Hg B. Severe lower back pain, decreased blood pressure, decreased RBC count, increased WBC
C. 40 mm Hg count.
D. 80 mm Hg C. Severe lower back pain, decreased blood pressure, decreased RBC count, decreased RBC
count, decreased WBC count.
Hg; Pao2 46 mm Hg; HCO3- 24 mEq/L; Sao2 81%. This ABG result represents which D. Intermittent lower back pain, decreased blood pressure, decreased RBC count, increased
of the following conditions? WBC count.
A. Metabolic acidosis 14. After undergoing a cardiac catheterization, Tracy has a large puddle of blood
B. Metabolic alkalosis under his buttocks. Which of the following steps should the nurse take first?
C. Respiratory acidosis A. Call for help.
D. Respiratory alkalosis B. Obtain vital signs
8. Norma has started a new drug for hypertension. Thirty minutes after she takes the
drug, she develops chest tightness and becomes short of breath and tachypneic. She D. Apply gloves and assess the groin site
15. Which of the following treatment is a suitable surgical intervention for a client 22. When prioritizing care, which of the following clients should the nurse Olivia
with unstable angina? assess first?
A. Cardiac catheterization A. A 17-year-old client 24-hours post appendectomy
B. Echocardiogram B. A 33-year-old client with a recent diagnosis of Guillain-Barre syndrome
C. Nitroglycerin C. A 50-year-old client 3 days post myocardial infarction
D. Percutaneous transluminal coronary angioplasty (PTCA) D. A 50-year-old client with diverticulitis
16. The nurse is aware that the following terms used to describe reduced cardiac 23. JP has been diagnosed with gout and wants to know why colchicine is used in the
output and perfusion impairment due to ineffective pumping of the heart is: treatment of gout. Which of the
A. Anaphylactic shock effective for gout?
B. Cardiogenic shock A. Replaces estrogen
C. Distributive shock B. Decreases infection
D. Myocardial infarction (MI) C. Decreases inflammation
17. A client with hypertension ask the nurse which factors can cause blood pressure D. Decreases bone demineralization
to drop to normal levels? 24. Norma asks for information about osteoarthritis. Which of the following
statements about osteoarthritis is correct?
water A. Osteoarthritis is rarely debilitating
B. Osteoarthritis is a rare form of arthritis
C. Osteoarthritis is the most common form of arthritis
18. Nurse Rose is aware that the statement that best explains why furosemide (Lasix) D. Osteoarthritis affects people over 60
is administered to treat hypertension is: 25. Ruby is receiving thyroid replacement therapy develops the flu and forgets to
A. It dilates peripheral blood vessels. take her thyroid replacement medicine. The nurse understands that skipping
B. It decreases sympathetic cardioacceleration. this medication will put the client at risk for developing which of the following life
C. It inhibits the angiotensin-converting enzymes threatening complications?
D. It inhibits reabsorption of sodium and water in the loop of Henle. A. Exophthalmos
19. Nurse Nikki knows that laboratory results supports the diagnosis of B. Thyroid storm
systemic lupus erythematosus (SLE) is: C. Myxedema coma
A. Elevated serum complement level D. Tibial myxedema
B. Thrombocytosis, elevated sedimentation rate 26. Nurse Sugar is
C. Pancytopenia, elevated antinuclear antibody (ANA) titer should the nurse report to the physician immediately?
D. Leukocytosis, elevated blood urea nitrogen (BUN) and creatinine levels A. Pitting edema of the legs
20. Arnold, a 19-year-old client with a mild concussion is discharged from the B. An irregular apical pulse
emergency department. Before discharge, he complains of a headache. When offered C. Dry mucous membranes
acetaminophen, his mother tells the nurse the headache is severe and she would like D. Frequent urination
her son to have something stronger. Which of the following responses by the nurse is 27. Cyrill with severe head trauma sustained in a car accident is admitted to the
appropriate? intensive care unit. Thirty-
above 200 ml/hour, leading the nurse to suspect diabetes insipidus. Which
Aspirin is avoi of diabetes insipidus?
