Basic Care and Comfort 9.

An 86 year-old nursing home resident who has impaired

mental status is hospitalized with pneumonic infiltrates in the
1. The nurse is planning care for a client with a cerebral vascular right lower lobe. When the nurse assists the client with a clear
accident (CVA). Which of the following measures planned by the liquid diet, the client begins to cough. What should the nurse do
nurse would be most effective in preventing skin breakdown? next?
A) Place client in the wheelchair for four hours each day A) Add a thickening agent to the fluids
B) Pad the bony prominence B) Check the client’s gag reflex
C) Reposition every two hours C) Feed the client only solid foods
D) Massage reddened bony prominence D) Increase the rate of intravenous fluids

2. After a client has an enteral feeding tube inserted, the most 10. An 85 year-old client complains of generalized muscle aches
accurate method for verification of placement is and pains. The first action by the nurse should be
A) abdominal x-ray A) assess the severity and location of the pain
B) auscultation B) obtain an order for an analgesic
C) flushing tube with saline C) reassure him that this is not unusual for his age
D) aspiration for gastric contents D) encourage him to increase his activity

3. The nurse has been teaching a client with congestive heart 11. A client was just taken off the ventilator after surgery and
failure about proper nutrition. Which of these lunch selections has a nasogastric tube draining bile-colored liquids. Which
indicates the client has learned about sodium restriction? nursing measure will provide the most comfort to the client?
A) Cheese sandwich with a glass of 2% milk A) Allow the client to melt ice chips in the mouth
B) Sliced turkey sandwich and canned pineapple B) Provide mints to freshen the breath
C) Cheeseburger and baked potato C) Perform frequent oral care with a tooth sponge
D) Mushroom pizza and ice cream D) Swab the mouth with glycerin swabs

4. The nurse is caring for a 7 year-old with acute 12. The nurse is instructing a 65 year-old female client
glomerulonephritis (AGN). Findings include moderate edema diagnosed with osteoporosis. The most important instruction
and oliguria. Serum blood urea nitrogen and creatinine are regarding exercise would be to
elevated. What dietary modifications are most appropriate? A) exercise doing weight bearing activities
A) Decreased carbohydrates and fat B) exercise to reduce weight
B) Decreased sodium and potassium C) avoid exercise activities that increase the risk of fracture
C) Increased potassium and protein D) exercise to strengthen muscles and thereby protect bones
D) Increased sodium and fluids
13. A nurse is assessing several clients in a long term health care
5. After a myocardial infarction, a client is placed on a sodium facility. Which client is at highest risk for development of
restricted diet. When the nurse is teaching the client about the decubitus ulcers?
diet, which meal plan would be the most appropriate to A) A 79 year-old malnourished client on bed rest
suggest? B) An obese client who uses a wheelchair
A) 3 oz. broiled fish, 1 baked potato, ½ cup canned beets, 1 C) An incontinent client who has had 3 diarrhea stools
orange, and milk D) An 80 year-old ambulatory diabetic client
B) 3 oz. canned salmon, fresh broccoli, 1 biscuit, tea, and 1
apple 14. Constipation is one of the most frequent complaints of
C) A bologna sandwich, fresh eggplant, 2 oz fresh fruit, tea, and elders. When assessing this problem, which action should be the
apple juice nurse's priority?
D) 3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, A) obtain a complete blood count
milk, and 1 orange B) obtain a health and dietary history
C) refer to a provider for a physical examination
6. What finding of the nursing assessment of a paralyzed client D) measure height and weight
would indicate the probable presence of a fecal impaction?
A) Presence of blood in stools 15. A nurse is working with a client in an extended care facility.
B) Oozing liquid stool Which bed position is preferred for a client, who is at risk for
C) Continuous rumbling flatulence falls, as part of a prevention protocol?
D) Absence of bowel movements A) All 4 side rails up, wheels locked, bed closest to door
B) Lower side rails up, bed facing doorway
7. The nurse is teaching the client to select foods rich in C) Knees bent, head slightly elevated, bed in lowest position
potassium to help prevent digitalis toxicity. Which choice D) Bed in lowest position, wheels locked, place bed against wall
indicates the client understands dietary needs?
A) three apricots 16. The nurse is teaching an 87 year-old client methods for
B) medium banana maintaining regular bowel movements. The nurse would
C) naval orange caution the client to avoid
D) baked potato A) glycerine suppositories
B) fiber supplements
8. When administering enteral feeding to a client via a C) laxatives
jejunostomy tube, the nurse should administer the formula D) stool softeners
A) every four to six hours
B) continuously 17. Which statement best describes the effects of immobility in
C) in a bolus children?
D) every hour A) Immobility prevents the progression of language and fine
motor development
B) Immobility in children has similar physical effects to those C) An elderly client with hypertension and self-reported non-
found in adults compliance
C) Children are more susceptible to the effects of immobility D) A new admission with a history of transient ischemic attacks
than are adults and dizziness
D) Children are likely to have prolonged immobility with
subsequent complications 5. A practical nurse (PN) from the pediatric unit is assigned to
work in a critical care unit. Which client assignment would be
18. A client with diarrhea should avoid which of the following? appropriate?
A) orange juice A) A client admitted with multiple trauma with a history of a
B) tuna newly implanted pacemaker
C) eggs B) A new admission with left-sided weakness from a stroke and
D) macaroni mild confusion
C) A 53 year-old client diagnosed with cardiac arrest from a
19. A client is being maintained on heparin therapy for deep suspected myocardial infarction
vein thrombosis (DVT). The nurse must closely monitor which of D) A 35 year-old client in balanced traction admitted 6 days ago
the following laboratory values? after a motor vehicle accident
A) bleeding time
B) platelet count 6. The RN delegates the task of taking vital signs of all the clients
C) activated PTT on the medical-surgical unit to an unlicensed assistive
D) clotting time personnel (UAP). Specific written and verbal instructions are
given to not take a post-mastectomy client’s blood pressure on
20. A client in a long term care facility complains of pain. The the left arm. Later as the RN is making rounds, the nurse finds
nurse collects data about the client’s pain. The first step in the blood pressure cuff on that client’s left arm. Which of these
painassessment is for the nurse to statements is most immediately accurate?
A) have the client identify coping methods A) The RN has no accountability for this situation
B) get the description of the location and intensity of the pain B) The RN did not delegate appropriately
C) accept the client’s report of pain C) The UAP is covered by the RN’s license
D) determine the client’s status of pain D) The UAP is responsible for following instructions
Delegation
7. As the RN responsible for a client in isolation, which can be
1. Which statement by the nurse is appropriate when giving an delegated to the practical nurse (PN)?
assignment to an unlicensed assistive personnel (UAP) to help a A) Reinforcement of isolation precautions
client ambulate for the first time after a colon resection? B) Assessment of the client's attitude about infection control
A) "Have the client sit on the side of the bed before helping the C) Evaluation of staffs' compliance with control measures
client to walk." D) Observation of the client's total environment for risks
B) "If the client is dizzy ask the client to take some slow, deep
breaths." 8. A 25 year-old client, unresponsive after a motor vehicle
C) "Help the client to walk in the room as often as the client accident, is being transferred from the hospital to a long term
wishes." care facility. To which staff member should the charge nurse
D) "When you help the client to walk, ask if any pain occurs." assign the client?
A) Unlicensed assistive personnel (UAP)
2. The home care nurse has been managing a client for 6 weeks. B) Senior nursing student
What is the best method to determine the quality of care C) PN
provided by a home health care aide assigned to assist with the D) RN
care of this client?
A) Ask the client and family if they are satisfied with the care 9. The charge nurse on a cardiac step-down unit makes
given assignments for the team consisting of a registered nurse (RN),
B) Determine if the home health aide's care is consistent with a practical nurse (PN), and an unlicensed assistive personnel
the plan of care (UAP). Which client should be assigned to the PN?
C) Investigate if the home health aide is prompt and stays an A) A 49 year-old with new onset atrial fibrillation with a rapid
appropriate length of time for care ventricular response
D) Check the documentation of the aide for appropriateness B) A 58 year-old hypertensive with possible angina
and comprehensiveness C) A 35 year-old scheduled for cardiac catheterization
D) A 65 year-old for discharge after angioplasty and stent
3. Which task for a client with anemia and confusion could the placement
nurse delegate to the unlicensed assistive personnel (UAP)?
A) Assess and document skin turgor and color changes 10. The measurement and documentation of vital signs is
B) Test stool for occult blood and urine for glucose and report expected for clients in a long term facility. Which staff type
results would it be a priority to delegate these tasks to?
C) Suggest foods high in iron and those easily consumed A) Practical nurse (PN)
D) Report mental status changes and the degree of mental B) Registered Nurse (RN)
clarity C) Unlicensed assistive personnel (UAP)
D) Volunteer
4. The care of which of the following clients can the nurse safely
delegate to an unlicensed assistive personnel (UAP)? 11. Which of these clients would be appropriate to assign to a
A) A client with peripheral vascular disease and an ulceration of practical nurse (PN)?
the lower leg. A) A trauma victim with multiple lacerations and requires
B) A pre-operative client awaiting adrenalectomy with a history complex dressings
of asthma
B) An elderly client with cystitis and an indwelling urethral B) "What type of care did you give in pediatrics?”
catheter C) "Do you have your competency checklist that we can
C) A confused client whose family complains about the nursing review?”
care 2 days after surgery D) "How comfortable are you to care for adult clients?”
D) A client admitted for possible transient ischemic attack with
unstable neurological signs 19. During the interview of a prospective employee who just
completed the agency orientation, which approach would be
12. Two people call in sick on the medical-surgical unit and no the best for the nurse manager to use to assess competence?
additional help is available. The team consists of an RN, an LPN A) "What degree of supervision for basic care do you think you
and an unlicensed assistive personnel (UAP). Which of these need?"
activities should the nurse assign to the UAP? B) "Let’s review your skills check-list for type and level of skill"
A) Assist with plans for any clients discharged C) "Are you comfortable working independently?"
B) Provide basic hygiene care to all clients on the unit D) "What client care tasks or assignments do you prefer?"
C) Assess a client after an acute myocardial infarction
D) Gather the vital signs of all clients on the unit 20. A charge nurse working in a long term care facility is making
out assignments. Which assignment made by a registered nurse
13. A staff nurse complains to the nurse manager that an to an unlicensed assistive personnel (UAP) requires intervention
unlicensed assistive personnel (UAP) consistently leaves the by the supervisor?
work area untidy and does not restock supplies. The best initial A) Provide decubitus ulcer care and apply a dry dressing
response by the nurse manager is which of these statements? B) Bathe and feed a client on bed rest
A) "I will arrange for a conference with you and the UAP within C) Oral suctioning of an unresponsive elderly client
the next week" D) Teaching a family intermittent (bolus) feedings via G-tube
B) "I can assure you that I will look into the matter" before discharge
C) "I would like for you to approach the UAP about the problem
the next time it occurs" 21. Which of these clients would be most appropriate to assign
D) I will add this concern to the agenda for the next unit to a practical nurse (PN)?
meeting A) A trauma victim with quadriplegia and a client 1 day post-op
radical neck dissection
14. A client has had a tracheostomy for 2 weeks after a motor B) A client with newly diagnosed type 2 diabetes mellitus and a
vehicle accident. Which task could the RN safely delegate to client with a history of AIDS admitted for pneumonia
unlicensed assistive personnel (UAP)? C) A client with hemiplegia is fed by a nasogastric tube and
A) Teach the client how to cough up secretions client with a left leg amputation in rehabilitation
B) Changes the tracheostomy trach ties D) A client with a history of schizophrenia in alcohol withdrawal
C) Monitor if client has shortness of breath and a client with chronic renal failure
D) Perform routine tracheostomy dressing care
22. The nurse assigns an unlicensed assistive personnel (UAP) to
15. An RN from the women’s health clinic is temporarily care for a client with a musculoskeletal disorder. The client
reassigned to a medical-surgical unit. Which of these client ambulates with a leg splint. Which task requires supervision of
assignments would be most appropriate for this nurse? the UAP?
A) A newly diagnosed client with type 2 diabetes mellitus who is A) Report signs of redness overlying a joint
learning foot care B) Monitor the client's response to ambulatory activity
B) A client from a motor vehicle accident with an external C) Encouragement for the independence in self-care
fixation device on the leg D) Assist the client to transfer from a bed to a chair
C) A client admitted for a barium swallow after a transient
ischemic attack 23. When walking past a client’s room, the nurse hears 1
D) A newly admitted client with a diagnosis of pancreatic cancer unlicensed assistive personnel (UAP) talking to another UAP.
Which statement requires follow-up intervention?
16. The nurse in a same-day surgery unit assigns the unlicensed A) "If we work together we can get all of the client care
assistive personnel (UAP) to provide a hernia patient with a completed."
lunch tray. Which statement by the nurse is most appropriate? B) "Since I am late for lunch, would you do this one client's
A) "Tell the family they can bring in a pizza if the patient would glucose test?"
prefer that." C) "This client seems confused, we need to watch monitor
B) "Make sure the patient gets at least 2 cartons of milk." closely."
C) "Stop the IV if the patient is able to eat solid food." D) "I’ll come back and make the bed after I go to the lab."
D) "Encourage the patient to eat slowly to prevent gas."
24. A client is receiving an intravenous (IV) infusion for pain
17. Which one of these tasks can be safely delegated to a control. When caring for this client, which one of these actions
practical nurse (PN)? can the RN safely assign to an unlicensed assistive personnel
A) Assess the function of a newly created ileostomy (UAP)?
B) Care for a client with a recent complicated double barrel A) Ask the client the degree of relief and document the client’s
colostomy response
C) Provide stoma care for a client with a well functioning ostomy B) Decrease the set rate on the pump by 2 ml/minute
D) Teach ostomy care to a client and their family members C) Check the IV site for drainage and loose tape
D) Assist the client with ambulation and a gown change with
18. An unlicensed assistive personnel (UAP), who usually works supervision
in pediatrics is assigned to work on a medical-surgical unit.
Which one of the questions by the charge nurse would be most 25. Which client data should the nurse act upon when a home
appropriate prior to making delegation decisions? health aide calls the nurse from the client's home to report
A) "How long have you been a UAP?” these items?
A) "The client has complaints of not sleeping well for the past
week" 7. When screening children for scoliosis, at what time of
B) "The family wants to discontinue the home meal service, development would the nurse expect early signs to appear?
meals on wheels" A) Prenatally on ultrasound
C) "The urine in the urinary catheter bag is of a deeper amber, B) In early infancy
almost brown color" C) When the child begins to bear weight
D) "The partner says the client has slower days every other day" D) During the preadolescent growth spurt

8. A client is admitted to the hospital with a history of

confusion. The client has difficulty remembering recent events
and becomes disoriented when away from home. Which
Health Promotion and Maintenance statement would provide the best reality orientation for this
client?
1. The nurse has been teaching adult clients about cardiac risks A) "Good morning. Do you remember where you are?"
when they visit the hypertension clinic. Which evaluation data B) "Hello. My name is Elaine Jones and I am your nurse for
would best measure learning? today."
A) Performance on written tests C) "How are you today? Remember, you're in the hospital."
B) Responses to verbal questions D) "Good morning. You’re in the hospital. I am your nurse Elaine
C) Completion of a mailed survey Jones."
D) Reported behavioral changes
9. The nurse is assessing a 4 month-old infant. Which motor skill
2. The nurse is assessing a client who states her last menstrual would the nurse anticipate finding?
period was March 16, and she has missed one period. She A) Hold a rattle
reports episodes of nausea and vomiting. Pregnancy is B) Bang two blocks
confirmed by a urine test. What will the nurse calculate as the C) Drink from a cup
estimated date of delivery (EDD)? D) Wave "bye-bye"
A) April 8
B) January 15 10. An appropriate treatment goal for a client with anxiety
C) February 11 would be to
D) December 23 A) ventilate anxious feelings to the nurse
B) establish contact with reality
3. The parents of a child who has suddenly been hospitalized for C) learn self-help techniques
an acute illness state that they should have taken the child to D) become desensitized to past trauma
the pediatrician earlier. Which approach by the nurse is best
when dealing with the parents' comments? 11. The family of a 6 year-old with a fractured femur asks the
A) Focus on the child's needs and recovery nurse if the child's height will be affected by the injury. Which
B) Explain the cause of the child's illness statement is true concerning long bone fractures in children?
C) Acknowledge that early care would have been better A) Growth problems will occur if the fracture involves the
D) Accept their feelings without judgment periosteum
B) Epiphyseal fractures often interrupt a child's normal growth
4. When observing 4 year-old children playing in the hospital pattern
playroom, what activity would the nurse expect to see the C) Children usually heal very quickly, so growth problems are
children participating in? rare
A) Competitive board games with older children D) Adequate blood supply to the bone prevents growth delay
B) Playing with their own toys along side with other children after fractures
C) Playing alone with hand held computer games
D) Playing cooperatively with other preschoolers 12. While caring for a client, the nurse notes a pulsating mass in
the client's periumbilical area. Which of the following
5. A 64 year-old client scheduled for surgery with a general assessments is appropriate for the nurse to perform?
anesthetic refuses to remove a set of dentures prior to leaving A) Measure the length of the mass
the unit for the operating room. What would be the most B) Auscultate the mass
appropriate intervention by the nurse? C) Percuss the mass
A) Explain to the client that the dentures must come out as they D) Palpate the mass
may get lost or broken in operating room
B) Ask the client if there are second thoughts about having the 13. While the nurse is administering medications to a client, the
procedure client states "I do not want to take that medicine today." Which
C) Notify the anesthesia department and the surgeon of the of the following responses by the nurse would be best?
client's refusal A) "That's OK, its all right to skip your medication now and
D) Ask the client if the preference would be to remove the then."
dentures in the operating room receiving area B) "I will have to call your doctor and report this."
C) "Is there a reason why you don't want to take your
6. When teaching a 10 year-old child about their impending medicine?"
heart surgery, which form of explanation meets the D) "Do you understand the consequences of refusing your
developmental needs of this age child? prescribed treatment?"
A) Provide a verbal explanation just prior to the surgery
B) Provide the child with a booklet to read about the surgery 14. The nurse is teaching the parents of a 3 month-old infant
C) Introduce the child to another child who had heart surgery 3 about nutrition. What is the main source of fluids for an infant
days ago until about 12 months of age?
D) Explain the surgery using a model of the heart A) Formula or breast milk
B) Dilute nonfat dry milk 1. The nurse receives a report on an older adult client with
C) Warmed fruit juice middle stage dementia. What information suggests the nurse
D) Fluoridated tap water should do immediate follow up rather than delegate care to the
nursing assistant? The client
15. A client states, "People think I’m no good, you know what I A) has had a change in respiratory rate by an increase of 2
mean?" Which of these responses would be most therapeutic? breaths
A) "Well people often take their own feelings of inadequacy out B) has had a change in heart rate by an increase of 10 beats
on others." C) was minimally responsive to voice and touch
B) "I think you’re good. So you see, there’s one person who likes D) has had a blood pressure change by a drop in 8 mmHg
you." systolic
C) "I’m not sure what you mean. Tell me a bit more about that."
D) "Let's discuss this to see the reasons you create this 2. A client tells the nurse, "I have something very important to
impression on people." tell you if you promise not to tell." The best response by the
nurse is
A) "I must document and report any information."
B) "I can’t make such a promise."
16. When teaching effective stress management techniques to a C) "That depends on what you tell me."
client 1 hour before surgery, which of the following should the D) "I must report everything to the treatment team."
nurse recommend? 3. The nurse is caring for a 69 year-old client with a diagnosis of
A) Biofeedback hyperglycemia. Which tasks could the nurse delegate to the
B) Deep breathing unlicensed assistive personnel (UAP)?
C) Distraction A) Test blood sugar every 2 hours by Accu-Check
D) Imagery B) Review with family and client signs of hyperglycemia
C) Monitor for mental status changes
17. The nurse is planning care for an 18 month-old child. Which D) Check skin condition of lower extremities
action should be included in the child's care?
A) Hold and cuddle the child frequently 4. A nurse from the maternity unit is floated to the critical care
B) Encourage the child to feed himself finger food unit because of staff shortage on the evening shift. Which client
C) Allow the child to walk independently on the nursing unit would be appropriate to assign to this nurse? A client with
D) Engage the child in games with other children A) a Dopamine drip IV with vital signs monitored every 5
minutes
18. A client being treated for hypertension returns to the B) a myocardial infarction that is free from pain and
community clinic for follow up. The client says, "I know these dysrhythmias
pills are important, but I just can't take these water pills C) a tracheotomy of 24 hours in some respiratory distress
anymore. I drive a truck for a living, and I can't be stopping D) a pacemaker inserted this morning with intermittent capture
every 20 minutes to go to the bathroom." Which of these is the
best nursing diagnosis? 5. Which task could be safely delegated by the nurse to an
A) Noncompliance related to medication side effects unlicensed assistive personnel (UAP)?
B) Knowledge deficit related to misunderstanding of disease A) Be with a client who self-administers insulin
state B) Cleanse and dress a small decubitus ulcer
C) Defensive coping related to chronic illness C) Monitor a client's response to passive range of motion
D) Altered health maintenance related to occupation exercises
D) Apply and care for a client's rectal pouch
19. A client with congestive heart failure is newly admitted to
home health care. The nurse discovers that the client has not 6. The unlicensed assistive personnel (UAP) reports a sudden
been following the prescribed diet. What would be the most increase in temperature to 101 degrees Fahrenheit for a post
appropriate nursing action? surgical client. The nurse checks on the client’s condition and
A) Discharge the client from home health care because of observes a cup of steaming coffee at the bedside. What
noncompliance instructions are appropriate to give to the UAP?
B) Notify the provider of the client's failure to follow prescribed A) Encourage oral fluids to prevent dehydration
diet B) Recheck temperature 15 minutes after removing hot liquids
C) Discuss diet with the client to learn the reasons for not from the bedside
following the diet C) Ask the client to drink only cold water and juices
D) Make a referral to Meals-on-Wheels D) Chart this temperature elevation on the flow sheet