A. Above-normal urine and serum osmolality levels
Narcotics are avoided after a head injury because they may hide a worsening B. Below-normal urine and serum osmolality levels
D. Stronger medications may lead to vomiting, which increases the intracranial pressure C. Above-normal urine osmolality level, below-normal serum osmolality level
D. Below-normal urine osmolality level, above-normal serum osmolality level
21. When evaluating an arterial blood gas from a male client with a subdural 28. Jomari is diagnosed with hyperosmolar hyperglycemic nonketotic syndrome
hematoma, the nurse notes the Paco2 is 30 mm Hg. Which of the following responses (HHNS) is stabilized and prepared for discharge. When preparing the client for
best describes the result? discharge and home management, which of the following statements indicates that
A. Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP) the client understands her condition and how to control it?
B. Emergent; the client is poorly oxygenated
C. Normal
D. Significant; the client has alveolar hypoventilation drink a glass of soda that
 glucose 35. Rico with diabetes mellitus must learn how to self-administer insulin. The
physician has prescribed 10 U of U-100 regular insulin and 35 U of U-100 isophane
insulin suspension (NPH) to be taken before breakfast. When teaching the client how
29. A 66-year-old client has been complaining of sleeping more, increased to select and rotate insulin injection sites, the nurse should provide which
urination, anorexia, weakness, irritability, depression, and bone pain that interferes instruction?
with her going outdoors. Based on these assessment findings, the nurse would arge blood vessels and nerves
suspect which of the following disorders?
A. Diabetes mellitus
B. Diabetes insipidus
C. Hypoparathyroidism
D. Hyperparathyroidism 36. Nurse Sarah expects to note an elevated serum glucose level in a client with
30. Nurse Lourdes is teaching a client recovering from Addisonian crisis about the hyperosmolar hyperglycemic nonketotic syndrome (HHNS). Which other laboratory
need to take fludrocortisone acetate and hydrocortisone at home. Which statement finding should the nurse anticipate?
by the client indicates an understanding of the instructions? A. Elevated serum acetone level
B. Serum ketone bodies
C. Serum alkalosis
-thirds of the dose when I wake up and one- D. Below-normal serum potassium level
comfort?
31. Which of the following laboratory test results would suggest to the nurse Len that A. Restricting intake of oral fluids
a client has a corticotropin-secreting pituitary adenoma?
A. High corticotropin and low cortisol levels C. Limiting intake of high-carbohydrate foods
B. Low corticotropin and high cortisol levels D. Maintaining room temperature in the low-normal range
C. High corticotropin and high cortisol levels fracture sustained
D. Low corticotropin and low cortisol levels fracture?
32. A male client is scheduled for a transsphenoidal hypophysectomy to remove a A. Fracture of the distal radius
pituitary tumor. Preoperatively, the nurse should assess for potential complications B. Fracture of the olecranon
by doing which of the following? C. Fracture of the humerus
A. Testing for ketones in the urine D. Fracture of the carpal scaphoid
B. Testing urine specific gravity 39. Cleo is diagnosed with osteoporosis. Which electrolytes are involved in the
C. Checking temperature every 4 hours development of this disorder?
D. Performing capillary glucose testing every 4 hours A. Calcium and sodium
33. Capillary glucose monitoring is being performed every 4 hours for a client B. Calcium and phosphorous
diagnosed with diabetic ketoacidosis. Insulin is administered using a scale of regular C. Phosphorous and potassium
insulin according to glucose results. At 2 p.m., the client has a capillary glucose level D. Potassium and sodium
of 250 mg/dl for which he receives 8 U of regular insulin. Nurse Mariner should 40. Johnny a firefighter was involved in extinguishing a house fire and is being
treated to smoke inhalation. He develops severe hypoxia 48 hours after the incident,
A. onset to be at 2 p.m. and its peak to be at 3 p.m. requiring intubation and mechanical ventilation. He most likely has developed
B. onset to be at 2:15 p.m. and its peak to be at 3 p.m. which of the following conditions?
C. onset to be at 2:30 p.m. and its peak to be at 4 p.m. A. Adult respiratory distress syndrome (ARDS)
D. onset to be at 4 p.m. and its peak to be at 6 p.m. B. Atelectasis
34. The physician orders laboratory tests to confirm hyperthyroidism in a female C. Bronchitis
client with classic signs and symptoms of this disorder. Which test result would D. Pneumonia
confirm the diagnosis? 41. A 67-year-old client develops acute shortness of breath and progressive hypoxia
A. No increase in the thyroid-stimulating hormone (TSH) level after 30 minutes during the requiring right femur. The hypoxia was probably caused by which of the following
TSH stimulation test conditions?
B. A decreased TSH level A. Asthma attack
C. An increase in the TSH level after 30 minutes during the TSH stimulation test B. Atelectasis
D. Below-normal levels of serum triiodothyronine (T3) and serum thyroxine (T4) as C. Bronchitis
detected by radioimmunoassay D. Fat embolism
42. A client with shortness of breath has decreased to absent breath sounds on the 49. Mickey, a 6-year-old child with a congenital heart disorder is admitted
right side, from the apex to the base. Which of the following conditions would best with congestive heart failure. Digoxin (lanoxin) 0.12 mg is ordered for the child. The
explain this? bottle of Lanoxin contains .05 mg of Lanoxin in 1 ml of solution. What amount should
A. Acute asthma the nurse administer to the child?
B. Chronic bronchitis A. 1.2 ml
C. Pneumonia B. 2.4 ml
D. Spontaneous pneumothorax C. 3.5 ml
43. A 62-year-old male client was in a motor vehicle accident as an unrestrained D. 4.2 ml
50. Nurse Alexandra teaches a client about elastic stockings. Which of the following
and chest pain. On auscultation of his lung field, no breath sounds are present in the statements, if made by the client, indicates to the nurse that the teaching was
upper lobe. This client may have which of the following conditions? successful?
A. Bronchitis
B. Pneumonia
C. Pneumothorax
D. Tuberculosis (TB)
44. If a client requires a pneumonectomy, what fills the area of the thoracic cavity?
A. The space remains filled with air only
Answers and Rationale
B. The surgeon fills the space with a gel Gauge your performance by counter checking your answers to the answers below. Learn
C. Serous fluids fills the space and consolidates the region more about the question by reading the rationale. If you have any disputes or questions,
please direct them to the comments section.
D. The tissue from the other lung grows over to the other side
45. Hemoptysis may be present in the client with a pulmonary embolism because of -grow new hair in 3-6 months but
which of the following reasons?
A. Alveolar damage in the infarcted area Option D: This is the appropriate response. The nurse should help the mother
B. Involvement of major blood vessels in the occluded area as not to affect
C. Loss of lung parenchyma the child negatively. When the hair grows back, it is still of the same color and
D. Loss of lung tissue texture.
46. Alvin with a massive pulmonary embolism will have an arterial blood gas 2. Answer: B. Apply viscous Lidocaine to oral ulcers as needed.
analysis performed to determine the extent of hypoxia. The acid-base disorder that Option B: Stomatitis can cause pain and this can be relieved by applying topical
may be present is? anesthetics such as lidocaine before mouth care.
A. Metabolic acidosis Options A, C, and D: When the patient is already comfortable, the nurse can
B. Metabolic alkalosis proceed with providing the patient with oral rinses of saline solution mixed with
C. Respiratory acidosis equal part of water or hydrogen peroxide mixed water in 1:3 concentrations to
D. Respiratory alkalosis promote oral hygiene. Every 2-4 hours.
3. Answer: C. Immediately discontinue the infusion
47. After a motor vehicle accident, Armand a 22-year-old client is admitted with a
pneumothorax. The surgeon inserts a chest tube and attaches it to a chest drainage Option C: Edema or swelling at the IV site is a sign that the needle has been
system. Bubbling soon appears in the water seal chamber. Which of the following is dislodged and the IV solution is leaking into the tissues causing the edema. The
patient feels pain as the nerves are irritated by pressure and the IV solution. The
the most likely cause of the bubbling?