20. A partner is concerned because the client frequently 7. A client has a nasogastric tube after colon surgery. Which one
daydreams about moving to Arizona to get away from the of these tasks can be safely delegated to an unlicensed assistive
pollution and crowding in southern California. The nurse personnel (UAP)?
explains that A) To observe the type and amount of nasogastric tube drainage
A) such fantasies can gratify unconscious wishes or prepare for B) Monitor the client for nausea or other complications
anticipated future events C) Irrigate the nasogastric tube with the ordered irrigant
B) detaching or dissociating in this way postpones painful D) Perform nostril and mouth care
feelings
C) converting or transferring a mental conflict to a physical 8. A client asks the nurse to call the police and states: “I need to
symptom can lead to conflict within the partnership report that I am being abused by a nurse.” The nurse should
D) isolating the feelings in this way reduces conflict within the first
client and with others A) focus on reality orientation to place and person
B) assist with the report of the client’s complaint to the police
Management of Care C) obtain more details of the client’s claim of abuse
D) document the statement on the client’s chart with a report 15. An unlicensed assistive personnel (UAP), who usually works
to the manager on a surgical unit is assigned to float to a pediatric unit. Which
question by the charge nurse would be most appropriate when
9. When assessing a client, it is important for the nurse to be making delegation decisions?
informed about cultural issues related to the client's A) "How long have you been a UAP and what units you have
background because worked on?"
A) normal patterns of behavior may be labeled as deviant, B) "What type of care do you give on the surgical unit and what
immoral, or insane ages of clients?"
B) the meaning of the client's behavior can be derived from C) "What is your comfort level in caring for children and at what
conventional wisdom ages?"
C) personal values will guide the interaction between persons D) "Have you reviewed the list of expected skills you might need
from 2 cultures on this unit?"
D) the nurse should rely on her knowledge of different
developmental mental stages 16. A client with a diagnosis of bipolar disorder has been
referred to a local boarding home for consideration for
10. The nursing student is discussing with a preceptor the placement. The social worker telephoned the hospital unit for
delegation of tasks to an unlicensed assistive personnel (UAP). information about the client’s mental status and adjustment.
Assigning which of these tasks to a UAP indicates the student The appropriate response of the nurse should be which of these
needs further teaching about the delegation process? statements?
A) Assist a client post cerebral vascular accident to ambulate A) "I am sorry. Referral information can only be provided by the
B) Feed a 2 year-old in balanced skeletal traction client’s providers"
C) Care for a client with discharge orders B) "I can never give any information out by telephone. How do I
D) Collect a sputum specimen for acid fast bacillus know who you are?"
C) "Since this is a referral, I can give you this information"
11. The nurse is responsible for several elderly clients, including D) "I need to get the client’s written consent before I release
a client on bed rest with a skin tear and hematoma from a fall 2 any information to you"
days ago. What is the best care assignment for this client? 17. A client frequently admitted to the locked psychiatric unit
A) Assign an RN to provide total care of the client repeatedly compliments and invites one of the nurses to go out
B) Assign a nursing assistant to help the client with self-care on a date. The nurse’s response should be to
activities A) ask to not be assigned to this client or to work on another
C) Delegate complete care to an unlicensed assistive personnel unit
D) Supervise a nursing assistant for skin care B) tell the client that such behavior is inappropriate
C) inform the client that hospital policy prohibits staff to date
12. A client continuously calls out to the nursing staff when clients
anyone passes the client’s door and asks them to do something D) discuss the boundaries of the therapeutic relationship with
in the room. The best response by the charge nurse would be to the client
A) keep the client’s room door cracked to minimize the
distractions 18. Which statement by the nurse is appropriate when directing
B) assign 1 of the nursing staff to visit the client regularly an unlicensed assistive personnel (UAP) to assist a 69 year-old
C) reassure the client that 1 staff person will check frequently if surgical client to ambulate for the first time?
the client needs anything A) "Have the client sit on the side of the bed for at least 2
D) arrange for each staff member to go into the client’s room to minutes before helping him stand."
check on needs every hour on the hour B) "If the client is dizzy on standing, ask him to take some deep
breaths."
C) "Assist the client to the bathroom at least twice on this shift."
13. A client is admitted with a diagnosis of schizophrenia. The D) "After you assist him to the chair, let me know how he feels."
client refuses to take medication and states “I don’t think I need
those medications. They make me too sleepy and drowsy. I 19. After working with a client, an unlicensed assistive personnel
insist that you explain their use and side effects.” The nurse (UAP) tells the nurse, "I have had it with that demanding client. I
should understand that just can’t do anything that pleases him. I’m not going in there
A) a referral is needed to the psychiatrist who is to provide the again." The nurse should respond by saying
client with answers A) "He has a lot of problems. You need to have patience with
B) the client has a right to know about the prescribed him."
medications B) "I will talk with him and try to figure out what to do."
C) such education is an independent decision of the individual C) "He may be scared and taking it out on you. Let's talk to
nurse whether or not to teach clients about their figure out what to do."
medications D) "Ignore him and get the rest of your work done. Someone
D) clients with schizophrenia are at a higher risk of psychosocial else can take care of him for the rest of the day."
complications when they know about their
medication side effects 20. A nurse is working with one licensed practical nurse (PN), a
student nurse and an unlicensed assistive personnel (UAP).
14. The charge nurse is planning assignments on a medical unit. Which newly admitted clients would be most appropriate to
Which client should be assigned to the practical nurse (PN)? assign to the UAP?
A) Test a stool specimen for occult blood A) A 76-year-old client with severe depression
B) Assist with the ambulation of a client with a chest tube B) A middle-aged client with an obsessive compulsive disorder
system C) An adolescent with dehydration and anorexia
C) Irrigate and redress a leg wound D) A young adult who is a heroin addict in withdrawal with
D) Admit a client from the emergency room hallucinations
NCSBN ON-LINE REVIEW C) the appearance of eyeballs that appear to "pop" out of the
client's eye sockets
1.A client has been hospitalized after an automobile accident. A D) a report of the sudden onset of irritability in the past 2 weeks
full leg cast was applied in the emergency room. The most
important reason for the nurse to elevate the casted leg is to 9. The nurse has performed the initial assessments of 4 clients
A) Promote the client's comfort admitted with an acute episode of asthma. Which assessment
B) Reduce the drying time finding would cause the nurse to call the provider immediately?
C) Decrease irritation to the skin A) prolonged inspiration with each breath
D) Improve venous return B) expiratory wheezes that are suddenly absent in 1 lobe
C) expectoration of large amounts of purulent mucous
2. The nurse is reviewing with a client how to collect a clean D) appearance of the use of abdominal muscles for breathing
catch urine specimen. What is the appropriate sequence to
teach the client? 10.During the initial home visit, a nurse is discussing the care of
A) Clean the meatus, begin voiding, then catch urine stream a client newly diagnosed with Alzheimer's disease with family
B) Void a little, clean the meatus, then collect specimen members. Which of these interventions would be most helpful
C) Clean the meatus, then urinate into container at this time?
D) Void continuously and catch some of the urine A) leave a book about relaxation techniques
B) write out a daily exercise routine for them to assist the client
3. Following change-of-shift report on an orthopedic unit, which to do
client should the nurse see first? C) list actions to improve the client's daily nutritional intake
A) 16 year-old who had an open reduction of a fractured wrist D) suggest communication strategies
10 hours ago
B) 20 year-old in skeletal traction for 2 weeks since a motor 11.An 80 year-old client admitted with a diagnosis of possible
cycle accident cerebral vascular accident has had a blood pressure from
C) 72 year-old recovering from surgery after a hip replacement 2 160/100 to 180/110 over the past 2 hours. The nurse has also
hours ago noted increased lethargy. Which assessment finding should the
D) 75 year-old who is in skin traction prior to planned hip nurse report immediately to the provider?
pinning surgery. A) Slurred speech
4. A client with Guillain Barre is in a nonresponsive state, yet B) Incontinence
vital signs are stable and breathing is independent. What should C) Muscle weakness
the nurse document to most accurately describe the client's D) Rapid pulse
condition?
A) Comatose, breathing unlabored 12. A school-aged child has had a long leg (hip to ankle)
B) Glascow Coma Scale 8, respirations regular synthetic cast applied 4 hours ago. Which statement from the
C) Appears to be sleeping, vital signs stable parent indicates that teaching has been inadequate?
D) Glascow Coma Scale 13, no ventilator required A) "I will keep the cast uncovered for the next day to prevent
burning of the skin."
5. When caring for a client receiving warfarin sodium B) "I can apply an ice pack over the area to relieve itching inside
(Coumadin), which lab test would the nurse monitor to the cast."
determine therapeutic response to the drug? C) "The cast should be propped on at least 2 pillows when my
A) Bleeding time child is lying down."
B) Coagulation time D) "I think I remember that my child should not stand until after
C) Prothrombin time 72 hours."
D) Partial thromboplastin time
13. Which blood serum finding in a client with diabetic
6.A client with moderate persistent asthma is admitted for a ketoacidosis alerts the nurse that immediate action is required?
minor surgical procedure. On admission the peak flow meter is A) pH below 7.3
measured at 480 liters/minute. Post-operatively the client is B) Potassium of 5.0
complaining of chest tightness. The peak flow has dropped to C) HCT of 60
200 liters/minute. D) Pa O2 of 79%
What should the nurse do first?
A) Notify both the surgeon and provider 14. The nurse is preparing a client with a deep vein thrombosis
B) Administer the prn dose of albuterol (DVT) for a Venous Doppler evaluation. Which of the following
C) Apply oxygen at 2 liters per nasal cannula would be necessary for preparing the client for this test?
D) Repeat the peak flow reading in 30 minutes A) Client should be NPO after midnight
B) Client should receive a sedative medication prior to the test
7.A client had 20 mg of Lasix (furosemide) PO at 10 AM. Which C) Discontinue anti-coagulant therapy prior to the test
would be essential for the nurse to include at the change of D) No special preparation is necessary
shift- report?
A) The client lost 2 pounds in 24 hours 15. A client is admitted with infective endocarditis (IE). Which
B) The client’s potassium level is 4 mEq/liter. finding would alert the nurse to a complication of this
C) The client’s urine output was 1500 cc in 5 hours condition?
D) The client is to receive another dose of Lasix at 10 PM A) dyspnea
B) heart murmur
8.A client has been tentatively diagnosed with Graves' disease C) macular rash
(hyperthyroidism). Which of these findings noted on the initial D) Hemorrhage
nursing assessment requires quick intervention by the nurse?
A) a report of 10 pounds weight loss in the last month 16. The nurse explains an autograft to a client scheduled for
B) a comment by the client "I just can't sit still." excision of a skin tumor. The nurse knows the client
understands the procedure when the client says, "I will receive A) Place the child on clear liquids and gelatin for 24 hours
tissue from B) Continue with the regular diet and include oral rehydration
A) a tissue bank." fluids
B) a pig." C) Give bananas, apples, rice and toast as tolerated
C) my thigh." D) Place NPO for 24 hours, then rehydrate with milk and water
D) synthetic skin."
25. The nurse is teaching parents about the appropriate diet for
17.A client is admitted to the emergency room following an a 4 month-old infant with gastroenteritis and mild dehydration.
acute asthma attack. Which of the following assessments would In addition to oral rehydration fluids, the diet should include
be expected by the nurse? A) formula or breast milk
A) Diffuse expiratory wheezing B) broth and tea
B) Loose, productive cough C) rice cereal and apple juice
C) No relief from inhalant D) gelatin and ginger ale
D) Fever and chills
26. A child is injured on the school playground and appears to
18. A client has been admitted with a fractured femur and has have a fractured leg. The first action the school nurse should
been placed in skeletal traction. Which of the following nursing take is
interventions should receive priority? A) call for emergency transport to the hospital
A) Maintaining proper body alignment B) immobilize the limb and joints above and below the injury
B) Frequent neurovascular assessments of the affected leg C) assess the child and the extent of the injury
C) Inspection of pin sites for evidence of drainage or D) apply cold compresses to the injured area
inflammation
D) Applying an over-bed trapeze to assist the client with 27. The mother of a 3 month-old infant tells the nurse that she
movement in bed wants to change from formula to whole milk and add cereal and
meats to the diet. What should be emphasized as the nurse
19. The nurse is assigned to care for a client who had a teaches about infant nutrition?
myocardial infarction (MI) 2 days ago. The client has many A) Solid foods should be introduced at 3-4 months
questions about this condition. What area is a priority for the B) Whole milk is difficult for a young infant to digest
nurse to discuss at this time? C) Fluoridated tap water should be used to dilute milk
A) Daily needs and concerns D) Supplemental apple juice can be used between feedings
B) The overview cardiac rehabilitation
C) Medication and diet guideline 28. The nurse is preparing a handout on infant feeding to be
D) Activity and rest guidelines distributed to families visiting the clinic. Which notation should
be included in the teaching materials?
20. A 3 year-old child is brought to the clinic by his grandmother A) Solid foods are introduced one at a time beginning with
to be seen for "scratching his bottom and wetting the bed at cereal
night." Based on these complaints, the nurse would initially B) Finely ground meat should be started early to provide iron
assess for which problem? C) Egg white is added early to increase protein intake
A) allergies D) Solid foods should be mixed with formula in a bottle
B) scabies
C) regression 29. The nurse planning care for a 12 year-old child with sickle
D) pinworms cell disease in a vaso-occlusive crisis of the elbow should include
which one of the following as a priority?
21. The nurse is caring for a newborn with tracheoesophageal A) Limit fluids
fistula. Which nursing diagnosis is a priority? B) Client controlled analgesia
A) Risk for dehydration C) Cold compresses to elbow
B) Ineffective airway clearance D) Passive range of motion exercise
C) Altered nutrition
D) Risk for injury 30. The nurse is performing a physical assessment on a toddler.
Which of the following actions should be the first?
22. The nurse is developing a meal plan that would provide the A) Perform traumatic procedures
maximum possible amount of iron for a child with anemia. B) Use minimal physical contact
Which dinner menu would be best? C) Proceed from head to toe
A) Fish sticks, french fries, banana, cookies, milk D) Explain the exam in detail
B) Ground beef patty, lima beans, wheat roll, raisins, milk
C) Chicken nuggets, macaroni, peas, cantaloupe, milk 31. What finding signifies that children have attained the stage
D) Peanut butter and jelly sandwich, apple slices, milk of concrete operations (Piaget)?
A) Explores the environment with the use of sight and
23. The nurse admitting a 5 month-old who vomited 9 times in movement
the past 6 hours should observe for signs of which overall B) Thinks in mental images or word pictures
imbalance? C) Makes the moral judgment that "stealing is wrong"
A) Metabolic acidosis D) Reasons that homework is time-consuming yet necessary
B) Metabolic alkalosis
C) Some increase in the serum hemoglobin 32. The mother of a child with a neural tube defect asks the
D) A little decrease in the serum potassium nurse what she can do to decrease the chances of having
another baby with a neural tube defect. What is the best
24. A two year-old child is brought to the provider's office with a response by the nurse?
chief complaint of mild diarrhea for two days. Nutritional A) "Folic acid should be taken before and after conception."
counseling by the nurse should include which statement?
B) "Multivitamin supplements are recommended during which of the following is most important to prevent lead
pregnancy." poisoning?
C) "A well balanced diet promotes normal fetal development." A) Use ready-to-feed commercial infant formula
D) "Increased dietary iron improves the health of mother and B) Boil the tap water for 10 minutes prior to preparing the
fetus." formula
C) Let tap water run for 2 minutes before adding to concentrate
33. The provider orders Lanoxin (digoxin) 0.125 mg PO and D) Buy bottled water labeled "lead free" to mix the formula
furosemide 40 mg every day. Which of these foods would the
nurse reinforce for the client to eat at least daily? 40. Which of the following manifestations observed by the
A) Spaghetti school nurse confirms the presence of pediculosis capitis in
B) Watermelon students?
C) Chicken A) Scratching the head more than usual
D) Tomatoes B) Flakes evident on a student's shoulders
C) Oval pattern occipital hair loss
34. While teaching the family of a child who will take phenytoin D) Whitish oval specks sticking to the hair
(Dilantin) regularly for seizure control, it is most important for
the nurse to teach them about which of the following actions? 41. When interviewing the parents of a child with asthma, it is
A) Maintain good oral hygiene and dental care most important to assess the child's environment for what
B) Omit medication if the child is seizure free factor?
C) Administer acetaminophen to promote sleep A) Household pets
D) Serve a diet that is high in iron B) New furniture
C) Lead based paint
35. The nurse is offering safety instructions to a parent with a D) Plants such as cactus
four month-old infant and a four year-old child. Which
statement by the parent indicates understanding of appropriate 42. The mother of a 2 month-old baby calls the nurse 2 days
precautions to take with the children? after the first DTaP, IPV, Hepatitis B and HIB immunizations. She
A) "I strap the infant car seat on the front seat to face reports that the baby feels very warm, cries inconsolably for as
backwards." long as 3 hours, and has had several shaking spells. In addition
B) "I place my infant in the middle of the living room floor on a to referring her to the emergency room, the nurse should
blanket to play with my four year-old while I make document the reaction on the baby's record and expect which
supper in the kitchen." immunization to be most associated with the findings the infant
C) "My sleeping baby lies so cute in the crib with the little is displaying?
buttocks stuck up in the air while the four year-old naps on A) DTaP
the sofa." B) Hepatitis B
D) "I have the four year-old hold and help feed the four month- C) Polio
old a bottle in the kitchen while I make supper." D) H. Influenza

36. The nurse admits a 7 year-old to the emergency room after 43.The mother of a 2 year-old hospitalized child asks the nurse's
a leg injury. The x-rays show a femur fracture near the advice about the child's screaming every time the mother gets
9epiphysis. The parents ask what will be the outcome of this ready to leave the hospital room. What is the best response by
injury. The appropriate response by the nurse should be which the nurse?
of these statements? A) "I think you or your partner needs to stay with the child while
A) "The injury is expected to heal quickly because of thin in the hospital."
periosteum." B) "Oh, that behavior will stop in a few days."
B) "In some instances the result is a retarded bone growth." C) "Keep in mind that for the age this is a normal response to
C) "Bone growth is stimulated in the affected leg." being in the hospital."
D) "This type of injury shows more rapid union than that of D) "You might want to "sneak out" of the room once the child
younger children." falls asleep."

37. The parents of a 4 year-old hospitalized child tell the nurse, 44. A couple experienced the loss of a 7 month-old fetus. In
“We are leaving now and will be back at 6 PM.” A few hours planning for discharge, what should the nurse emphasize?
later the child asks the nurse when the parents will come again. A) To discuss feelings with each other and use support persons
What is the best response by the nurse? B) To focus on the other healthy children and move through the
A) "They will be back right after supper." loss
B) "In about 2 hours, you will see them." C) To seek causes for the fetal death and come to some safe
C) "After you play awhile, they will be here." conclusion
D) "When the clock hands are on 6 and 12." D) To plan for another pregnancy within 2 years and maintain
physical health
38. The nurse is giving instructions to the parents of a child with
cystic fibrosis. The nurse would emphasize that pancreatic 45. The nurse is performing a pre-kindergarten physical on a 5
enzymes should be taken year-old. The last series of vaccines will be administered. What
A) once each day is the preferred site for injection by the nurse?
B) 3 times daily after meals A) vastus intermedius
C) with each meal or snack B) gluteus maximus
D) each time carbohydrates are eaten C) vastus lateralis
D) dorsogluteaI
39. A nurse is providing a parenting class to individuals living in a
community of older homes. In discussing formula preparation,
46. A 7 month pregnant woman is admitted with complaints of 53. The nurse instructs the client taking dexamethasone
painless vaginal bleeding over several hours. The nurse should (Decadron) to take it with food or milk. The physiological basis
prepare the client for an immediate for this instruction is that the medication
A) Non stress test A) retards pepsin production
B) Abdominal ultrasound B) stimulates hydrochloric acid production
C) Pelvic exam C) slows stomach emptying time
D) X-ray of abdomen D) decreases production of hydrochloric acid

47. A nurse entering the room of a postpartum mother observes 54. A client receiving chlorpromazine HCL (Thorazine) is in
the baby lying at the edge of the bed while the woman sits in a psychiatric home care. During a home visit the nurse observes
chair. The mother states "This is not my baby, and I do not want the client smacking her lips alternately with grinding her teeth.
it." After repositioning the child safely, the nurse's best The nurse recognizes this assessment finding as what?
response is A) Dystonia
A) "This is a common occurrence after birth, but you will come B) Akathisia
to accept the baby." C) Brady dyskinesia
B) "Many women have postpartum blues and need some time D) Tardive dyskinesia
to love the baby."
C) "What a beautiful baby! Her eyes are just like yours." 55. Which of the following findings contraindicate the use of
D) "You seem upset; tell me what the pregnancy and birth were haloperidol (Haldol) and warrant withholding the dose?
like for you." A) Drowsiness, lethargy, and inactivity
B) Dry mouth, nasal congestion, and blurred vision
48. The nurse notes that a 2 year-old child recovering from a C) Rash, blood dyscrasias, severe depression
tonsillectomy has an temperature of 98.2 degrees Fahrenheit at D) Hyperglycemia, weight gain, and edema
8:00 AM. At 10:00 AM the child's parent reports that the child
"feels very warm" to touch. The first action by the nurse should 56. The nurse is reinforcing teaching to a 24 year-old woman
be to receiving acyclovir (Zovirax) for a Herpes Simplex Virus type 2
A) reassure the parent that this is normal infection. Which of these instructions should the nurse give the
B) offer the child cold oral fluids client?
C) reassess the child's temperature A) Complete the entire course of the medication for an effective
D) administer the prescribed acetaminophen cure
B) Begin treatment with acyclovir at the onset of symptoms of
49. The nurse is caring for a client who was successfully recurrence
resuscitated from a pulseless dysrhythmia. Which of the C) Stop treatment if she thinks she may be pregnant to prevent
following assessments is critical for the nurse to include in the birth defects
plan of care? D) Continue to take prophylactic doses for at least 5 years after
A) hourly urine output the diagnosis
B) white blood count
C) blood glucose every 4 hours 57. A 14 month-old child ingested half a bottle of aspirin tablets.
D) temperature every 2 hours Which of the following would the nurse expect to see in the
child?
50. A client is admitted to the rehabilitation unit following a A) Hypothermia
cerebral vascular accident (CVA) and mild dysphagia. The most B) Edema
appropriate intervention for this client is to C) Dyspnea
A) position client in upright position while eating D) Epistaxis
B) place client on a clear liquid diet
C) tilt head back to facilitate swallowing reflex 58. An 80 year-old client on digitalis (Lanoxin) reports nausea,
D) offer finger foods such as crackers or pretzels vomiting, abdominal cramps and halo vision. Which of the
following laboratory results should the nurse analyze first?
51. A 72 year-old client with osteomyelitis requires a 6 week A) Potassium levels
course of intravenous antibiotics. In planning for home care, B) Blood pH
what is the most important action by the nurse? C) Magnesium levels
A) Investigating the client's insurance coverage for home IV D) Blood urea nitrogen
antibiotic therapy
B) Determining if there are adequate hand washing facilities in 59. A 42 year-old male client refuses to take propranolol
the home hydrochloride (Inderal) as prescribed. Which client statement
C) Assessing the client's ability to participate in self care and/or from the assessment data is likely to explain his
the reliability of a caregiver noncompliance?
D) Selecting the appropriate venous access device A) "I have problems with diarrhea."
B) "I have difficulty falling asleep."
52. A nurse administers the influenza vaccine to a client in a C) "I have diminished sexual function."
clinic. Within 15 minutes after the immunization was given, the D) "I often feel jittery."
client complains of itchy and watery eyes, increased anxiety,
and difficulty breathing. The nurse expects that the first action 60. The nurse caring for a 9 year-old child with a fractured
in the sequence of care for this client will be to femur is told that a medication error occurred. The child
A) Maintain the airway received twice the ordered dose of morphine an hour ago.
B) Administer epinephrine 1:1000 as ordered Which nursing diagnosis is a priority at this time?
C) Monitor for hypotension with shock A) Risk for fluid volume deficit related to morphine overdose
D) Administer diphenhydramine as ordered B) Decreased gastrointestinal mobility related to mucosal
irritation
C) Ineffective breathing patterns related to central nervous 68. Which nursing intervention will be most effective in helping
system depression a withdrawn client to develop relationship skills?
D) Altered nutrition related to inability to control nausea and A) Offer the client frequent opportunities to interact with 1
vomiting person
B) Provide the client with frequent opportunities to interact
61. Lactulose (Chronulac) has been prescribed for a client with with other clients
advanced liver disease. Which of the following assessments C) Assist the client to analyze the meaning of the withdrawn
would the nurse use to evaluate the effectiveness of this behavior
treatment? D) Discuss with the client the focus that other clients have
A) An increase in appetite similar problems
B) A decrease in fluid retention
C) A decrease in lethargy 69. An important goal in the development of a therapeutic
D) A reduction in jaundice inpatient milieu is to
A) provide a businesslike atmosphere where clients can work on
62. The nurse is teaching a class on HIV prevention. Which of individual goals
the following should be emphasized as increasing risk? B) provide a group forum in which clients decide on unit rules,
A) Donating blood regulations, and policies
B) Using public bathrooms C) provide a testing ground for new patterns of behavior while
C) Unprotected sex the client takes responsibility for his or her own actions
D) Touching a person with AIDS D) discourage expressions of anger because they can be
disruptive to other clients
63. While interviewing a new admission, the nurse notices that
the client is shifting positions, wringing her hands, and avoiding 70. A client with paranoid delusions stares at the nurse over a
eye contact. It is important for the nurse to period of several days. The client suddenly walks up to the
A) ask the client what she is feeling nurse and shouts "You think you’re so perfect and pure and
B) assess the client for auditory hallucination good." An appropriate response for the nurse is
C) recognize the behavior as a side effect of medication A) "Is that why you’ve been staring at me?"
D) re-focus the discussion on a less anxiety provoking topic B) "You seem to be in a really bad mood."
C) "Perfect? I don’t quite understand."
64. A young adult seeks treatment in an outpatient mental D) "You seem angry right now."
health center. The client tells the nurse he is a government
official being followed by spies. On further questioning, he 71. A client who is a former actress enters the day room
reveals that his warnings must be heeded to prevent nuclear wearing a sheer nightgown, high heels, numerous bracelets,
war. What is the most therapeutic approach by the nurse? bright red lipstick and heavily rouged cheeks. Which nursing
A) Listen quietly without comment action is the best in response to the client’s attire?
B) Ask for further information on the spies A) Gently remind her that she is no longer on stage
C) Confront the client’s delusion B) Directly assist client to her room for appropriate apparel
D) Contact the government agency C) Quietly point out to her the dress of other clients on the unit
D) Tactfully explain appropriate clothing for the hospital

72. When teaching suicide prevention to the parents of a 15

65. The nurse is assessing a 17 year-old female client with year-old who recently attempted suicide, the nurse describes
bulimia. Which of the following laboratory reports would the the following behavioral cue as indicating a need for
nurse anticipate? intervention.
A) Increased serum glucose A) Angry outbursts at significant others
B) Decreased albumin B) Fear of being left alone
C) Decreased potassium C) Giving away valued personal items
D) Increased sodium retention D) Experiencing the loss of a boyfriend

66. A client, recovering from alcoholism, asks the nurse, "What 73. Which statement made by a client indicates to the nurse
can I do when I start recognizing relapse triggers within myself?" that the client may have a thought disorder?
How might the nurse best respond? A) "I’m so angry about this. Wait until my partner hears about
A) "When you have the impulse to stop in a bar, contact a sober this."
friend and talk with him." B) "I’m a little confused. What time is it?"
B) "Go to an AA meeting when you feel the urge to drink." C) "I can't find my 'mesmer' shoes. Have you seen them?"
C) "It is important to exercise daily and get involved in activities D) "I’m fine. It's my daughter who has the problem."
that will cause you not to
think about drug use." 74. In a psychiatric setting, the nurse limits touch or contact
D) "Let’s talk about possible options you have when you used with clients to handshaking because
recognize relapse triggers in A) some clients misconstrue hugs as an invitation to sexual
yourself." advances
B) handshaking keeps the gesture on a professional level
67. Therapeutic nurse-client interaction occurs when the nurse C) refusal to touch a client denotes lack of concern
A) assists the client to clarify the meaning of what the client has D) inappropriate touch often results in charges of assault and
said battery
B) interprets the client’s covert communication
C) praises the client for appropriate feelings and behavior 75. A client with anorexia is hospitalized on a medical unit due
D) advises the client on ways to resolve problems to electrolyte imbalance and cardiac dysrhythmias. Additional
assessment findings that the nurse would expect to observe are
A) brittle hair, lanugo, amenorrhea B) Withhold treatment until telephone consent can be obtained
B) diarrhea, nausea, vomiting, dental erosion from the partner
C) hyperthermia, tachycardia, increased metabolic rate C) Refer the teenager to a community pediatric hospital
D) excessive anxiety about symptoms emergency department
D) Proceed with the triage process in the same manner as any
76. Which intervention best demonstrates the nurse's sensitivity adult client
to a 16 year-old’s appropriate need for autonomy?
A) Alertness for feelings regarding body image 84. The pediatric clinic nurse examines a toddler with a
B) Allows young siblings to visit tentative diagnosis of neuroblastoma. Findings observed by the
C) Provides opportunity to discuss concerns without presence of nurse that is associated with this problem include which of
parents these?
D) Explores his feelings of resentment to identify causes A) Lymphedema and nerve palsy
B) Hearing loss and ataxia
77. The nurse's primary intervention for a client who is C) Headaches and vomiting
experiencing a panic attack is to D) Abdominal mass and weakness
A) develop a trusting relationship
B) assist the client to describe his experience in detail 85. The nurse is preparing the teaching plan for a group of
C) maintain safety for the client parents about risks to toddlers and is including the proper
D) teach the client to control his or her own behavior communication in the event of accidental poisoning. The nurse
should tell the parents to first state what substance was
78. A client was admitted to the eating disorder unit with ingested and then what information should be the priority for
bulimia nervosa. The nurse assessing for a history of the parents to communicate?
complications of this disorder expects A) The parents' name and telephone number
A) Respiratory distress, dyspnea B) The currency of the immunization and allergy history of the
B) Bacterial gastrointestinal infections, overhydration child
C) Metabolic acidosis, constricted colon C) The estimated time of the accidental poisoning and a
D) Dental erosion, parotid gland enlargement confirmation that the parents will bring the containers of the
ingested substance
79. Which of the following times is a depressed client at highest D) The affected child's age and weight
risk for attempting suicide?
A) Immediately after admission, during one-to-one observation 86. The nurse has admitted a 4 year-old with the diagnosis of
B) 7 to 14 days after initiation of antidepressant medication and possible rheumatic fever. Which statement by the parent would
psychotherapy the nurse suspect is relevant to this disease?
C) Following an angry outburst with family A) Our child had chickenpox 6 months ago.
D) When the client is removed from the security room B) Strep throat went through all the children at the day care last
month.
80. A client is admitted to a psychiatric unit with delusions. C) Both ears were infected at 3 months of age.
What findings could the nurse observe that would be consistent D) Last week both feet had a fungal skin infection.
with delusional thought patterns?
A) Flight of ideas and hyperactivity 87. The nurse provides discharge teaching to the parents of a 15
B) Suspiciousness and resistance to therapy month-old child with Kawasaki disease. The child has received
C) Anorexia and hopelessness immunoglobulin therapy. Which instruction would be
D) Panic and multiple physical complaints appropriate?
A) High doses of aspirin will be continued for some time
81. As the nurse takes a history of a 3 year-old with B) Complete recovery is expected within several days
neuroblastoma, what comments by the parents require follow- C) Active range of motion exercises should be done frequently
up and are consistent with the diagnosis? D) The measles, mumps and rubella vaccine should be delayed
A) "The child has been listless and has lost weight."
B) "The urine is dark yellow and small in amounts." 88. A 10 year-old client is recovering from a splenectomy
C) "Clothes are becoming tighter across her abdomen." following a traumatic injury. The clients laboratory results show
D) "We notice muscle weakness and some unsteadiness." a hemoglobin of 9 g/dL and a hematocrit of 28 percent. The
best approach for the nurse to use is to
82. Parents call the emergency room to report that a toddler A) limit milk and milk products
has swallowed drain cleaner. The triage nurse instructs them to B) encourage bed activities and games
call for emergency transport to the hospital. The nurse would C) plan nursing care around lengthy rest periods
also suggest that the parents give the toddler sips of _______ D) promote a diet rich in iron
while waiting
for an ambulance. 89. The nurse is planning care for a 14 year-old client returning
A) Tea from scoliosis corrective surgery. Which of the following actions
B) Water should receive priority in the plan?
C) Milk A) Antibiotic therapy for 10 days
D) Soda B) Teach client isometric exercises for legs
C) Assess movement and sensation of extremities
83. A 16 year-old enters the emergency department. The triage D) Assist to stand up at bedside within the first 24 hours
nurse identifies that this teenager is legally married and signs
the consent form for treatment. What would be the 90. The nurse is teaching parents about accidental poisoning in
appropriate action by the nurse? children. Which point should be emphasized?
A) Ask the teenager to wait until a parent or legal guardian can A) Call the Poison Control Center once the situation is identified
be contacted B) Empty the child's mouth in any case of possible poisoning
C) Keep the child as quiet as possible if a toxic substance was A) congenital abnormalities
inhaled B) chronic toxoplasmosis
D) Do not induce vomiting if the poison is a hydrocarbon C) fetal alcohol syndrome (FAS)
D) lead poisoning
91. The nurse is assessing an 8 month-old infant with a
malfunctioning ventriculoperitoneal shunt. Which one of the 98. A 15 year-old client has been placed in a Milwaukee brace.
following manifestations would the infant be most likely to Which statement from the adolescent indicates the need for
exhibit? additional teaching?
A) Lethargy A) "I will only have to wear this for 6 months."
B) Irritability B) "I should inspect my skin daily."
C) Negative Moro C) "The brace will be worn day and night."
D) Depressed fontanel D) "I can take it off when I shower."