A. Air leak first action of the nurse would be to discontinue the infusion right away to prevent
B. Adequate suction further edema and other complication.
C. Inadequate suction 4. Answer: C. Chronic obstructive bronchitis
D. Kinked chest tube Option C: Clients with chronic obstructive bronchitis appear bloated; they have
48. Nurse Michelle calculates the IV flow rate for a postoperative client. The client large barrel chest and peripheral edema, cyanotic nail beds, and at times,
receives 3,000 ml of solution IV to run over 24 hours. The IV infusion circumoral cyanosis.
Option A: Clients with ARDS are acutely short of breath and frequently need
IV to deliver how many drops per minute? intubation for mechanical ventilation and large amount of oxygen.
Option B: chronic disease.
A. 18
B. 21 Option D: Clients with emphysema appear pink and cachectic.
5. Answer: D. Emphysema
C. 35
D. 40
 Option D: Because of the large amount of energy it takes to breathe, clients with Option B: Severe lower back pain indicates an aneurysm rupture, secondary to
breathe through pressure being applied within the abdominal cavity. When rupture occurs, the
the aneurysm is repaired. Blood
Option A: Clients with ARDS are usually acutely short of breath. pressure decreases due to the loss of blood. After the aneurysm ruptures, the
Option B: y particular characteristics. vasculature is interrupted and blood vol
Option C: Clients with chronic obstructive bronchitis are bloated and cyanotic in increase. For the same reason, the RBC count is decreased not increased. The
appearance. WBC count increases as cell migrate to the site of injury.
6. Answer: D. 80 mm Hg 14. Answer: D. Apply gloves and assess the groin site
Option D: A client about to go into respiratory arrest will have Option D: Observing standard precautions is the first priority when dealing with
inefficient ventilation and will be retaining carbon dioxide. The value expected any blood fluid. Assessment of the groin site is the second priority. This establishes
would be around 80 mm Hg. All other values are lower than expected. where the blood is coming from and determines how much blood has been lost.
7. Answer: C. Respiratory acidosis The goal in this situation is to stop the bleeding.
Option C: Because Paco2 is high at 80 mm Hg and the metabolic measure, HCO3- Option A: The nurse would call for help if it were warranted after the assessment
is normal, the client has respiratory acidosis. of the situation.
Options B and D: The pH is less than 7.35, academic, which eliminates metabolic Option B: After determining the extent of the bleeding, vital signs assessment is
and respiratory alkalosis as possibilities. important.
Option A: If the HCO3- was below 22 mEq/L the client would have metabolic Option C: The nurse should never move the client, in case a clot has formed.
acidosis. Moving can disturb the clot and cause rebleeding.
8. Answer: C. Respiratory failure 15. Answer: D. Percutaneous transluminal coronary angioplasty (PTCA)
Option C: The client was reacting to the drug with respiratory signs Option D: PTCA can alleviate the blockage and restore blood flow
of impending anaphylaxis, which could lead to eventually respiratory failure. and oxygenation.
Options A and B: Although the signs are also related to an asthma attack or a Option B: An echocardiogram is a noninvasive diagnosis test.
pulmonary embolism, consider the new drug first. Option C: Nitroglycerin is an oral sublingual medication.
Option D: Rheumatoid arthritis manifest these signs. Option A: Cardiac catheterization is a diagnostic tool not a treatment.
9. Answer: D. Elevated serum aminotransferase 16. Answer: B. Cardiogenic shock
Option D: Hepatic cell death causes release of liver enzymes Option B: Cardiogenic shock is shock related to ineffective pumping of the heart.
alanine aminotransferase (ALT), aspartate aminotransferase (AST) and Option A: Anaphylactic shock results from an allergic reaction.
lactate dehydrogenase (LDH) into the circulation. Liver cirrhosis is a chronic Option C: Distributive shock results from changes in the intravascular volume
and irreversible disease of the liver characterized by generalized distribution and is usually associated with increased cardiac output.
inflammation and fibrosis of the liver tissues. Option D: though a severe MI can lead to shock.