92. The nurse is caring for a 4 year-old two hours after 99. The nurse is caring for a 4 year-old admitted after receiving
tonsillectomy and adenoidectomy. Which of the following burns to more than 50% of his body. Which laboratory data
assessments must be reported immediately? should be reviewed by the nurse as a priority in the first 24
A) Vomiting of dark emesis hours?
B) Complaints of throat pain A) Blood urea nitrogen
C) Apical heart rate of 110 B) Hematocrit
D) Increased restlessness C) Blood glucose
D) White blood count
93. The nurse is caring for a client with sickle cell disease who is
scheduled to receive a unit of packed red blood cells. Which of 100. The nurse is caring for a client with a colostomy pouch.
the following is an appropriate action for the nurse when During a teaching session, the nurse appropriately recommends
administering the infusion? that the pouch be emptied
A) Storing the packed red cells in the medicine refrigerator A) when it is 1/3 to 1/2 full
while starting IV B) prior to meals
B) Slow the rate of infusion if the client develops fever or chills C) after each fecal elimination
C) Limit the infusion time of each of the unit to a maximum of 4 D) at the same time each day
hours
D) Assess vital signs every 15 minutes throughout the entire 101. An 18 year-old client is admitted to intensive care from the
infusion emergency room following a diving accident. The injury is
suspected to be at the level of the 2nd cervical vertebrae. The
94. The nurse is caring for a 17 month-old with acetaminophen nurse's priority assessment should be the client’s
poisoning. Which of the following lab reports should the nurse A) response to stimuli
review first? B) bladder control
A) Prothrombin Time (PT) and partial thromboplastin time (PTT) C) respiratory function
B) Red blood cell and white blood cell counts D) muscle weakness
C) Blood urea nitrogen and creatinine clearance
D) Liver enzymes (AST and ALT) 102. A client has been admitted to the coronary care unit with a
myocardial infarction. Which nursing diagnosis should have
priority?
A) pain related to ischemia
B) risk for altered elimination: constipation
95. A nurse admits a premature infant who has respiratory C) risk for complication: dysrhythmias
distress syndrome (RDS). In planning care, nursing actions are D) anxiety related to pain
based on the fact that the most likely cause of this problem
stems from the infant's inability to 103.The nurse is caring for a client with a distal tibia fracture.
A) stabilize thermoregulation The client has had a closed reduction and application of a toe to
B) maintain alveolar surface tension groin cast. 36 hours after surgery, the client suddenly becomes
C) begin normal pulmonary blood flow confused, short of breath and spikes a temperature of 103
D) regulate intracardiac pressure degrees Fahrenheit. The first assessment the nurse should
perform is
96. The nurse is planning care for a 3 month-old infant A) orientation to time, place and person
immediately postoperative following placement of a B) pulse oximetry
ventriculoperitoneal shunt for hydrocephalus. The nurse needs C) circulation to casted extremity
to D) blood pressure
A) assess for abdominal distention
B) maintain infant in an upright position 104.The nurse is assessing a client with a Stage 2 skin ulcer.
C) begin formula feedings when infant is alert Which of the following treatments is most effective to promote
D) pump the shunt to assess for proper function healing?
A) Covering the wound with a dry dressing
97. A 6 year-old child is seen for the first time in the clinic. Upon B) Using hydrogen peroxide soak
assessment, the nurse finds that the child has deformities of the C) Leaving the area open to dry
joints, limbs, and fingers, thinned upper lip, and small teeth with D) Applying a hydrocolloid or foam dressing
faulty enamel. The mother states: ”My child seems to have
problems in learning to count and recognizing basic colors.” 105.A client is recovering from a thyroidectomy. While
Based on this data, the nurse suspects that the child is most monitoring the client's initial post-operative condition, which of
likely showing the effects of which problem? the
following should the nurse report immediately?
A) Tetany and paresthesia 113. The nurse is teaching a newly diagnosed asthma client on
B) Mild stridor and hoarseness how to use a peak flow meter. The nurse explains that this
C) Irritability and insomnia should be used to
D) Headache and nausea A) determine oxygen saturation
B) measure forced expiratory volume
106. A client is scheduled for an intravenous pyelogram (IVP). C) monitor atmosphere for presence of allergens
Which of the following data from the client’s history indicate a D) provide metered doses for inhaled bronchodilator
potential hazard for this test?
A) Reflex incontinence 114. The nurse is assessing a 55 year-old female client who is
B) Allergy to shellfish scheduled for abdominal surgery. Which of the following
C) Claustrophobia information would indicate that the client is at risk for thrombus
D) Hypertension formation in the post-operative period?
A) Estrogen replacement therapy
107. A client enters the emergency department unconscious via B) 10% less than ideal body weight
ambulance. What document should be given priority to guide C) Hypersensitivity to heparin
the direction of care for this client? D) History of hepatitis
A) The statement of client rights and the client self
determination act 115. During the check up of a 2 month-old infant at a well baby
B) Orders written by the provider clinic, the mother expresses concern to the nurse because a flat
C) A notarized original of advance directives brought in by the pink birthmark on the baby's forehead and eyelid has not gone
partner away. What is an appropriate response by the nurse?
D) The clinical pathway protocol of the agency and the A) "Mongolian spots are a normal finding in dark-skinned
emergency department children."
B) "Port wine stains are often associated with other
108. A client diagnosed with hepatitis C discusses his health malformations."
history with the admitting nurse. The nurse should recognize C) "Telangiectatic nevi are normal and will disappear as the baby
which statement by the client as the most important? grows."
A) I got back from Central America a few weeks ago. D) "The child is too young for consideration of surgical removal
B) I had the best raw oysters last week. of these at this time."
C) I have many different sex partners.
D) I had a blood transfusion 15 years ago. 116. A 3 year-old child diagnosed as having celiac disease
attends a day care center. Which of the following would be an
109. Which of these children at the site of a disaster at a child appropriate snack?
day care center would the triage nurse put in the "treat last" A) Cheese crackers
category? B) Peanut butter sandwich
A) An infant with intermittent bulging anterior fontanel C) Potato chips
between crying episodes D) Vanilla cookies
B) A toddler with severe deep abrasions over 98% of the body
C) A preschooler with a lower leg fracture on one side and an 117. A nurse assigned to a manipulative client for 5 days
upper leg fracture on the other becomes aware of feelings of reluctance to interact with the
D) A school-age child with singed eyebrows and hair on the client. The next action by the nurse should be to
arms A) Discuss the feeling of reluctance with an objective peer or
supervisor
B) Limit contacts with the client to avoid reinforcement of the
manipulative behavior
110. A client has returned to the unit following a renal biopsy. C) Confront the client about the negative effects of behaviors on
Which of the following nursing interventions is appropriate? other clients and staff
A) Ambulate the client 4 hours after procedure D) Develop a behavior modification plan that will promote more
B) Maintain client on NPO status for 24 hours functional behavior
C) Monitor vital signs
D) Change dressing every 8 hours 118. A client is being treated for paranoid schizophrenia. When
the client became loud and boisterous, the nurse immediately
111. The nurse is providing instructions for a client with asthma. placed him in seclusion as a precautionary measure. The client
Which of the following should the client monitor on a daily willingly complied. The nurse’s action
basis? A) may result in charges of unlawful seclusion and restraint
A) Respiratory rate B) leaves the nurse vulnerable for charges of assault and battery
B) Peak air flow volumes C) was appropriate in view of a client history of violence
C) Pulse oximetry D) was necessary to maintain the therapeutic milieu of the unit
D) Skin color
119. The provisions of the law for the Americans with
112.A client with a documented pulmonary embolism has the Disabilities Act require nurse managers to
following arterial blood gases: PO2 - 70 mm hg, PCO2 - 32 mm A) Maintain an environment free from associated hazards
hg, pH- 7.45, SaO2 - 87%, HCO3 - 22. Based on these data, what B) Provide reasonable accommodations for disabled individuals
is the first nursing action? C) Make all necessary accommodations for disabled individuals
A) Review other lab data D) Consider both mental and physical disabilities
B) Notify the health care provider
C) Administer oxygen
D) Calm the client
120. Upon completing the admission documents, the nurse 128. The nurse is teaching a client with non-insulin dependent
learns that the 87 year-old client does not have an advance diabetes mellitus about the prescribed diet. The nurse should
directive. What action should the nurse take? teach the client to
A) Record the information on the chart A) maintain previous calorie intake
B) Give information about advance directives B) keep a candy bar available at all times
C) Assume that this client wishes a full code C) reduce carbohydrates intake to 25% of total calories
D) Refer this issue to the unit secretary D) keep a regular schedule of meals and snacks

121.A client with a diagnosis of Methicillin resistant 129. A depressed client in an assisted living facility tells the
Staphylococcus aureus (MRSA) has died. Which type of nurse that "life isn't worth living anymore." What is the best
precautions is appropriate to use when performing response to this statement?
postmortem care? A) "Come on, it is not that bad."
A) Airborne precautions B) "Have you thought about hurting yourself?"
B) Droplet precautions C) "Did you tell that to your family?"
C) Contact precautions D) "Think of the many positive things in life."
D) Compromised host precautions
130. The nurse is observing a client with an obsessive-
122. An 8 year-old client is admitted to the hospital for surgery. compulsive disorder in an inpatient setting. Which behavior is
The child’s parent reports the allergies listed below. Which of consistent with this diagnosis?
these allergies should all health care personnel be aware of? A) Repeatedly checking that the door is locked
A) Shellfish B) Verbalized suspicions about thefts
B) Molds C) Preference for consistent caregivers
C) Balloons D) Repetitive, involuntary movements
D) Perfumed soap
131.A female client is admitted for a breast biopsy. She says,
123.A nurse is stuck in the hand by an exposed used hypodermic tearfully to the nurse, "If this turns out to be cancer and I have
needle. What immediate action should the nurse take? to have my breast removed, my partner will never come near
A) Look up the policy on needle sticks me." The nurse's best response would be which of these
B) Contact employee health services statements?
C) Immediately wash the hands with vigor A) "I hear you saying that you have a fear for the loss of love."
D) Notify the supervisor and risk management B) "You sound concerned that your partner will reject you."
C) "Are you wondering about the effects on your sexuality?"
124. The nurse is having difficulty reading the health care D) "Are you worried that the surgery will lead to changes?"
provider's written order that was left just before the shift
change. What action should be taken? 132. A client is admitted for treatment of a right upper lobe
A) Leave the order for the oncoming staff to follow-up on infiltrate and to rule out tuberculosis. Which of these would be
B) Contact the charge nurse for an interpretation the most appropriate self-protective action by the nurse ?
C) Ask the pharmacy for assistance in the interpretation A) Provide negative room ventilation
D) Call the provider for clarification B) Wear a face mask with shield
C) Wear a particulate respirator mask
125. When admitting a client to an acute care facility, an D) Institute airborne precautions
identification bracelet is sent up with the admission form. In the
event these do not match, the nurse’s best action is to 133. The charge nurse has a health care team that consists of 1
A) change whichever item is incorrect to the correct information practical nurse (PN), 1 unlicensed assistive personnel (UAP) and
B) use the bracelet and admission form until a replacement is 1 PN nursing student. Which assignment should be questioned
supplied by the nurse manager?
C) notify the admissions office and wait to apply the bracelet A) An admission at the change of shifts with atrial fibrillation
D) make a corrected identification bracelet for the client and heart failure - PN
B) Client who had a major stroke 6 days ago - PN nursing
student
126.The nurse is planning discharge for a 90 year-old client with C) A child with burns who has packed cells and albumin IV
musculo-skeletal weakness. Which intervention should be running - charge nurse
included in the plan that would be most effective for the D) An elderly client who had a myocardial infarction a week ago
prevention of falls? – UAP
A) Place nightlights in the bedroom
B) Wear eyeglasses at all times 134. The nurse is teaching an elderly client how to use MDI's
C) Install grab bars in the bathroom (multi-dose inhalers). The nurse is concerned that the client is
D) Teach muscle strengthening exercises unable to coordinate the release of the medication with the
inhalation phase. What is the nurse's best recommendation to
127.An 8 year-old child is hospitalized during the edema phase improve delivery of the medication?
of minimal change nephrotic syndrome. The nurse is assisting in A) Nebulized treatments for home care
choosing the lunch menu. Which menu is the best choice? B) Adding a spacer device to the MDI canister
A) Bologna sandwich, pudding, milk C) Asking a family member to assist the client with the MDI
B) Frankfurter, baked potato, milk D) Request a visiting nurse to follow the client at home
C) Chicken strips, corn on the cob, milk
D) Grilled cheese sandwich, apple, milk 135.The nurse is teaching a client newly diagnosed with asthma
how to use the metered-dose inhaler (MDI). The client asks
when they will know the canister is empty. The best response is
A) Drop the canister in water to observe floating
B) Estimate how many doses are usually in the canister D) Request an immediate private meeting with the provider and
C) Count the number of doses as the inhaler is used staff nurse
D) Shake the canister to detect any fluid movement
143. The charge nurse is planning assignments on a medical
136.A client has an order for 1000 ml of D5W over an 8 hour unit. The client with _______should be assigned to the
period. The nurse discovers that 800 ml has been infused after 4 unlicensed assistive personnel (UAP).
hours. What is the priority nursing action? A) d ifficulty swallowing after a mild stroke
A) Ask the client if there are any breathing problems B) an order of enemas until clear prior to colonoscopy
B) Have the client void as much as possible C) an order for a post-op abdominal dressing change
C) Check the vital signs D) transfer orders to a long term facility
D) Auscultate the lungs
144. The nurse manager has been using a block scheduling plan
137. A nurse observes a family member administer a rectal to staff the nursing unit. However, staff have asked for many
suppository by having the client lie on the left side for the changes and exceptions to the schedule over the past few
administration. The family member pushed the suppository months. The manager considers self-scheduling knowing that
until the finger went up to the second knuckle. After 10 minutes this method will
the client was told by the family member to turn to the right A) Improve the quality of care
side and the client did this. What is the appropriate comment B) Decrease staff turnover
for the nurse to make? C) Minimize the amount of overtime payouts
A) Why don’t we now have the client turn back to the left side. D) Improve team morale
B) That was done correctly. Did you have any problems with the
insertion? 145. A client is admitted to a voluntary hospital mental health
C) Let’s check to see if the suppository is in far enough. unit due to suicidal ideation. The client has been on the unit for
D) Did you feel any stool in the intestinal tract? 2 days and now states “I demand to be released now!” The
appropriate from the nurse is
138. As the nurse observes the student nurse during the A) You cannot be released because you are still suicidal.
administration of a narcotic analgesic IM injection, the nurse B) You can be released only if you sign a no suicide contract.
notes that the student begins to give the medication without C) Let’s discuss your decision to leave and then we can prepare
first aspirating. What should the nurse do? you for discharge.
A) Ask the student: "What did you forget to do?” D) You have a right to sign out as soon as we get the provider's
B) Stop. Tell me why aspiration is needed. discharge order.
C) Loudly state: “You forgot to aspirate.”
D) Walk up and whisper in the student’s ear “Stop. Aspirate. 146.The nurse is caring for a client who is post-op following a
Then inject.” thoracotomy. The client has 2 chest tubes in place, connected to
1 chest drain. The nursing assessment reveals bubbling in the
139. An adult client is found to be unresponsive on morning water seal chamber when the client coughs. What is the most
rounds. After checking for responsiveness and calling for help, appropriate nursing action?
the next action that should be taken by the nurse is to: A) Clamp the chest tube
A) check the carotid pulse B) Call the surgeon immediately
B) deliver 5 abdominal thrusts C) Continue to monitor the client to see if the bubbling
C) give 2 rescue breaths increases
D) ensure an open airway D) Instruct the client to try to avoid coughing

140. A practical nurse (PN) is assigned to care for a newborn 147. A newly admitted elderly client is severely dehydrated.
with a neural tube defect. Which dressing, if applied by the PN, When planning care for this client, which task is appropriate to
would need no further intervention by the charge nurse? assign to an unlicensed assistive personnel (UAP)?
A) Telfa dressing with antibiotic ointment A) Converse with the client to determine if the mucous
B) Moist sterile nonadherent dressing membranes are impaired
C) Dry sterile dressing that is occlusive B) Report hourly outputs of less than 30 ml/hr
D) Sterile occlusive pressure dressing C) Monitor client's ability for movement in the bed
D) Check skin turgor every 4 hours
141. A parent brings her 3 month-old into the clinic, reporting
that the child seems to be spitting up all the time and has a lot 148. Which statement best describes time management
of gas. The nurse expects to find which of the following on the strategies applied to the role of a nurse manager?
initial history and physical assessment? A) Schedule staff efficiently to cover the anticipated needs on
A) increased temperature and lethargy the managed unit
B) restlessness and increased mucus production B) Assume a fair share of direct client care as a role model
C) increased sleeping and listlessness C) Set daily goals with a prioritization of the work
D) diarrhea and poor skin turgor D) Delegate tasks to reduce work load associated with direct
care and meetings
142.The nurse manager hears a provider loudly criticize one of
the staff nurses within the hearing range of others. The nurse 149. The charge nurse on the night shift at an urgent care center
manager's next action should be to has to deal with admitting clients of a higher acuity than usual
A) Walk up to the provider and quietly state: "Stop this because of a large fire in the area. Which style of leadership and
unacceptable behavior." decision-making would be best in this circumstance?
B) Allow the staff nurse to handle this situation without A) Assume a decision-making role
interference B) Seek input from staff
C) Notify the of the other administrative persons of a breech of C) Use a non-directive approach
professional conduct D) Shared decision-making with others
 A) Stop the infusion
150. Which activity can the RN ask an unlicensed assistive B) Slow the rate of infusion
personnel (UAP) to perform? C) Take vital signs and observe for further deterioration
A) Take a history on a newly admitted client D) Administer Benadryl and continue the infusion
B) Adjust the rate of a gastric tube feeding
C) Check the blood pressure of a 2 hours post operative client 9. A nurse is providing care to a 63 year-old client with
D) Check on a client receiving chemotherapy pneumonia. Which intervention promotes the client’s comfort?
A) Increase oral fluid intake
Pharmacological and Parenteral Therapies B) Encourage visits from family and friends
C) Keep conversations short
1. A client is receiving intravenous heparin therapy. What D) Monitor vital signs frequently
medication should the nurse have available in the event of an
overdose of heparin? 10. An antibiotic IM injection for a 2 year-old child is ordered.
A) Protamine The total volume of the injection equals 2.0 ml. The correct
B) Amicar action is to
C) Imferon A) administer the medication in 2 separate injections
D) Diltiazem B) give the medication in the dorsal gluteal site
C) call to get a smaller volume ordered
2. Although nonsteroidal anti-inflammatory drugs (NSAIDs) such D) check with pharmacy for a liquid form of the medication
as ibuprofen (Motrin) are beneficial in managing arthritis pain,
the nurse should caution clients about which of the following 11. A client is recovering from a hip replacement and is taking
common side effects? Tylenol #3 every 3 hours for pain. In checking the client, which
A) Urinary incontinence finding suggests a side effect of the analgesic?
B) Constipation A) Bruising at the operative site
C) Nystagmus B) Elevated heart rate
D) Occult bleeding C) Decreased platelet count
D) No bowel movement for 3 days
3. A client is being discharged with a prescription for
chlorpromazine (Thorazine). Before leaving for home, which of 12. Why is it important for the nurse to monitor blood pressure
these findings should the nurse teach the client to report? in clients receiving antipsychotic drugs?
A) Change in libido, breast enlargement A) Orthostatic hypotension is a common side effect
B) Sore throat, fever B) Most antipsychotic drugs cause elevated blood pressure
C) Abdominal pain, nausea, diarrhea C) This provides information on the amount of sodium allowed
D) Dyspnea, nasal congestion in the diet
D) It will indicate the need to institute antiparkinsonian drugs
4. The nurse receives an order to give a client iron by deep
injection. The nurse know that the reason for this route is to 13. A parent asks the school nurse how to eliminate lice from
A) enhance absorption of the medication their child. What is the most appropriate response by the
B) ensure that the entire dose of medication is given nurse?
C) provide more even distribution of the drug A) Cut the child's hair short to remove the nits
D) prevent the drug from causing tissue irritation B) Apply warm soaks to the head twice daily
C) Wash the child's linen and clothing in a bleach solution
5. A client diagnosed with cirrhosis of the liver and ascites is D) Application of pediculicides
receiving spironolactone (Aldactone). The nurse understands
that this medication spares elimination of which element? 14. The nurse has given discharge instructions to parents of a
A) Sodium child on phenytoin (Dilantin). Which of the following statements
B) Potassium suggests that the teaching was effective?
C) Phosphate A) "We will call the health care provider if the child develops
D) Albumin acne."
B) "Our child should brush and floss carefully after every meal."
6. Discharge instructions for a client taking alprazolam (Xanax) C) "We will skip the next dose if vomiting or fever occur."
should include which of the following? D) "When our child is seizure-free for 6 months, we can stop the
A) Sedative hypnotics are effective analgesics medication."
B) Sudden cessation of alprazolam (Xanax) can cause rebound
insomnia and nightmares 15. A client with heart failure has Lanoxin (digoxin) ordered.
C) Caffeine beverages can increase the effect of sedative What would the nurse expect to find when evaluating for the
hypnotics therapeutic effectiveness of this drug?
D) Avoidance of excessive exercise and high temperature is A) Diaphoresis with decreased urinary output
recommended B) Increased heart rate with increased respirations
7. A client has received 2 units of whole blood today following C) Improved respiratory status and increased urinary output
an episode of GI bleeding. Which of the following laboratory D) Decreased chest pain and decreased blood pressure
reports would the nurse monitor most closely? 16. The nurse is teaching a client about precautions with
A) Bleeding time Coumadin therapy. The client should be instructed to avoid
B) Hemoglobin and hematocrit which over-the-counter medication?
C) White blood cells A) Non-steroidal anti-inflammatory drugs (NSAIDs)
D) Platelets B) Cough medicines with guaifenesin
8. The nurse is caring for a client receiving a blood transfusion C) Histamine blockers
who develops urticaria one-half hour after the transfusion has D) Laxatives containing magnesium salts
begun. What is the first action the nurse should take?
17. The nurse is caring for a client with clinical depression who is
receiving a monoamine oxidase inhibitor (MAOI). When 4. A nurse is performing CPR on an adult who went into
providing instructions about precautions with this medication, cardiopulmonary arrest. Another nurse enters the room in
which action should the nurse stress to the client as important? response to the call. After checking the client’s pulse and
A) Avoid chocolate and cheese respirations, what should be the function of the second nurse?
B) Take frequent naps A) Relieve the nurse performing CPR
C) Take the medication with milk B) Go get the code cart
D) Avoid walking without assistance C) Participate with the compressions or breathing
D) Validate the client's advanced directive
18. The nurse has been teaching a client with Insulin Dependent
Diabetes Mellitus. Which statement by the client indicates a 5. Which these findings would the nurse more closely associate
need for further teaching? with anemia in a 10 month-old infant?
A) "I use a sliding scale to adjust regular insulin to my sugar A) hemoglobin level of 12 g/dL
level." B) pale mucosa of the eyelids and lips
B) "Since my eyesight is so bad, I ask the nurse to fill several C) hypoactivity
syringes." D) a heart rate between 80 and 130
C) "I keep my regular insulin bottle in the refrigerator."
D) "I always make sure to shake the NPH bottle hard to mix it 6. An elderly client admitted after a fall begins to seize and loses
well." consciousness. What action by the nurse is appropriate to do
next?
19. A client with amyotrophic lateral sclerosis has a A) Stay with client and observe for airway obstruction
percutaneous endoscopic gastrostomy (PEG) tube for the B) Collect pillows and pad the side rails of the bed
administration of feedings and medications. Which nursing C) Place an oral airway in the mouth and suction
action is appropriate? D) Announce a cardiac arrest, and assist with intubation
A) Pulverize all medications to a powdery condition
B) Squeeze the tube before using it to break up stagnant liquids 7. Which of these statements from clients who call the
C) Cleanse the skin around the tube daily with hydrogen community health clinic would suggest the need for a same-day
peroxide appointment to be seen by the health care provider?
D) Flush adequately with water before and after using the tube A) "I started my period and now my urine has turned bright red"
B) "I am an diabetic and today I have been going to the
20. While providing home care to a client with congestive heart bathroom every hour"
failure, the nurse is asked how long diuretics must be taken. C) "I was started on medicine yesterday for a urine infection.
What is the nurse’s best response? Now my lower belly hurts when I go to the bathroom"
A) "As you urinate more, you will need less medication to D) "I went to the bathroom and my urine looked very red and it
control fluid." didn’t hurt when I went"
B) "You will have to take this medication for about a year."
C) "The medication must be continued so the fluid problem is 8. A 14 year-old with a history of sickle cell disease is admitted
controlled." to the hospital with a diagnosis of vaso-occlusive crisis. Which
D) "Please talk to your health care provider about medications statements by the client would be most indicative of the
and treatments." etiology of this crisis?
A) "I knew this would happen. I've been eating too much red
Physiological Adaptation meat lately."
B) "I really enjoyed my fishing trip yesterday. I caught two fish."
1. A man diagnosed with epididymitis 2 days ago calls the nurse C) "I have really been working hard practicing with the debate
at a health clinic to discuss the problem. What information is team at school."
most important for the nurse to ask about at this time? D) "I went to get a cold checked out last week, and I have gotten
A) "What are you taking for pain and does it provide total worse."
relief?"
B) "Did your provider recommend that you be tested for 9. The nurse assesses a 72 year-old client who was admitted for
Chlamydia?" right-sided congestive heart failure. Which of the following
C) "Do you have any questions about your care?" would the nurse anticipate finding?
D) "Did you know a consequence of epididymitis is infertility?" A) Decreased urinary output
B) Jugular vein distention
2. A client with heart failure has a prescription for Digoxin. The C) Pleural effusion
nurse is aware that sufficient potassium should be included in D) Bibasilar crackles
the diet because hypokalemia in combination with this
medication 10. The nurse is caring for a client in atrial fibrillation. The atrial
A) can predispose to dysrhythmias heart rate is 250 and the ventricular rate is controlled at 75.
B) may lead to oliguria Which of the following findings is cause for the most concern?
C) may cause irritability and anxiety A) Diminished bowel sounds
D) sometimes alters consciousness B) Loss of appetite
C) A cold, pale lower leg
3. A client has altered renal function and is being treated at D) Tachypnea
home. The nurse recognizes that the most accurate indicator of
fluid balance during the weekly visits is 11. A client is admitted with a tentative diagnosis of congestive
A) difference in the intake and output heart failure. Which of the following assessments would the
B) changes in the mucous membranes nurse expect to be consistent with this problem?
C) skin turgor A) Chest pain
D) weekly weight B) Pallor
C) Inspiratory crackles treatment is for. The needles usually are left in for 15 to 30
D) Heart murmur minutes."
B) "In traditional Chinese medicine, imbalances in the basic
12. A client is admitted for first and second degree burns on the energetic flow of life — known as qi or chi —
face, neck, anterior chest and hands. The nurse's priority should are thought to cause illness."
be to C) "The flow of life is believed to flow through major pathways
A) cover the areas with dry sterile dressings called nerve clusters in your body."
B) assess for dyspnea or stridor D) "By inserting extremely fine needles into some of the over
C) initiate intravenous therapy 400 acupuncture points in various combinations it is
D) administer pain medication believed that energy flow will rebalance to allow the body's
natural healing mechanisms to take over."
13. A client with pneumococcal pneumonia was started on
antibiotics 16 hours ago. During the nurse’s initial evening 19. A primigravida in the third trimester is hospitalized for
rounds the nurse notices a foul smell in the room. The client preeclampsia. The nurse determines that the client’s blood
makes all of these statements during their conversation. Which pressure is increasing. Which action should the nurse take first?
one would alert the nurse to a complication? A) Check the protein level in urine
A) "I have a sharp pain in my chest when I take a breath." B) Have the client turn to the left side
B) "I have been coughing up foul-tasting, brown, thick sputum." C) Take the temperature
C) "I have been sweating all day." D) Monitor the urine output
D) "I feel hot off and on."
20. A client has viral pneumonia affecting 2/3 of the right lung.
14. Which information is a priority for the nurse to reinforce to What would be the best position to teach the client to lie in
an older client after intravenous pyelography? every other hour during first 12 hours after admission?
A) Eat a light diet for the rest of the day A) Side-lying on the left with the head elevated 10 degrees
B) Rest for the next 24 hours since the preparation and the test B) Side-lying on the left with the head elevated 35 degrees
is tiring C) Side-lying on the right with the head elevated 10 degrees
C) During waking hours drink at least 1 8-ounce glass of fluid D) Side-lying on the right with the head elevated 35 degrees
every hour for the next 2 days
D) Measure the urine output for the next day and immediately 21. The nurse is caring for a client in hypertensive crisis in an
notify the health care provider if it should intensive care unit. The priority assessment in the first hour of
decrease care is
A) heart rate
15. A nurse is providing care to a 17 year-old client in the post- B) pedal pulses
operative care unit (PACU) after an emergency appendectomy. C) lung sounds
Which finding is an early indication that the client is D) pupil responses
experiencing poor oxygenation?
A) Abnormal breath sounds 22. The nurse is performing an assessment on a client in
B) Cyanosis of the lips congestive heart failure. Auscultation of the heart is most likely
C) Increasing pulse rate to reveal
D) Pulse oximeter reading of 92% A) S3 ventricular gallop
B) apical click
16. A nurse is observing a client during an excretory urogram. C) systolic murmur
Which of these observations indicate a complication is D) split S2
occurring?
A) "The client complains of a salty taste in the mouth when the 23. A 2 year-old child is brought to the emergency department
dye is injected." at 2:00 in the afternoon. The mother states: “My child has not
B) "The client’s entire body turns a bright red color. had a wet diaper all day.” The nurse finds the child is pale with a
C) "The client states “I have a feeling of getting warm.” heart rate of 132. What assessment data should the nurse
D) "The client gags and complains “I am getting sick.” obtain next?
A) Status of the eyes and the tongue
17. The nurse is assessing an 8 month-old child with atonic B) Description of play activity
cerebral palsy. Which statement from the parent supports the C) History of fluid intake
presence of this problem? D) Dietary patterns

A) "When I put my finger in the left hand the baby doesn’t 24. Which of these clients who are all in the terminal stage of
respond with a grasp." cancer is least appropriate to suggest the use of patient
B) "My baby doesn’t seem to follow when I shake toys in front controlled analgesia (PCA) with a pump?
of its face." A) A young adult with a history of Down syndrome
C) "When it thundered loudly last night the baby didn’t even B) A teenager who reads at a 4th grade level
jump." C) An elderly client with numerous arthritic nodules on the
D) "When I put the baby in a back lying position that’s how I find hands
it hours later." D) A preschooler with intermittent episodes of alertness

18. A client who is to have antineoplastic chemotherapy tells 25. The client with infective endocarditis must be assessed
the nurses of a fear of being sick all the time and indicates a frequently by the home health nurse. Which finding suggests
wish to try acupuncture. Which of these beliefs stated by the that antibiotic therapy is not effective, and must be reported by
client would be incorrect about acupuncture? the nurse immediately to the provider?
A) "Some needles go as deep as 3 inches, depending on where A) nausea and vomiting
they're placed in the body and what the B) fever of 103 degrees Fahrenheit (39.5 degrees Celsius)
C) diffuse macular rash 32. A client who was medicated with meperidine hydrochloride
D) muscle tenderness (Demerol) 100 mg and hydroxyzine hydrochloride (Vistaril
Intramuscular) 50 mg IM for pain related to a fractured lower
26. The nurse is caring for a client with uncontrolled right leg 1 hour ago reports that the pain is getting worse. The
hypertension. Which findings require immediate nursing action? nurse should recognize that the client may be developing which
A) lower extremity pitting edema complication?
B) rales A) acute compartment syndrome
C) jugular vein distension B) thromboembolitic complications
D) weakness in left arm C) fatty embolism
D) osteomyelitis
27. A client has had heart failure. Which intervention is most
important for the nurse to implement prior to the initial 33. Which statements by the client would indicate to the nurse
administration of digoxin to this client? an understanding of the issues with end stage renal disease?
A) Assess the apical pulse, counting for a full 60 seconds A) "I have to go at intervals for epoetin (Procrit) injections at the
B) Take a radial pulse, counting for a full 60 seconds health department."
C) Use the pulse reading from the electronic blood pressure B) "I know I have a high risk of clot formation since my blood is
device thick from too many red cells."
D) Check for a pulse deficit C) "I expect to have periods of little water with voiding and then
sometimes to have a lot of water."
28. A client has been diagnosed with Zollinger-Ellison syndrome. D) "My bones will be stronger with this disease since I will have
Which information is most important for the nurse to higher calcium than normal."
reinforce?
A) It is a condition in which one or more tumors called 34. While caring for a client who was admitted with myocardial
gastrinomas form in the pancreas or in the upper infarction (MI) 2 days ago, the nurse notes today's temperature
part of the small intestine (duodenum) is 101.1 degrees Fahrenheit (38.5 degrees Celsius). The
B) It is critical to report promptly to your health care provider appropriate nursing intervention is to
any findings of peptic ulcers A) call the health care provider immediately
C) Treatment consists of medications to reduce acid and heal B) administer acetaminophen as ordered as this is normal at this
any peptic ulcers and, if possible, surgery to time
remove any tumors C) send blood, urine and sputum for culture
D) With the average age at diagnosis at 50 years the peptic D) increase the client's fluid intake
ulcers may occur at unusual areas of the stomach or
Intestine 35. A nurse is providing care to a primigravida whose
membranes spontaneously ruptured (ROM) 4 hours ago. Labor
29. As the nurse is speaking with a group of teens, which of is to be induced. At the time of the ROM, the vital signs were T-
these side effects of chemotherapy for cancer would the nurse 99.8 degrees Fahrenheit, P-84, R-20, BP-130/78, and fetal heart
expect this group to be more interested in during the tones (FHT) 148 beats/min. Which assessment findings may be
discussion? an early indication that the client is developing a complication
A) Mouth sores of labor?
B) Fatigue A) FHT 168 beats/min
C) Diarrhea B) Temperature 100 degrees Fahrenheit
D) Hair loss C) Cervical dilation of 4 cm
D) BP 138/88
30. The nurse is discussing Kawasaki disease with a group of
students. What statement made by a student about Kawasaki 36. A client who had a vasectomy is in the post recovery unit at
disease is incorrect? an outpatient clinic. Which of these points is most important to
A) "It also called mucocutaneous lymph node syndrome because be reinforced by the nurse?
it affects the mucous membranes (inside A) "Until the health care provider has determined that your
the mouth, throat and nose), skin and lymph nodes." ejaculate doesn't contain sperm, continue to use
B) "In the second phase of the disease, findings include peeling another form of contraception."
of the skin on the hands and feet with joint B) "This procedure doesn't impede the production of male
and abdominal pain." hormones or the production of sperm in the
C) "Kawasaki disease occurs most often in boys, children testicles. The sperm can no longer enter your semen and no
younger than age 5 and children of Hispanic sperm are in your ejaculate."
descent." C) "After your vasectomy, strenuous activity needs to be
D) "Initially findings are a sudden high fever, usually above 104 avoided for at least 48 hours. If your work doesn't
degrees Fahrenheit, which lasts 1 to 2 involve hard physical labor, you can return to your job as soon
weeks." as you feel to it. The stitches
generally dissolve in 7-10 days."
31. The nurse is about to assess a 6 month-old child with non- D) "The health care provider at this clinic recommends rest, ice,
organic failure-to-thrive (NOFTT). Upon entering the room, the an athletic supporter or over-the-counter pain
nurse would expect the baby to be medication to relieve any discomfort."
A) irritable and "colicky," making no attempts to pull to standing
B) alert, laughing, playing with a rattle, and sitting with support 37. A female client talks to the nurse in the provider’s office
C) dusky in color with poor skin turgor over abdomen about uterine fibroids, also called leiomyomas or myomas.
D) pale, have thin arms and legs, and uninterested in What statement by the woman indicates more education is
surroundings needed?
A) "I am the one out of every 4 women that get fibroids, and of
women my age – between the 30s or 40s,
fibroids occur more frequently." C) 3 days post partum, temperature of 100.8 degrees Fahrenheit
B) "My fibroids are noncancerous tumors that grow slowly." the past 2 days
C) "My associated problems I have had are pelvic pressure and D) 4 days post partum, temperature of 100 degrees Fahrenheit
pain, urinary incontinence,and constipation." since delivery
D) "Fibroids that cause no problems still need to be taken out."
6. The nurse is caring for a client with a chest tube. On the
38. A client has an indwelling catheter with continuous bladder second postoperative day, the chest tube accidentally
irrigation after undergoing a transurethral resection of the disconnects from the drainage tube. The first action the nurse
prostate (TURP) 12 hours ago. Which finding at this time should should take is
be reported to the health care provider? A) reconnect the tube
A) light, pink urine B) raise the collection chamber above the client's chest
B) occasional suprapubic cramping C) call the health care provider
C) minimal drainage into the urinary collection bag D) clamp the chest tube
D) reports of the feeling of pulling on the urinary catheter 7. A client is placed on sulfamethoxazole-trimethoprim
(Bactrim) for a recurrent urinary tract infection. Which of the
39. Which order can be associated with the prevention of following is appropriate reinforcement of information by the
atelectasis and pneumonia in a client with amyotrophic lateral nurse?
sclerosis (ALS)? A) "Drink at least 8 glasses of water a day."
A) Active and passive range of motion exercises twice a day B) "Be sure to take the medication with food."
B) Use incentive spirometer every 4 hours C) "It is safe to take with oral contraceptives."
C) Chest physiotherapy twice a day D) "Stop the medication after 5 days."
D) Repositioning every 2 hours around the clock
8. A client calls the evening health clinic to state “I know I have a
40. A nurse assesses a young adult in the emergency room severely low sugar since the Lantus insulin was given 3 hours
following a motor vehicle accident. Which of the following ago and it peaks in 2 hours.” What should be the nurse’s initial
neurological signs is of most concern? response to the client?
A) Flaccid paralysis A) What else do you know about this type of insulin?
B) Pupils fixed and dilated B) What are you feeling at this moment?
C) Diminished spinal reflexes C) Have you eaten anything today?
D) Reduced sensory responses D) Are you taking any other insulin or medication?

Priority 9. The nurse is caring for a client who is receiving total

1. The nurse must know that the most accurate oxygen delivery parenteral nutrition (TPN) (hyperalimentation and lipids). What
system available is is the priority nursing action on every 8 hour shift?
A) the Venturi mask A) Monitor blood pressure, temperature and weight
B) nasal cannula B) Change the tubing under sterile conditions
C) partial non-rebreather mask C) Check urine glucose, acetone and specific gravity
D) simple face mask D) Adjust the infusion rate to provide for total volume
2. A client arrives in the emergency department after a
radiologic accident at a local factory. The first action of the 10. The nurse reviews an order to administer Rh (D) immune
nurse would be to globulin to an Rh negative woman following the birth of an Rh
A) begin decontamination procedures for the client positive baby. Which assessment is a priority before the nurse
B) ensure physiologic stability of the client gives the injection?
C) wrap the client in blankets to minimize staff contamination A) Newborn's blood type
D) double bag the client’s contaminated clothing B) Coombs' test results
C) Previous RhoGAM history
3. The nurse is caring for a client on complete bed rest. Which D) Gravida and parity
action by the nurse is most important in preventing the
formation of deep vein thrombosis? 11. A client has been on antibiotics for 72 hours for cystitis.
A) Elevate the foot of the bed Which report from the client requires priority attention by the
B) Apply knee high support stockings nurse?
C) Encourage passive exercises A) foul smelling urine
D) Prevent pressure at back of knees B) burning on urination
C) elevated temperature
4. If a very active two year-old client pulls his tunneled central D) nausea and anorexia
venous catheter out, what initial nursing action is appropriate?
A) Obtain emergency equipment 12. The nurse is caring for a school-aged child with a diagnosis
B) Assess heart rate, rhythm and all pulses of secondary hyperparathyroidism following treatment for
C) Apply pressure to the vessel insertion site chronic renal disease. Which of the following lab data should
D) Use cold packs at the exit incision site receive priority attention?
A) Calcium and phosphorus levels
5. The nurse assesses several post partum women in the clinic. B) Blood sugar
Which of the following women is at highest risk for puerperal C) Urine specific gravity
infection? D) Blood urea nitrogen
A) 12 hours post partum, temperature of 100.4 degrees
Fahrenheit since delivery 13. When caring for a client with urinary incontinence, which
B) 2 days post partum, temperature of 101.2 degrees content should be reinforced by the nurse?
Fahrenheit this morning A) hold the urine to increase bladder capacity
B) avoid eating foods high in sodium
C) restrict fluid to prevent elimination accidents D) Generalized weakness
D) avoid taking antihistamines
22. The registered nurse (RN) is making decisions regarding
14. A client returns from the operating room after a right client room assignments on a pediatric unit. Which possible
orchiectomy. For the immediate post-operative period the roommate would be most appropriate for a 3 year-old child
nursing priority would be to with minimal change nephrotic syndrome?
A) maintain fluid and electrolyte balance A) 2 year-old with respiratory infection
B) manage post-operative pain B) 3 year-old fracture whose sibling has chickenpox
C) ambulate the client within 1 hour of surgery C) 4 year-old with bilateral inguinal hernia repair
D) control bladder spasms D) 6 year-old with a sickle cell anemia crisis