10. Answer: A. Impaired clotting mechanism
Option A: Cirrhosis of the liver results in decreased Vitamin K absorption and Option C: The kidneys respond to rise in blood pressure by excreting sodium and
formation of clotting factors resulting in impaired clotting mechanism. excess water. This response ultimately affects systolic blood pressure by
11. Answer: B. Altered level of consciousness regulating blood volume.
Option B: Changes in behavior and level of consciousness are the first signs of Option B: Sodium or water retention would only further increase blood pressure.
hepatic encephalopathy. Hepatic encephalopathy is caused by liver failure and Option D: Sodium and water travel together across the membrane in the kidneys;
develops when the liver is unable to convert protein metabolic product ammonia
to urea. This results in accumulation of ammonia and other toxic in the blood that 18. Answer: D. It inhibits reabsorption of sodium and water in the loop of Henle.
damages the cells. Option D: Furosemide is a loop diuretic that inhibits sodium and
4 stools a water reabsorption in the loop Henle, thereby causing a decrease in
blood pressure.
Option C: Lactulose is given to a patient with hepatic encephalopathy to reduce Option A: Vasodilators cause dilation of peripheral blood vessels, directly relaxing
absorption of ammonia in the intestines by binding with ammonia and promoting vascular smooth muscle and decreasing blood pressure.
more frequent bowel movements. If the patient experience diarrhea, it indicates Option B: Adrenergic blockers decrease sympathetic cardioacceleration
overdosage and the nurse must reduce the amount of medication given to the and decrease blood pressure.
patient. The stool will be mushy or soft. Lactulose is also very sweet and may Option C: Angiotensin-converting enzyme inhibitors decrease blood pressure due
cause cramping and bloating. to their action on angiotensin.
13. Answer: B. Severe lower back pain, decreased blood pressure, decreased RBC 19. Answer: C. Pancytopenia, elevated antinuclear antibody (ANA) titer
count, increased WBC count.
 Option C: Laboratory findings for clients with SLE usually show pancytopenia, Option B: overproduction, which
elevated ANA titer, and decreased serum complement levels. increases urinary potassium loss, the disorder may lead to hypokalemia.
Option D: Clients may have elevated BUN and creatinine levels from nephritis, but Therefore, the nurse should immediately report signs and symptoms of
the increase does not indicate SLE. hypokalemia, such as an irregular apical pulse, to the physician.
20. Answer: C. Narcotics are avoided after a head injury because they may hide a Option A: Edema is an expected finding because aldosterone overproduction
worsening condition. causes sodium and fluid retention.
Option C: Narcotics may mask changes in the level of consciousness that indicate Options C and D: Dry mucous membranes and frequent urination
increased ICP. signal dehydration
Option A: Acetaminophen is strong enough 27. Answer: D. Below-normal urine osmolality level, above-normal serum osmolality
level
Option B: Aspirin is contraindicated in conditions that may have bleeding, such as Option D: In diabetes insipidus, excessive polyuria causes dilute urine, resulting in
trauma, and for children or young adults with viral illnesses due to the danger of a below-normal urine osmolality level. At the same time, polyuria depletes the
syndrome. body of water, causing dehydration that leads to an above-normal serum
Option D: Stronger medications may not necessarily lead to vomiting but will osmolality level.
sedate the client, thereby masking changes in his level of consciousness. Options A, B, and C: For the same reasons, diabetes
21. Answer: A. Appropriate; lowering carbon dioxide (CO2) reduces intracranial above-normal urine osmolality or below-normal serum osmolality levels.
pressure (ICP) paying
Option A: A normal Paco2 value is 35 to 45 mm Hg CO2 has vasodilating attention to my need to uri
properties; therefore, lowering Paco2 through hyperventilation will lower ICP Option A: Inadequate fluid intake during hyperglycemic episodes often leads to
caused by dilated cerebral vessels. HHNS. By recognizing the signs of hyperglycemia (polyuria, polydipsia, and
Option B: Oxygenation is evaluated through Pao2 and oxygen saturation. polyphagia) and increasing fluid intake, the client may prevent HHNS.