15. A client with a fracture of the radius had a plaster cast 23. The nurse is caring for a pregnant woman with pregnancy
applied 2 days ago. The client complains of constant pain and induced hypertension (PIH) receiving magnesium sulfate
swelling of the fingers. The first action of the nurse should be intravenously. In assessing the client, it is noted that
A) elevate the arm no higher than heart level respirations are 12, pulse and blood pressure have dropped
B) remove the cast significantly, and 8 hour output is 200 ml. What should the
C) assess capillary refill of the exposed hand and fingers nurse do first?
D) apply a warm soak to the hand A) Administer calcium gluconate
B) Call the provider immediately
16. A client is 2 days post operative. The vital signs are: BP - C) Discontinue the magnesium sulfate
120/70, HR -- 110 BPM, RR - 26, and Temperature - 100.4 D) Perform additional assessments
degrees Fahrenheit (38 degrees Celsius). The client suddenly
becomes profoundly short of breath, skin color is gray. Which 24. A client has a serum glucose of 385 mg/dl. Which of these
assessment would have alerted the nurse first to the client's orders would the nurse question first?
change in condition? A) Repeat glycohemoglobin in 24 hours
A) Heart rate B) Document Accu-checks, intake and output every 4 hours
B) Respiratory rate C) Humulin N 20 units IV push
C) Blood pressure D) IV fluids of 0.9% normal saline at 125 ml per hour
D) Temperature
25. The nurse performs an assessment during a fluid exchange
17. A client is waiting to have an intravenous pyelogram (IVP). for the client who is 48 hours post-insertion of an abdominal
The most important information to be obtained by the nurse Tenckhoff catheter for peritoneal dialysis. The nurse knows that
prior to the procedure is the appearance of which of the following needs to be reported
A) time of the client's last meal to the provider immediately?
B) client's allergy history A) slight pink-tinged drainage
C) assessment of the peripheral pulses B) abdominal discomfort
D) results of the blood coagulation studies C) muscle weakness
D) cloudy drainage
18. What must the nurse emphasize when teaching a client with
depression about a new prescription for nortriptyline Q&A Pharmacology
(Pamelor)?
A) Symptom relief occurs in a few days 1. A post-operative client has a prescription for acetaminophen
B) Alcohol use is to be avoided with codeine. What should the nurse recognizes as a primary
C) Medication must be stored in the refrigerator effect of this combination?
D) Episodes of diarrhea can be expected A) Enhanced pain relief
B) Minimized side effects
19. Before administering a feeding through a gastrostomy tube, C) Prevention of drug tolerance
what is the priority nursing assessment? D) Increased onset of action
A) Measure the vital signs
B) Palpate the abdomen 2. A nurse is caring for a client who is receiving methyldopa
C) Assess for breath sounds hydrochloride (Aldomet) intravenously. Which of the following
D) Verify tube patency assessment findings would indicate to the nurse that the client
may be having an adverse reaction to the medication?
20. The nurse is caring for a client with a vascular access for A) Headache
hemodialysis. Which of these findings necessitates immediate B) Mood changes
action by the nurse? C) Hyperkalemia
A) pruritic rash D) Palpitations
B) dry, hacking cough
C) chronic fatigue 3. When providing discharge teaching to a client with asthma,
D) elevated temperature the nurse will warn against the use of which of the following
over-the-counter medications?
21. The nurse is caring for a client several days following a A) Cortisone ointments for skin rashes
cerebral vascular accident. Coumadin (warfarin) has been B) Aspirin products for pain relief
prescribed. Today's prothrombin level is 40 seconds (normal C) Cough medications containing guaifenesin
range 10-14 seconds). Which of the following findings requires D) Histamine blockers for gastric distress
priority follow-up?
A) Gum bleeding 4. The nurse practicing in a long term care facility recognizes
B) Lung sounds that elderly clients are at greater risk for drug toxicity than
C) Homan's sign
younger adults because of which of the following physiological B) Hardened eschar
changes of advancing age? C) Increased neutrophils
A) Drugs are absorbed more readily from the GI tract D) Urine sulfa crystals
B) Elders have less body water and more fat
C) The elderly have more rapid hepatic metabolism 13. The nurse is caring for a client who is receiving procainamide
D) Older people are often malnourished and anemic (Pronestyl) intravenously. It is important for the nurse to
monitor which of the following parameters?
5. In providing care for a client with pain from a sickle cell crisis, A) Hourly urinary output
which one of the following medication orders for pain B) Serum potassium levels
control should be questioned by the nurse? C) Continuous EKG readings
A) Demerol D) Neurological signs
B) Morphine
C) Methadone 14. The nurse is teaching a parent how to administer oral iron
D) Codeine supplements to a 2 year-old child. Which of the following
interventions should be included in the teaching?
6. The nurse is administering diltiazem (Cardizem) to a client. A) Stop the medication if the stools become tarry green
Prior to administration, it is important for the nurse to assess B) Give the medicine with orange juice and through a straw
which parameter? C) Add the medicine to a bottle of formula
A) Temperature D) Administer the iron with your child's meals
B) Blood pressure
C) Vision 15. A client with bi-polar disorder is taking lithium (Lithane).
D) Bowel sounds What should the nurse emphasize when teaching about this
medication?
7. A client with an aplastic sickle cell crisis is receiving a blood A) Take the medication before meals
transfusion and begins to complain of "feeling hot." Almost B) Maintain adequate daily salt intake
immediately, the client begins to wheeze. What is the nurse's C) Reduce fluid intake to minimize diuresis
first action? D) Use antacids to prevent heartburn
A) Stop the blood infusion
B) Notify the health care provider 16. The nurse is assessing a 7 year-old after several days of
C) Take/record vital signs treatment for a documented strep throat. Which of the
D) Send blood samples to lab following statements suggests that further teaching is needed?
A) "Sometimes I take my medicine with fruit juice."
8. A client with atrial fibrillation is receiving digoxin (Lanoxin). B) "My mother makes me take my medicine right after school."
Which of these assessments is most important for the nurse to C) "Sometimes I take the pills in the morning and other times at
perform? night."
A) Monitor blood pressure every 4 hours D) "I am feeling much better than I did last week."
B) Measure apical pulse prior to administration
C) Maintain accurate intake and output records 17. An elderly client is on an anticholinergic metered dose
D) Record an EKG strip after administration inhaler (MDI) for chronic obstructive pulmonary disease. The
nurse would suggest a spacer to
9. The nurse is caring for a 10 year-old client who will be placed A) enhance the administration of the medication
on heparin therapy. Which assessment is critical for the nurse to B) increase client compliance
make before initiating therapy C) improve aerosol delivery in clients who are not able to
A) Vital signs coordinate the MDI
B) Weight D) prevent exacerbation of COPD
C) Lung sounds
D) Skin turgor 18. The nurse is providing education for a client with newly
diagnosed tuberculosis. Which statement should be included in
10. The use of atropine for treatment of symptomatic the information that is given to the client?
bradycardia is contraindicated for a client with which of the A) "Isolate yourself from others until you are finished taking
following conditions? your medication."
A) Urinary incontinence B) "Follow up with your primary care provider in 3 months."
B) Glaucoma C) "Continue to take your medications even when you are
C) Increased intracranial pressure feeling fine."
D) Right sided heart failure D) "Continue to get yearly tuberculin skin tests."

11. The health care provider orders an IV aminophylline infusion 19. The nurse is administering an intravenous vesicant
at 30 mg/hr. The pharmacy sends a 1,000 ml bag of D5W chemotherapeutic agent to a client. Which assessment would
containing 500 mg of aminophylline. In order to administer 30 require the nurse's immediate action?
mg per hour, the RN will set the infusion rate at: A) Stomatitis lesion in the mouth
A) 20 ml per hour B) Severe nausea and vomiting
B) 30 ml per hour C) Complaints of pain at site of infusion
C) 50 ml per hour D) A rash on the client's extremities
D) 60 ml per hour
20. The nurse is instructing a client with moderate persistent
12. The nurse is applying silver sulfadiazine (Silvadene) to a child asthma on the proper method for using MDIs (multi-dose
with severe burns to arms and legs. Which side effect should the inhalers). Which medication should be administered first?
nurse be monitoring for? A) Steroid
A) Skin discoloration B) Anticholinergic
C) Mast cell stabilizer B) Increased response to motor stimuli
D) Beta agonist C) A widening pulse pressure
D) Temperature of 37 degrees Celsius
21. The nurse is teaching a group of women in a community
clinic about prevention of osteoporosis. Which of the following 29. The nurse is assessing a client who is on long term
over-the-counter medications should the nurse recognize as glucocorticoid therapy. Which of the following findings would
having the most elemental calcium per tablet? the nurse expect?
A) Calcium chloride A) Buffalo hump
B) Calcium citrate B) Increased muscle mass
C) Calcium gluconate C) Peripheral edema
D) Calcium carbonate D) Jaundice

22. The provider has ordered daily high doses of aspirin for a 30. A client is ordered atropine to be administered
client with rheumatoid arthritis. The nurse instructs the client to preoperatively. Which physiological effect should the nurse
discontinue the medication and contact the provider if which of monitor for?
the following symptoms occur? A) Elevate blood pressure
A) Infection of the gums B) Drying up of secretions
B) Diarrhea for more than one day C) Reduce heart rate
C) Numbness in the lower extremities D) Enhance sedation
D) Ringing in the ears

23. A 5 year-old has been rushed to the emergency room 31. A client confides in the RN that a friend has told her the
several hours after acetaminophen poisoning. Which laboratory medication she takes for depression, Wellbutrin, was taken off
result should receive attention by the nurse? the market because it caused seizures. What is an appropriate
A) Sedimentation rate response by the nurse?
B) Profile 2 A) "Ask your friend about the source of this information."
C) Bilirubin B) "Omit the next doses until you talk with the doctor."
D) Neutrophils C) "There were problems, but the recommended dose is
changed."
24. The nurse is caring for a client with schizophrenia who has D) "Your health care provider knows the best drug for your
been treated with quetiapine (Seroquel) for 1 month. Today the condition."
client is increasingly agitated and complains of muscle stiffness.
Which of these findings should be reported to the health care 32. A child presents to the Emergency Department with
provider? documented acetaminophen poisoning. In order to provide
A) Elevated temperature and sweating. counseling and education for the parents, which principle must
B) Decreased pulse and blood pressure. the nurse understand?
C) Mental confusion and general weakness. A) The problem occurs in stages with recovery within 12-24
D) Muscle spasms and seizures. hours
B) Hepatic problems may occur and may be life-threatening
25. A client is receiving dexamethasone (Decadron) therapy. C) Full and rapid recovery can be expected in most children
What should the nurse plan to monitor in this client? D) This poisoning is usually fatal, as no antidote is available
A) Urine output every 4 hours
B) Blood glucose levels every 12 hours 33. A client is receiving digitalis. The nurse should instruct the
C) Neurological signs every 2 hours client to report which of the following side effects?
D) Oxygen saturation every 8 hours A) Nausea, vomiting, fatigue
B) Rash, dyspnea, edema
26. The nurse is teaching a child and the family about the C) Polyuria, thirst, dry skin
medication phenytoin (Dilantin) prescribed for seizure control. D) Hunger, dizziness, diaphoresis
Which of the following side effects is most likely to occur?
A) Vertigo 34. The provider has ordered transdermal nitroglycerin patches
B) Drowsiness for a client. Which of these instructions should be included
C) Gingival hyperplasia when teaching a client about how to use the patches?
D) Vomiting A) Remove the patch when swimming or bathing
B) Apply the patch to any non-hairy area of the body
27. A newly admitted client has a diagnosis of depression. She C) Apply a second patch with chest pain
complains of “twitching muscles” and a “racing heart”, and D) Remove the patch if ankle edema occurs
states she stopped taking Zoloft a few days ago because it was
not helping her depression. Instead, she began to take her 35. A pregnant woman is hospitalized for treatment of
partner's Parnate. The nurse should immediately assess for pregnancy induced hypertension (PIH) in the third trimester.
which of these adverse reactions? She is receiving magnesium sulfate intravenously. The nurse
A) Pulmonary edema understands that this medication is used mainly for what
B) Atrial fibrillation purpose?
C) Mental status changes A) Maintain normal blood pressure
D) Muscle weakness B) Prevent convulsive seizures
C) Decrease the respiratory rate
28. A client has been receiving dexamethasone (Decadron) for D) Increase uterine blood flow
control of cerebral edema. Which of the following assessments
would indicate that the treatment is effective? 36. A client with anemia has a new prescription for ferrous
A) A positive Babinski's reflex sulfate. In teaching the client about diet and iron supplements,
the nurse should emphasize that absorption of iron is enhanced D) Verification of provider's orders for the plan of care with
if taken with which substance? identification of outcomes
A) Acetaminophen
B) Orange juice 44. The nurse is caring for clients over the age of 70. The nurse
C) Low fat milk knows that due to age-related changes, the elderly clients
D) An antacid tolerate diets that are
A) high protein
37. The health care provider has written "Morphine sulfate 2 B) high carbohydrates
mgs IV every 3-4 hours prn for pain" on the chart of a child C) low fat
weighing 22 lb. (10 kg). What is the nurse's initial action? D) high calories
A) Check with the pharmacist
B) Hold the medication and contact the provider 45. A client is to receive 3 doses of potassium chloride 10 mEq in
C) Administer the prescribed dose as ordered 100cc normal saline to infuse over 30 minutes each. Which of
D) Give the dose every 6-8 hours the following is a priority assessment to perform before giving
this medication?
38. The nurse is monitoring a client receiving a thrombolytic A) Oral fluid intake
agent, alteplase (Activase tissue plasminogen activator), for B) Bowel sounds
treatment of a myocardial infarction. What outcome indicates C) Grip strength
the client is receiving adequate therapy within the first hours of D) Urine output
treatment?
A) Absence of a dysrhythmia (or arrhythmia) 46. A hypertensive client is started on atenolol (Tenormin). The
B) Blood pressure reduction nurse instructs the client to immediately report which of these
C) Cardiac enzymes are within normal limits findings?
D) Return of ST segment to baseline on ECG A) Rapid breathing
B) Slow, bounding pulse
39. A nurse is assigned to perform well-child assessments at a C) Jaundiced sclera
day care center. A staff member interrupts the examinations to D) Weight gain
ask for assistance. They find a crying 3 year-old child on the
floor with mouth wide open and gums bleeding. Two unlabeled 47. During nursing rounds which of these assessments would
open bottles lie nearby. The nurse's first action should be require immediate corrective action and further instruction to
A) call the poison control center, then 911 the practical nurse (PN) about proper care?
B) administer syrup of Ipecac to induce vomiting A) The weights of the skin traction of a client are hanging about
C) give the child milk to coat her stomach 2 inches from the floor
D) ask the staff about the contents of the bottles B) A client with a hip prosthesis 1 day post operatively is lying in
bed with internal rotation and adduction of the
40. A client is receiving erythromycin 500mg IV every 6 hours to affected leg
treat a pneumonia. Which of the following is the most C) The nurse observes that the PN moves the extremity of a
common side effect of the medication? client with an external fixation device by picking up the
A) Blurred vision frame
B) Nausea and vomiting D) A client with skeletal traction states "The other nurse said
C) Severe headache that the clear, yellow and crusty drainage around the pin
D) Insomnia site is a good sign"

41. A 4 year-old child is admitted with burns on his legs and 48. A client is scheduled for an intravenous pyelogram (IVP).
lower abdomen. When assessing the child’s hydration status, After the contrast material is injected, which of the following
which of the following indicates a less than adequate fluid client reactions should be reported immediately?
replacement? A) Feeling warm
A) Decreasing hematocrit and increasing urine volume B) Face flushing
B) Rising hematocrit and decreasing urine volume C) Salty taste
C) Falling hematocrit and decreasing urine volume D) Hives
D) Stable hematocrit and increasing urine volume
49. You are caring for a hypertensive client with a new order for
42. Prior to administering Alteplase (TPA) to a client admitted captopril (Capoten). Which information should the nurse
for a cerebral vascular accident (CVA), it is critical that the nurse include in client teaching?
assess: A) Avoid green leafy vegetables
A) Neuro signs B) Restrict fluids to 1000cc/day
B) Mental status C) Avoid the use of salt substitutes
C) Blood pressure D) Take the medication with meals
D) PT/PTT
50. A client has bilateral knee pain from osteoarthritis. In
43. A nurse who has been named in a lawsuit can use which of addition to taking the prescribed non-steroidal anti-
these factors for the best protection in a court of law? inflammatory drug (NSAID), the nurse should instruct the client
A) Clinical specialty certification in the associated area of to
practice A) start a regular exercise program
B) Documentation on the specific client record with a focus on B) rest the knees as much as possible to decrease inflammation
the nursing process C) avoid foods high in citric acid
C) Yearly evaluations and proficiency reports prepared by D) keep the legs elevated when sitting
nurse’s manager
51. A client in respiratory distress is admitted with arterial blood 59. A client diagnosed with gouty arthritis is admitted with
gas results of: PH 7.30; PO2 58, PCO2 34; and HCO3 19. The severe pain and edema in the right foot. When the nurse
nurse determines that the client is in develops a plan of care, which intervention should be included?
A) metabolic acidosis A) high protein diet
B) metabolic alkalosis B) salicylates
C) respiratory acidosis C) hot compresses to affected joints
D) respiratory alkalosis D) intake of at least 3000cc/day
60. One hour before the first treatment is scheduled, the client
52. A woman with a 28 week pregnancy is on the way to the becomes anxious and states he does not wish to go through
emergency department by ambulance with a tentative diagnosis with electroconvulsive therapy. Which response by the nurse is
of abruptio placenta. Which should the nurse do first when the most appropriate?
woman arrives? A) "I’ll go with you and will be there with you during the
A) administer oxygen by mask at 100% treatment."
B) start a second IV with an 18 gauge cannula B) "You’ll be asleep and won’t remember anything."
C) check fetal heart rate every 15 minutes C) "You have the right to change your mind. You seem anxious.
D) insert urethral catheter with hourly urine outputs Can we talk about it?"
D) "I’ll call the health care provider to notify them of your
53. You are caring for a client with deep vein thrombosis who is decision."
on Heparin IV. The latest APTT is 50 seconds. If the
laboratory normal range is 16-24 seconds, you would anticipate 61. A male client is admitted with a spinal cord injury at level C4.
A) maintaining the current heparin dose The client asks the nurse how the injury is going to affect his
B) increasing the heparin as it does not appear therapeutic. sexual function. The nurse would respond
C) giving protamine sulfate as an antidote. A) "Normal sexual function is not possible."
D) repeating the blood test 1 hour after giving heparin. B) "Sexual functioning will not be impaired at all."
C) "Erections will be possible."
54. A client newly diagnosed with Type I Diabetes Mellitus asks D) "Ejaculation will be normal."
the purpose of the test measuring glycosylated hemoglobin.
The nurse should explain that the purpose of this test is to 62. An 82 year-old client complains of chronic constipation. To
determine: improve bowel function, the nurse should first suggest
A) The presence of anemia often associated with Diabetes A) Increasing fiber intake to 20-30 grams daily
B) The oxygen carrying capacity of the client's red cells B) Daily use of laxatives
C) The average blood glucose for the past 2-3 months C) Avoidance of binding foods such as cheese and chocolate
D) The client's risk for cardiac complications D) Monitoring a balance between activity and rest
63. The unlicensed assistive personnel (UAP) reports to the
55. An 80 year-old client is admitted with a diagnosis of nurse that a client with cirrhosis who had a paracentesis
malnutrition. In addition to physical assessments, which of the yesterday has become more lethargic and has musty smelling
following lab tests should be closely monitored? breath. A critical assessment for increasing encephalopathy is
A) Urine protein A) monitor the client's clotting status
B) Urine creatinine B) assess upper abdomen for bruits
C) Serum calcium C) assess for flap-like tremors of the hands
D) Serum albumin D) measure abdominal girth changes