Option D: Alveolar hypoventilation would be reflected in an increased Paco2. Option B: Drinking a glass of non-diet soda would be appropriate
22. Answer: B. A 33-year-old client with a recent diagnosis of Guillain- for hypoglycemia.
Barre syndrome Option C: A client whose diabetes is controlled with oral antidiabetic agents
Option B: Guillain-Barre syndrome is characterized by ascending paralysis and
potential respiratory failure. The order of client assessment should follow client Option D: A high carbohydrate
priorities, with disorder of airways, breathing, and then particularly if fluid intake is low.
information to suggest the postmyocardial infarction client has an arrhythmia or 29. Answer: D. Hyperparathyroidism
evidence to suggest hemorrhage or perforation for Option D: Hyperparathyroidism is most common in older women and
the remaining clients as a priority of care. is characterized by bone pain and weakness from excess parathyroid hormone
23. Answer: C. Decreases inflammation (PTH). Clients also exhibit hypercalciuria-causing polyuria.
Option C: The action of colchicines is to decrease inflammation by reducing the Options A and B: While clients with diabetes mellitus and diabetes insipidus also
migration of leukocytes to synovial fluid. have polyuria,
Options A, B, and D: replace estrogen, decrease infection, or Option C: Hypoparathyroidism is characterized by urinary frequency rather than
decrease bone demineralization. polyuria.
24. Answer: C. Osteoarthritis is the most common form of arthritis -thirds of the dose when I wake up and one-third in the
Option C: Osteoarthritis is the most common form of arthritis and can
be extremely debilitating. It can afflict people of any age, although most Option C: Hydrocortisone, a glucocorticoid, should be administered according to a
are elderly. this hormone; therefore,
25. Answer: C. Myxedema coma two-thirds of the dose of hydrocortisone should be taken in the morning and one-
Option C: Myxedema coma, severe hypothyroidism, is a life-threatening condition third in the late afternoon. This dosage schedule reduces adverse effects.
that may develop if thyroid replacem 31. Answer: C. High corticotropin and high cortisol levels
Option A: Exophthalmos, protrusion of the eyeballs, is seen with hyperthyroidism. Option C: A corticotropin-secreting pituitary tumor would cause
Option B: Thyroid storm is life-threatening but is caused by severe high corticotropin and high cortisol levels.
hyperthyroidism. Options A and D: A high corticotropin level with a low cortisol level and a low
Option D: Tibial myxedema, peripheral mucinous edema involving the lower leg, corticotropin level with a low cortisol level would be associated with
is associated with hypothyroidism -threatening. hypocortisolism.
26. Answer: B. An irregular apical pulse Option B: Low corticotropin and high cortisol levels would be seen if there was a
primary defect in the adrenal glands.
32. Answer: D. Performing capillary glucose testing every 4 hours reduce heat intolerance and
Option D: The nurse should perform capillary glucose testing every 4 hours temperature in the low-normal range.
because excess cortisol may cause insulin resistance, placing the client at risk for Option A: To replace fluids lost via diaphoresis, the nurse should encourage, not
hyperglycemia. restrict, intake of oral fluids.
Option A: because the client does secrete Option B: Placing extra blankets on the bed of a client with heat intolerance would
ketosis. cause discomfort.
Option B: balance can Option C: To provide needed energy and calories, the nurse should encourage the
sly imbalanced. client to eat high-carbohydrate foods.
Option C: 38. Answer: A. Fracture of the distal radius
an accurate indicator of infection. Option A: Col a fall on an
33. Answer: C. onset to be at 2:30 p.m. and its peak to be at 4 p.m.
Option C: Regular insulin, which is a short-acting insulin, has an onset of 15 to 30 Options B, C, and D:
minutes and a peak of 2 to 4 hours. Because the nurse gave the insulin at 2 p.m., humerus, or carpal scaphoid.
the expected onset would be from 2:15 p.m. to 2:30 p.m. and the peak from 4 p.m. 39. Answer: B. Calcium and phosphorous
to 6 p.m. Option B: In osteoporosis, bones lose calcium and phosphate salts, becoming
34. Answer: A. No increase in the thyroid-stimulating hormone (TSH) level after 30 porous, brittle, and abnormally vulnerable to fracture.
minutes during the TSH stimulation test Option D: Sodium nvolved in the development of
Option A: In the TSH test, failure of the TSH level to rise after 30 minutes confirms osteoporosis.
hyperthyroidism. 40. Answer: A. Adult respiratory distress syndrome (ARDS)
Option B: A decreased TSH level indicates a pituitary deficiency of this hormone. Option A: Severe hypoxia after smoke inhalation is typically related to ARDS.