56. A 66 year-old client is admitted for mitral valve replacement 64. A client is admitted with a diagnosis of nodal bigeminy. The
surgery. The client has a history of mitral valve regurgitation and nurse knows that the atrioventricular (AV) node has an intrinsic
mitral stenosis since her teenage years. During the admission rate of
assessment, the nurse should ask the client if as a child she had A) 60-100 beats/minute
A) measles B) 10-30 beats/minute
B) rheumatic fever C) 40-70 beats/minute
C) hay fever D) 20-50 beats/minute
D) encephalitis
65. A client is admitted for a possible pacemaker insertion.
57. Which of these clients should the charge nurse assign to the What is the intrinsic rate of the heart's own pacemaker?
registered nurse (RN)? A) 30-50 beats/minute
A) A 56 year-old with atrial fibrillation receiving digoxin B) 60-100 beats/minute
B) A 60 year-old client with COPD on oxygen at 2 L/min C) 20-60 beats/minute
C) A 24 year-old post-op client with type 1 diabetes in the D) 90-100 beats/minute
process of discharge
D) An 80 year-old client recovering 24 hours post right hip 66. A client is diagnosed with gastroesophageal reflux disease
replacement (GERD). The nurse's instruction to the client regarding diet
should be to
58. The nurse discusses nutrition with a pregnant woman who is A) avoid all raw fruits and vegetables
iron deficient and follows a vegetarian diet. The selection of B) increase intake of milk products
which foods indicates the woman has learned sources of iron? C) decrease intake of fatty foods
A) Cereal and dried fruits D) focus on 3 average size meals a day
B) Whole grains and yellow vegetables
C) Leafy green vegetables and oranges 67. The nurse is teaching a client with chronic renal failure (CRF)
D) Fish and dairy products about medications. The client questions the purpose of
aluminum hydroxide (Amphojel) in her medication regimen.
What is the best explanation for the nurse to give the client D) Check the patency of the tube
about the therapeutic effects of this medication?
A) It decreases serum phosphate 76. A 72 year-old client is admitted for possible dehydration.
B) It will reduce serum calcium The nurse knows that older adults are particularly at risk for
C) Amphojel increases urine output dehydration because they have
D) The drug is taken to control gastric acid secretion A) an increased need for extravascular fluid
B) a decreased sensation of thirst
68. The client with goiter is treated with potassium iodide C) an increase in diaphoresis
preoperatively. What should the nurse recognize as the purpose D) higher metabolic demands
of this medication?
A) Reduce vascularity of the thyroid 77. Upon admission to an intensive care unit, a client diagnosed
B) Correct chronic hyperthyroidism with an acute myocardial infarction is ordered oxygen. The
C) Destroy the thyroid gland function nurse knows that the major reason that oxygen is administered
D) Balance enzymes and electrolytes in this situation is to
A) saturate the red blood cells
69. A client with testicular cancer has had an orchiectomy. Prior B) relieve dyspnea
to discharge the client expresses his fears related to his C) decrease cyanosis
prognosis. Which principle should the nurse base the response D) increase oxygen level in the myocardium
on?
A) Testicular cancer has a cure rate of 90% with early diagnosis 78. An arterial blood gases test (ABG) is ordered for a confused
B) Testicular cancer has a cure rate of 50% with early diagnosis client. The respiratory therapist draws the blood and then asks
C) Intensive chemotherapy is the treatment of choice the nurse to apply pressure to the area so the therapist can take
D) Testicular cancer is usually fatal the specimen to the lab. How long should the nurse apply
pressure to the area?
70. The nurse is caring for clients over the age of 70. The nurse A) 3 minutes
is aware that when giving medications to older clients, it is best B) 5 minutes
to C) 8 minutes
A) start low, go slow D) 10 minutes
B) avoid stopping a medication entirely
C) avoid drugs with side effects that impact cognition 79. A client receiving chemotherapy has developed sores in his
D) review the drug regimen yearly mouth. He asks the nurse why this happened. What is the
nurse’s best response?
71. The nurse enters the room of a client diagnosed with COPD. A) "It is a sign that the medication is working."
The client’s skin is pink, and respirations are 8 per minute. The B) "You need to have better oral hygiene."
client’s oxygen is running at 6 liters per minute. What should be C) "The cells in the mouth are sensitive to the chemotherapy."
the nurse’s first action? D) "This always happens with chemotherapy."
A) Call the health care provider
B) Put the client in Fowler’s position 80. A client with testicular cancer is scheduled for a right
C) Lower the oxygen rate orchiectomy. The nurse knows that an orchiectomy is the
D) Take the vital signs A) surgical removal of the entire scrotum
B) surgical removal of a testicle
72. A client has an order for antibiotic therapy after hospital C) dissection of related lymph nodes
treatment of a staph infection. Which of the following should D) partial surgical removal of the penis
the nurse emphasize?
A) Scheduling follow-up blood cultures Q&A Random Selection #1
B) Completing the full course of medications
C) Visiting the provider in a few weeks 1. An older adult client is to receive and antibiotic, gentamicin.
D) Monitoring for signs of recurrent infection What diagnostic finding indicates the client may have difficult
excreting the medication?
73. A 55 year-old woman is taking Prednisone and aspirin (ASA) A) High gastric pH
as part of her treatment for rheumatoid arthritis. Which of the B) High serum creatinine
following would be an appropriate intervention for the nurse? C) Low serum albumin
A) Assess the pulse rate q 4 hours D) Low serum blood urea nitrogen
B) Monitor her level of consciousness q shift
C) Test her stools for occult blood 2. A client is admitted to the hospital with findings of liver
D) Discuss fiber in the diet to prevent constipation failure with ascites. The health care provider orders
spironolactone (Aldactone). What is the pharmacological effect
74. A client is prescribed an inhaler. How should the nurse of this medication?
instruct the client to breathe in the medication? A) Promotes sodium and chloride excretion
A) As quickly as possible B) Increases aldosterone levels
B) As slowly as possible C) Depletes potassium reserves
C) Deeply for 3-4 seconds D) Combines safely with antihypertensives
D) Until hearing whistling by the spacer
3. A client with tuberculosis is started on Rifampin. Which one
75. After surgery, a client with a nasogastric tube complains of of the following statements by the nurse would be appropriate
nausea. What action would the nurse take? to include in teaching? "You may notice:
A) Call the health care provider A) an orange-red color to your urine."
B) Administer an antiemetic B) your appetite may increase for the first week.”
C) Put the bed in Fowler’s position C) it is common to experience occasional sleep disturbances."
D) if you take the medication with food, you may have nausea." D) PTT 70 seconds

4. The nurse has just received report on a group of clients and 12. A client has just been diagnosed with breast cancer. The
plans to delegate care of several of the clients to a practical nurse enters the room and the client tells the nurse that she is
nurse (PN). The first thing the RN should do before the tupid. What is the most therapeutic response by the nurse?
delegation of care is A) Explore what is going on with the client
A) Provide a time-frame for the completion of the client care B) Accept the client’s statement without comment
B) Assure the PN that the RN will be available for assistance C) Tell the client that the comment is inappropriate
C) Ask about prior experience with similar clients D) Leave the client's room
D) Review the specific procedures unique to the assignment
13. A 12 year-old child is admitted with a broken arm and is told
5. Which of the following assessments by the nurse would surgery is required. The nurse finds him crying and unwilling to
indicate that the client is having a possible adverse response to talk. What is the most appropriate response by the nurse?
the isoniazid (INH)? A) Give him privacy
A) Severe headache B) Tell him he will get through the surgery with no problem
B) Appearance of jaundice C) Try to distract him
C) Tachycardia D) Make arrangements for his friends to visit
D) Decreased hearing
14. A nurse is assigned to care for a comatose diabetic on IV
6. The nurse is caring for a client who is 4 days post-op for a insulin therapy. Which task would be most appropriate to
transverse colostomy. The client is ready for discharge and asks delegate to an unlicensed assistive personnel (UAP)?
the nurse to empty his colostomy pouch. What is the best A) Check the client's level of consciousness
response by the nurse? B) Obtain the regular blood glucose readings
A) "You should be emptying the pouch yourself." C) Determine if special skin care is needed
B) "Let me demonstrate to you how to empty the pouch." D) Answer questions from the client's spouse about the plan of
C) "What have you learned about emptying your pouch?" care
D) "Show me what you have learned about emptying your
pouch." 15. The clinic nurse is discussing health promotion with a group
of parents. A mother is concerned about Reye's Syndrome, and
7. A post-operative client is admitted to the post-anesthesia asks about prevention. Which of these demonstrates
recovery room (PACU). The anesthetist reports that malignant appropriate teaching?
hyperthermia occurred during surgery. The nurse recognizes A) "Immunize your child against this disease."
that this complication is related to what factor? B) "Seek medical attention for serious injuries."
A) Allergy to general anesthesia C) "Report exposure to this illness."
B) Pre-existing bacterial infection D) "Avoid use of aspirin for viral infections."
C) A genetic predisposition
D) Selected surgical procedures 16. The nurse is caring for a client with a new order for
bupropion (Wellbutrin) for treatment of depression. The order
8. Which of the following laboratory results would suggest to reads “Wellbutrin 175 mg. BID x 4 days.” What is the
the emergency room nurse that a client admitted after a severe appropriate action?
motor vehicle crash is in acidosis? A) Give the medication as ordered
A) Hemoglobin 15 gm/dl B) Question this medication dose
B) Chloride 100 mEq/L C) Observe the client for mood swings
C) Sodium 130 mEq/L D) Monitor neuro signs frequently
D) Carbon dioxide 20 mEq/L
17. A 3 year-old child has tympanostomy tubes in place. The
9. The nurse is teaching a school-aged child and family about child's parent asks the nurse if he can swim in the family pool.
the use of inhalers prescribed for asthma. What is the best way The best response from the nurse is
to evaluate effectiveness of the treatments? A) "Your child should not swim at all while the tubes are in
A) Rely on child's self-report place."
B) Use a peak-flow meter B) "Your child may swim in your own pool but not in a lake or
C) Note skin color changes ocean."
D) Monitor pulse rate C) "Your child may swim if he wears ear plugs."
D) "Your child may swim anywhere."
10. The nurse is providing care to a newly a hospitalized
adolescent. What is the major threat experienced by the 18. A nurse has administered several blood transfusions over 3
hospitalized adolescent? days to a 12 year-old client with Thalassemia. What lab value
A) Pain management should the nurse monitor closely during this therapy?
B) Restricted physical activity A) Hemoglobin
C) Altered body image B) Red Blood Cell Indices
D) Separation from family C) Platelet count
D) Neutrophil percent
11. A client on telemetry begins having premature ventricular
beats (PVBs) at 12 per minute. In reviewing the most recent 19. The nurse is explaining the effects of cocaine abuse to a
laboratory results, which would require immediate action by the pregnant client. Which of the following must the nurse
nurse? understand as a basis for teaching?
A) Calcium 9 mg/dl A) Cocaine use can cause fetal growth retardation
B) Magnesium 2.5 mg/dl B) The drug has been linked to neural tube defects
C) Potassium 2.5 mEq/L C) Newborn withdrawal generally occurs immediately after birth
D) Breast feeding promotes positive parenting behaviors
27. The nurse administers cimetidine (Tagamet) to a 79 year-old
20. The feeling of trust can best be established by the nurse male with a gastric ulcer. Which parameter may be affected by
during the process of the development of a nurse-client this drug, and should be closely monitored by the nurse?
relationship by which of these characteristics? A) Blood pressure
A) Reliability and kindness B) Liver function
B) Demeanor and sincerity C) Mental status
C) Honesty and consistency D) Hemoglobin
D) Sympathy and appreciativeness
28. A 9 year-old is taken to the emergency room with right
21. A client is receiving and IV antibiotic infusion and is lower quadrant pain and vomiting. When preparing the child for
scheduled to have blood drawn at 1:00 pm for a "peak" an emergency appendectomy, what must the nurse expect to
antibiotic level measurement. The nurse notes that the IV be the child's greatest fear?
infusion is running behind schedule and will not be competed by A) Change in body image
1:00. The nurse should: B) An unfamiliar environment
A) Notify the client's health care provider C) Perceived loss of control
B) Stop the infusion at 1:00 pm D) Guilt over being hospitalized
C) Reschedule the laboratory test
D) Increase the infusion rate 29. The nurse is planning care for a client who is taking
cyclosporin (Neoral). What would be an appropriate nursing
22. A 52 year-old post menopausal woman asks the nurse how diagnosis for this client?
frequently she should have a mammogram. What is the nurse's A) Alteration in body image
best response? B) High risk for infection
A) "Your doctor will advise you about your risks." C) Altered growth and development
B) "Unless you had previous problems, every 2 years is best." D) Impaired physical mobility
C) "Once a woman reaches 50, she should have a mammogram
yearly."
D) "Yearly mammograms are advised for all women over 35." 30. A client with paranoid thoughts refuses to eat because of
the belief that the food is poisoned. The appropriate statement
23. In discharge teaching, the nurse should emphasize that at this time for the nurse to say is
which of these is a common side effect of clozapine (Clozaril)
A) "Here, I will pour a little of the juice in a medicine cup to
therapy?
drink it to show you that it is OK."
A) Dry mouth
B) "The food has been prepared in our kitchen and is not
B) Rhinitis
poisoned."
C) Dry skin
C) "Let's see if your partner could bring food from home."
D) Extreme salivation
D) "If you don't eat, I will have to suggest for you to be tube
fed."
24. A client was admitted to the psychiatric unit for severe
depression. After several days, the client continues to withdraw
from the other clients. Which of these statements by the nurse
would be the most appropriate to promote interaction with
other clients?
31. A client has many delusions. As the nurse helps the client
A) "Your team here thinks it's good for you to spend time with
prepare for breakfast the client comments "Don’t waste good
others.
food on me. I’m dying from this disease I have." The appropriate
B) "It is important for you to participate in group activities."
response would be
C) "Come with me so you can paint a picture to help you feel
A) "You need some nutritious food to help you regain your
better."
weight."
D) "Come play Chinese Checkers with Gloria and me."
B) "None of the laboratory reports show that you have any
physical disease."
25. The mother of a 4 month-old infant asks the nurse about the
C) "Try to eat a little bit, breakfast is the most important meal of
dangers of sunburn while they are on vacation at the beach.
the day."
Which of the following is the best advice about sun protection
D) "I know you believe that you have an incurable disease."
for this child?
A) "Use a sunscreen with a minimum sun protective factor of
32. A client tells the RN she has decided to stop taking sertraline
15."
(Zoloft) because she doesn’t like the nightmares, sex dreams,
B) "Applications of sunscreen should be repeated every few
and obsessions she’s experiencing since starting on the
hours."
medication. What is an appropriate response by the nurse?
C) "An infant should be protected by the maximum strength
sunscreen."
A) "It is unsafe to abruptly stop taking any prescribed
D) "Sunscreens are not recommended in children younger than
medication."
6 months."
B) "Side effects and benefits should be discussed with your
health care provider."
26. A client has had a positive reaction to purified protein
C) "This medication should be continued despite unpleasant
derivative (PPD). The client asks the nurse what this means. The
symptoms."
nurse should indicate that the client has
D) "Many medications have potential side effects."
A) active tuberculosis
B) been exposed to mycobacterium tuberculosis
33. The nurse is beginning nutritional counseling/teaching with
C) never had tuberculosis
a pregnant woman. What is the initial step in this interaction?
D) never been infected with mycobacterium tuberculosis
A) Teach her how to meet the needs of self and her family
B) Explain the changes in diet necessary for pregnant women A) Central venous pressure reading of 11
C) Question her understanding and use of the food pyramid B) Respiratory rate of 22
D) Conduct a diet history to determine her normal eating C) Pulse rate of 48 BPM
routines D) Blood pressure of 144/92

34. A client diagnosed with cirrhosis is started on lactulose 2. The nurse is teaching a group of college students about
(Cephulac). The main purpose of the drug for this client is to breast self-examination. A woman asks for the best time to
A) add dietary fiber perform the monthly exam. What is the best reply by the nurse?
B) reduce ammonia levels A) "The first of every month, because it is easiest to remember"
C) stimulate peristalsis B) "Right after the period, when your breasts are less tender"
D) control portal hypertension C) "Do the exam at the same time every month"
D) "Ovulation, or mid-cycle is the best time to detect changes"
35. The nurse is teaching a client about the toxicity of digoxin.
Which one of the following statements made by the client to 3. Which medication is more helpful in treating bulimia than
the nurse indicates more teaching is needed? anorexia?
A) "I may experience a loss of appetite." A) Amphetamines
B) "I can expect occasional double vision." B) Sedatives
C) "Nausea and vomiting may last a few days." C) Anticholinergics
D) "I must report a bounding pulse of 62 immediately." D) Narcotics

36. A client is to begin taking Fosamax. The nurse must 4. The nurse is assessing a client with chronic obstructive
emphasize which of these instructions to the client when taking pulmonary disease receiving oxygen for low PaO2 levels. Which
this medication? "Take Fosamax assessment is a nursing priority?
A) on an empty stomach." A) Evaluating SaO2 levels frequently
B) after meals." B) Observing skin color changes
C) with calcium." C) Assessing for clubbing fingers
D) with milk 2 hours after meals." D) Identifying tactile fremitus

37. The nurse is caring for a 10 year-old child who has just been 5. The nurse is teaching a client about the difference between
diagnosed with diabetes insipidus. The parents ask about the tardive dyskinesia (TD) and neuroleptic malignant syndrome
treatment prescribed, vasopressin. A What is priority in teaching (NMS). Which statement is true with regards to tardive
the child and family about this drug? dyskinesia?
A) The child should carry a nasal spray for emergency use
B) The family must observe the child for dehydration A) TD develops within hours or years of continued antipsychotic
C) Parents should administer the daily intramuscular injections drug use in people under 20 andover 30
D) The client needs to take daily injections in the short-term B) It can occur in clients taking antipsychotic drugs longer than 2
years
38. The nurse is caring for a client with asthma who has C) Tardive dyskinesia occurs within minutes of the first dose of
developed gastroesophageal reflux disease (GERD). Which of antipsychotic drugs and is reversible
the following medications prescribed for the client may D) TD can easily be treated with anticholinergic drugs
aggravate GERD?
A) Anticholinergics
B) Corticosteroids 6. A client is treated in the emergency room for diabetic
C) Histamine blocker ketoacidosis and a glucose level of 650mg.D/L. In assessing the
D) Antibiotics client, the nurse's review of which of the following tests
suggests an understanding of this health problem?
39. A client is receiving a nitroglycerin infusion for unstable A) Serum calcium
angina. What assessment would be a priority when monitoring B) Serum magnesium
the effects of this medication? C) Serum creatinine
D) Serum potassium
A) Blood pressure
B) Cardiac enzymes 7. A client is discharged on warfarin sulfate (Coumadin). Which
C) ECG analysis statement by the client indicated a need for further teaching?
D) Respiratory rate A) "I know I must avoid crowds."
B) "I will keep all laboratory appointments."
40. The nurse assesses the use of coping mechanisms by an C) "I plan to use an electric razor for shaving."
adolescent 1 week after the client had a motor vehicle accident D) "I will report any bruises for bleeding."
resulting in multiple serious injuries. Which of these
characteristics are most likely to be displayed? 8. When teaching a client with a new prescription for lithium
A) Ambivalence, dependence, demanding (Lithane) for treatment of a bi-polar disorder which of these
B) Denial, projection, regression should the nurse emphasize?
C) Intellectualization, rationalization, repression A) Maintaining a salt restricted diet
D) Identification, assimilation, withdrawal B) Reporting vomiting or diarrhea
C) Taking other medication as usual
D) Substituting generic form if desired
Q&A Random Selection # 2
9. After assessing a 70 year-old male client's laboratory results
1. The nurse is administering lidocaine (Xylocaine) to a client during a routine clinic visit, which one of the following findings
with a myocardial infarction. Which of the following assessment would indicate an area in which teaching is needed:
findings requires the nurse's immediate action?
A) Serum albumin 2.5 g/dl 18. A client is taking tranylcypromine (Parnate) and has received
B) LDL Cholesterol 140 mg/dl dietary instruction. Which of the following food selections
C) Serum glucose 90 mg/dl would be contraindicated for this client?
D) RBC 5.0 million/mm3 A) Fresh juice, carrots, vanilla pudding
B) Apple juice, ham salad, fresh pineapple
10. The nurse is assessing a woman in early labor. While C) Hamburger, fries, strawberry shake
positioning for a vaginal exam, she complains of dizziness and D) Red wine, fava beans, aged cheese
nausea and appears pale. Her blood pressure has dropped
slightly. What should be the initial nursing action? 19. The nurse is assessing a client's home in preparation for
discharge. Which of the following should be given priority
A) Call the health care provider consideration?
B) Encourage deep breathing A) Family understanding of client needs
C) Elevate the foot of the bed B) Financial status
D) Turn her to her left side C) Location of bathrooms
D) Proximity to emergency services
11. Initial postoperative nursing care for an infant who has had a
pyloromyotomy would initially include 20. A client, admitted to the unit because of severe depression
A) bland diet appropriate for age and suicidal threats, is placed on suicidal precautions. The nurse
B) intravenous fluids for 3-4 days should be aware that the danger of the client committing
C) NPO then glucose and electrolyte solutions suicide is greatest
D) formula or breast milk as tolerated A) during the night shift when staffing is limited
B) when the client’s mood improves with an increase in energy
12. A client is receiving lithium carbonate 600 mg T.I.D. to treat level
bipolar disorder. Which of these indicate early signs of toxicity? C) at the time of the client's greatest despair
A) Ataxia and course hand tremors D) after a visit from the client's estranged partner
B) Vomiting, diarrhea and lethargy
C) Pruritus, rash and photosensitivity 21. A male client calls for a nurse because of chest pain. Which
D) Electrolyte imbalance and cardiac arrhythmias statement by the client would require the most immediate
action by the nurse?
13. The nurse is caring for a 2 month-old infant with a A) "When I take in a deep breath, it stabs like a knife."
congenital heart defect. Which of the following is a priority B) "The pain came on after dinner. That soup seemed very
nursing action? spicy."
A) Provide small feedings every 3 hours C) "When I turn in bed to reach the remote for the TV, my chest
B) Maintain intravenous fluids hurts."
C) Add strained cereal to the diet D) "I feel pressure in the middle of my chest, like an elephant is
D) Change to reduced calorie formula sitting on my chest."