Option D: Below-normal levels of T3 and T4, as detected by radioimmunoassay, Options B, C, and D: associated with
signal hypothyroidism. A below-normal T4 level also occurs in malnutrition and smoke inhalation and severe hypoxia.
liver disease and may result from administration of phenytoin and certain other 41. Answer: D. Fat embolism
drugs. Option D: Long bone fractures are correlated with fat emboli, which cause
not among shortness of breath and hypoxia.
Options A and C: developed asthma or bronchitis
Option B: The nurse should instruct the client to rotate injection sites within the without a previous history.
same anatomic region. Rotating sites among different regions may cause excessive Option B: He could
day-to-day variations in the blood glucose level; also, insulin absorption differs hypoxia.
from one region to the next. 42. Answer: D. Spontaneous pneumothorax
Option A: Insulin should be injected only into healthy tissue lacking large blood Option D: lung collapses,
vessels, nerves, or scar tissue or other deviations. causing an acute decreased in the amount of functional lung used in oxygenation.
Option C: Injecting insulin into areas of hypertrophy may delay absorption. The The sudden collapse was the cause of his chest pain and shortness of breath.
lipodystrophy (such as hypertrophy or Options A and B: An asthma attack would show wheezing breath sounds, and
atrophy); to prevent lipodystrophy, the client should rotate injection sites bronchitis would have rhonchi.
systematically. Option C: Pneumonia would have bronchial breath sounds over the area of
Option D: Exercise speeds drug absorption, so the client consolidation.
into sites above muscles that will be exercised heavily. 43. Answer: C. Pneumothorax
36. Answer: D. Below-normal serum potassium level Options A, B, and D:
Option D: A client with HHNS has an overall body deficit of potassium resulting has bronchitis, pneumonia, or TB; rhonchi with bronchitis, bronchial
from diuresis, which occurs secondary to the hyperosmolar, hyperglycemic state breath sounds with TB would be heard.
caused by the relative insulin deficiency. 44. Answer: C. Serous fluids fill the space and consolidate the region
Options A and B: An elevated serum acetone level and serum ketone bodies are Option C: Serous fluid fills the space and eventually consolidates, preventing
characteristic of diabetic ketoacidosis. extensive mediastinal shift of the heart and remaining lung.
Option C: Metabolic acidosis, not serum alkalosis, may occur in HHNS. Option A: Air
37. Answer: D. Maintaining room temperature in the low-normal range Option B: space.
Option D: hypermetabolism, such Option D: although a
as heat intolerance, diaphoresis, excessive thirst and appetite, and weight loss. To temporary mediastinal shift exits until space is filled.
45. Answer: A. Alveolar damage in the infarcted area
 Option A: The infarcted area produces alveolar damage that can lead to the
production of bloody sputum, sometimes in massive amounts.
Option B: Clot formation usually occurs in the legs.
Options C and D: and subsequent scar tissue
formation.
46. Answer: D. Respiratory alkalosis
Option D: A client with massive pulmonary embolism will have a large region and
blow off large amount of carbon dioxide, which crosses the unaffected alveolar-
capillary membrane more readily than does oxygen and results in respiratory
alkalosis.
47. Answer: A. Air leak
Option A: Bubbling in the water seal chamber of a chest drainage system stems
from an air leak. In pneumothorax, an air leak can occur as air is pulled from the
pleural space.
Options B and C: adequate or
inadequate suction or any preexisting bubbling in the water seal chamber.
48. Answer: B. 21
Option B: 3000 x 10 divided by 24 x 60.
49. Answer: B. 2.4 ml
Option B: .05 mg/ 1 ml = .12mg/ x ml, .05x = .12, x = 2.4 ml.
the
morning.
Option D: Promote venous return by applying external pressure on veins.