14. Clients taking lithium must be particularly sure to maintain 22. A client has been started on a long term corticosteroid
adequate intake of which of these elements? therapy. Which of the following comments by the client indicate
A) Potassium the need for further teaching?
B) Sodium A) "I will keep a weekly weight record."
C) Chloride B) "I will take medication with food."
D) Calcium C) "I will stop taking the medication for 1 week every month."
15. A client is admitted with severe injuries from an auto D) "I will eat foods high in potassium."
accident. The client's vital signs are BP 120/50, pulse rate 110,
and respiratory rate of 28. The initial nursing intervention would 23. The visiting nurse makes a postpartum visit to a married
be to female client. Upon arrival, the nurse observes that the client
A) begin intravenous therapy has a black eye and numerous bruises on her arms and legs. The
B) initiate continuous blood pressure monitoring initial nursing intervention would be to
C) administer oxygen therapy A) call the police to report indications of domestic violence
D) institute cardiac monitoring B) confront the husband about abusing his wife
C) leave the home because of the unsafe environment
16. A woman in labor calls the nurse to assist her in the D) interview the client alone to determine the origin of the
bathroom. The nurse notices a large amount of clear fluid on injuries
the bed linens. The nurse knows that fetal monitoring must now
assess for what complication? 24. A nurse is caring for a client who has just been admitted
A) Early decelerations with an overdose of aspirin. The following lab data is available:
B) Late accelerations PaO2 95, PaCO2 30, pH 7.5, K 3.2 mEq/l. Which should be the
C) Variable decelerations nurse's first action?
D) Periodic accelerations A) Monitor respiratory rate
B) Monitor intake and output every hour
17. The nurse can best ensure the safety of a client suffering C) Assist the client to breathe into a paper bag
from dementia who wanders from the room by which action? D) Prepare to administer oxygen by mask
A) Repeatedly remind the client of the time and location
B) Explain the risks of walking with no purpose 25. The spouse of a client with Alzheimer's disease expresses
C) Use protective devices to keep the client in the bed or chair concern about the burden of caregiving. Which of the following
in the room actions by the nurse should be a priority?
D) Attach a wander-guard sensor band to the client's wrist A) Link the caregiver with a support group
B) Ask friends to visit regularly
C) Schedule a home visit each week 34. The nurse is caring for a client receiving intravenous
D) Request anti-anxiety prescriptions nitroglycerin for acute angina. What is the most important
assessment during treatment?
26. In response to a call for assistance by a client in labor, the A) Heart rate
nurse notes that a loop on the umbilical cord protrudes from B) Neurologic status
the vagina. What is the priority nursing action? C) Urine output
A) call the health care provider D) Blood pressure
B) check fetal heart beat
C) put the client in knee-chest position 35. A client diagnosed with chronic depression is maintained on
D) turn the client to the side tranylcypromine (Parnate). An important nursing intervention is
to teach the client to avoid which of the following foods?
27. When teaching a client about an oral hypoglycemic A) Wine, beer, cheese, liver and chocolate
medication, the nurse should place primary emphasis on B) Wine, citrus fruits, yogurt and broccoli
A) recognizing findings of toxicity C) Beer, cheese, beef and carrots
B) taking the medication at specified times D) Wine, apples, sour cream and beef steak
C) increasing the dosage based on blood glucose
D) distinguishing hypoglycemia from hyperglycemia 36. Which clinical finding would the nurse expect to assess first
in a newborn with spastic cerebral palsy?
28. A male client is preparing for discharge following an acute A) cognitive impairment
myocardial infarction. He asks the nurse about his sexual activity B) hypotonic muscular activity
once he is home. What would be the nurse's initial response? C) seizures
A) Give him written material from the American Heart D) criss-crossing leg movement
Association about sexual activity with heart disease
B) Answer his questions accurately in a private environment 37. The nurse is working in a high risk antepartum clinic. A 40
C) Schedule a private, uninterrupted teaching session with both year-old woman in the first trimester gives a thorough health
the client and his wife history. Which information should receive priority attention by
D) Assess the client's knowledge about his health problems the nurse?
A) Her father and brother are insulin dependent diabetics
29. The nurse is aware that the effect of antihypertensive drug B) She has taken 800 mcg of folic acid daily for the past year
therapy may be affected by a 75 year-old client's C) Her husband was treated for tuberculosis as a child
A) poor nutritional status D) She reports recent use of over-the counter sinus remedies
B) decreased gastrointestinal motility
C) increased splanchnic blood flow 38. A client telephones the clinic to ask about a home pregnancy
D) altered peripheral resistance test she used this morning. The nurse understands that the
presence of which hormone strongly suggests a woman is
30. After 4 electroconvulsive treatments over 2 weeks, a client is pregnant?
very upset and states “I am so confused. I lose my money. I just A) Estrogen C) Alpha-fetoprotein
can’t remember telephone numbers.” The most therapeutic B) HCG D) Progesterone
response for the nurse to make is
A) "You were seriously ill and needed the treatments." 39. As a general guide for emergency management of acute
B) "Don't get upset. The confusion will clear up in a day or two." alcohol intoxication, it is important for the nurse initially to
C) "It is to be expected since most clients have the same obtain data regarding which of the following?
results." A) What and how much the client drinks, according to family
D) "I can hear your concern and that your confusion is upsetting and friends
to you." B) The blood alcohol level of the client
C) The blood pressure level of the client
31. The client asks the nurse how the health care provider could D) The blood glucose level of the client
tell she was pregnant “just by looking inside.” What is the best
explanation by the nurse? 40. A client is admitted to the hospital with a diagnosis of deep
A) Bluish coloration of the cervix and vaginal walls vein thrombosis. During the initial assessment, the client
B) Pronounced softening of the cervix complains of sudden shortness of breath. The SaO2 is 87. The
C) Clot of very thick mucous that obstructs the cervical canal priority nursing assessment at this time is
D) Slight rotation of the uterus to the right A) bowel sounds
B) heart rate
32. What must be the priority consideration for nurses when C) peripheral pulses
communicating with children? D) lung sounds
A) Present environment
B) Physical condition Q & A Random Selection #3
C) Nonverbal cues
D) Developmental level 1. The nurse is performing an assessment on a client who is
cachectic and has developed an enterocutaneous fistula
33. The nurse is caring for a post-operative client who develops following surgery to relieve a small bowel obstruction. The
a wound evisceration. The first nursing intervention should be client's total protein level is reported as 4.5 g/dl. Which of the
A) medicate the client for pain following would the nurse anticipate?
B) call the provider A) Additional potassium will be given IV
C) cover the wound with sterile saline dressing B) Blood for coagulation studies will be drawn
D) place the bed in a flat position C) Total parenteral nutrition (TPN) will be started
D) Serum lipase levels will be evaluated
2. The nurse is assessing a comatose client receiving gastric tube
feedings. Which of the following assessments requires an 10. While assessing the vital signs in children, the nurse should
immediate response from the nurse? know that the apical heart rate is preferred until the radial
A) Decreased breath sounds in right lower lobe pulsecan be accurately assessed at about what age?
B) Aspiration of a residual of 100cc of formula A) 1 year of age
C) Decrease in bowel sounds B) 2 years of age
D) Urine output of 250 cc in past 8 hours C) 3 years of age
D) 4 years of age
3. The nurse is preparing to take a toddler's blood pressure for
the first time. Which of the following actions should the nurse 11. As a part of a 9 pound full-term newborn's assessment, the
perform first? nurse performs a dextro-stick at 1 hour post birth. The serum
A) Explain that the procedure will help him to get well glucose reading is 45 mg/dl. What action by the nurse is
B) Show a cartoon character with a blood pressure cuff appropriate at this time?
C) Explain that the blood pressure checks the heart pump A) Give oral glucose water
D) Permit handling the equipment before putting the cuff in B) Notify the pediatrician
place C) Repeat the test in 2 hours
D) Check the pulse oximetry reading
4. A 35-year-old client of Puerto Rican-American descent is
diagnosed with ovarian cancer. The client states, “I refuse both 12. The nurse is teaching parents of a 7 month-old about adding
radiation and chemotherapy because they are 'hot.'” The next table foods. Which of the following is an appropriate finger
action for the nurse to take is to food?
A) document the situation in the notes A) Hot dog pieces
B) report the situation to the health care provider B) Sliced bananas
C) talk with the client's family about the situation C) Whole grapes
D) ask the client to talk about concerns regarding "hot" D) Popcorn
treatments
13. During a routine check-up, an insulin-dependent diabetic
5. Which of the following drugs should the nurse anticipate has his glycosylated hemoglobin checked. The results indicate a
administering to a client before they are to receive level of 11%. Based on this result, what teaching should the
electroconvulsive therapy? nurse emphasize?
A) Benzodiazepines A) Rotation of injection sties
B) Chlorpromazine (Thorazine) B) Insulin mixing and preparation
C) Succinylcholine (Anectine) C) Daily blood sugar monitoring
D) Thiopental sodium (Pentothal Sodium) D) Regular high protein diet

6. Which statement made by a nurse about the goal of total 14. A newborn weighed 7 pounds 2 ounces at birth. The nurse
quality management or continuous quality improvement in a assesses the newborn at home 2 days later and finds the weight
health care setting is correct? to be 6 pounds 7 ounces. What should the nurse tell the parents
A) It is to observe reactive service and product problem solving about this weight loss?
B) Improvement of the processes in a proactive, preventive A) The newborn needs additional assessments
mode is paramount B) The mother should breast feed more often
C) A chart audits to finds common errors in practice and C) A change to formula is indicated
outcomes associated with goals D) The loss is within normal limits
D) A flow chart to organize daily tasks is critical to the initial
stages 15. A client with chronic obstructive pulmonary disease (COPD)
and a history of coronary artery disease is receiving
7. The nurse admits a 2 year-old child who has had a seizure. aminophylline, 25mg/hour. Which one of the following findings
Which of the following statement by the child's parent would be by the nurse would require immediate intervention?
important in determining the etiology of the seizure? A) Decreased blood pressure and respirations
A) "He has been taking long naps for a week." B) Flushing and headache
B) "He has had an ear infection for the past 2 days." C) Restlessness and palpitations
C) "He has been eating more red meat lately." D) Increased heart rate and blood pressure
D) "He seems to be going to the bathroom more frequently."
16. A 72 year-old client is scheduled to have a cardioversion. A
8. The nurse is caring for a client with Hodgkin's disease who nurse reviews the client’s medication administration record. The
will be receiving radiation therapy. The nurse recognizes that, as nurse should notify the health care provider if the client
a result of the radiation therapy, the client is most likely to received which medication during the preceding 24 hours?
experience A) Digoxin (Lanoxin)
A) high fever C) face and neck edema B) Diltiazem (Cardizem)
B) nausea D) night sweats C) Nitroglycerine ointment
D) Metoprolol (Toprol XL)
9. A client with a panic disorder has a new prescription for
Xanax (alprazolam). In teaching the client about the drug's 17. A client taking isoniazid (INH) for tuberculosis asks the nurse
actions and side effects, which of the following should the nurse about side effects of the medication. The client should be
emphasize? instructed to immediately report which of these?
A) Short-term relief can be expected A) Double vision and visual halos
B) The medication acts as a stimulant B) Extremity tingling and numbness
C) Dosage will be increased as tolerated C) Confusion and lightheadedness
D) Initial side effects often continue D) Sensitivity of sunlight
 A) "Most people develop hypertension following an MI."
18. Which of these clients would the nurse monitor for the B) "A beta-Blocker will prevent orthostatic hypotension."
complication of C. difficile diarrhea? C) "This drug will decrease the workload on his heart."
A) An adolescent taking medications for acne D) "Beta-blockers increase the strength of heart contractions."
B) An elderly client living in a retirement center taking
prednisone 26. To prevent drug resistance from developing, the nurse is
C) A young adult at home taking a prescribed aminoglycoside aware that which of the following is a characteristic of the
D) A hospitalized middle aged client receiving clindamycin typical treatment plan to eliminate the tuberculosis bacilli?
A) An anti-inflammatory agent
19. The clinic nurse is counseling a substance-abusing post B) High doses of B complex vitamins
partum client on the risks of continued cocaine use. In order to C) Aminoglycoside antibiotics
provide continuity of care, which nursing diagnosis is a priority? D) Administering two anti-tuberculosis drugs
A) Social isolation
B) Ineffective coping 27. Which of these questions is priority when assessing a client
C) Altered parenting with hypertension?
D) Sexual dysfunction A) "What over-the-counter medications do you take?"
B) "Describe your usual exercise and activity patterns."
20. An 18 month-old child is on peritoneal dialysis in C) "Tell me about your usual diet."
preparation for a renal transplant in the near future. When the D) "Describe your family's cardiovascular history."
nurse obtains the child's health history, the mother indicates
that the child has not had the first measles, mumps, rubella 28. The nurse is performing an assessment of the motor
(MMR) immunization. The nurse understands that which of the function in a client with a head injury. The best technique is
following is true in regards to giving immunizations to this child? A) touching the trapezius muscle or arm firmly
A) Live vaccines are withheld in children with renal chronic B) pinching any body part
illness C) shaking a limb vigorously
B) The MMR vaccine should be given now, prior to the D) rubbing the sternum
transplant
C) An inactivated form of the vaccine can be given at any time 29. Which approach is a priority for the nurse who works with
D) The risk of vaccine side effects precludes giving the vaccine clients from many different cultures?
A) Speak at least 2 other languages of clients in the
21. A client is receiving Total Parenteral Nutrition (TPN) via a neighborhood
Hickman catheter. The catheter accidentally becomes dislodged B) Learn about the cultures of clients who are most often
from the site. Which action by the nurse should take priority? encountered
A) Check that the catheter tip is intact C) Have a list of persons for referral when interaction with these
B) Apply a pressure dressing to the site clients occur
C) Monitor respiratory status D) Recognize personal attitudes about cultural differences and
D) Assess for mental status changes real or expected biases

22. The nurse is preparing to administer a tube feeding to a 30. A client has gastroesophageal reflux. Which
postoperative client. To accurately assess for a gastrostomy recommendation made by the nurse would be most helpful to
tube placement, the priority is to the client?
A) auscultate the abdomen while instilling 10 cc of air into the A) Avoid liquids unless a thickening agent is used
tube B) Sit upright for at least 1 hour after eating
B) place the end of the tube in water to check for air bubbles C) Maintain a diet of soft foods and cooked vegetables
C) retract the tube several inches to check for resistance D) Avoid eating 2 hours before going to sleep
D) measure the length of tubing from nose to epigastrium
31. A client is brought to the emergency room following a motor
23. A nurse admits a client transferred from the emergency vehicle accident. When assessing the client one-half hour after
room (ER). The client, diagnosed with a myocardial infarction, is admission, the nurse notes several physical changes. Which
complaining of substernal chest pain, diaphoresis and nausea. finding would require the nurse's immediate attention?
The first action by the nurse should be to A) increased restlessness C) tracheal deviation
A) order an EKG B) tachycardia D) tachypnea
B) administer morphine sulfate
C) start an IV 32. During a situation of pain management, which statement is
D) measure vital signs a priority to consider for the ethical guidelines of the nurse?
A) The client's self-report is the most important consideration
24. The nurse is planning care for an 8 year-old child. Which of B) Cultural sensitivity is fundamental to pain management
the following should be included in the plan of care? C) Clients have the right to have their pain relieved
A) Encourage child to engage in activities in the playroom D) Nurses should not prejudge a client's pain using their own
B) Promote independence in activities of daily living values
C) Talk with the child and allow him to express his opinions 33. When teaching a client about the side effects of fluoxetine
D) Provide frequent reassurance and cuddling (Prozac), which of the following will the nurse include?
A) Tachycardia blurred vision, hypotension, anorexia
25. A client being discharged from the cardiac step-down unit B) Orthostatic hypotension, vertigo, reactions to tyramine-rich
following a myocardial infarction (MI), is given a prescription for foods
a beta-blocking drug. A nursing student asks the charge nurse C) Diarrhea, dry mouth, weight loss, reduced libido
why this drug would be used by a client who is not D) Photosensitivity, seizures, edema, hyperglycemia
hypertensive. What is an appropriate response by the charge
nurse?
34. The nurse is talking with the family of an 18 months-old 1. In addition to standard precautions, a nurse should
newly diagnosed with retinoblastoma. A priority in implement contact precautions for which client?
communicating with the parents is A) 60 year-old with herpes simplex
A) Discuss the need for genetic counseling B) 6 year-old with mononucleosis
B) Inform them that combined therapy is seldom effective C) 45 year-old with pneumonia
C) Prepare for the child's permanent disfigurement D) 3 year-old with scarlet fever
D) Suggest that total blindness may follow surgery
2. A 70 year-old woman is evaluated in the emergency
35. The nurse manager informs the nursing staff at morning department for a wrist fracture of unknown causes. During the
report that the clinical nurse specialist will be conducting a process of taking client history, which of these items should the
research study on staff attitudes toward client care. All staff are nurse identify as related to the client’s greatest risk factors for
invited to participate in the study if they wish. This affirms the osteoporosis?
ethical A) History of menopause at age 50
principle of B) Taking high doses of steroids for arthritis for many years
A) Anonymity C) Maintaining an inactive lifestyle for the past 10 years
B) Beneficence D) Drinking 2 glasses of red wine each day for the past 30 years
C) Justice
D) Autonomy 3. Which contraindication should the nurse assess for prior to
giving a child immunizations?
36. Which of these clients, all of whom have the findings of a A) Mild cold symptoms
board-like abdomen, would the nurse suggest that the provider B) Chronic asthma
examine first? C) Depressed immune system
A) An elderly client who stated, "My awful pain in my right side D) Allergy to eggs
suddenly stopped about 3 hours ago."
B) A pregnant woman of 8 weeks newly diagnosed with an 4. The nurse is caring for a 1 year-old child who has 6 teeth.
ectopic pregnancy What is the best way for the nurse to give mouth care to this
C) A middle-aged client admitted with diverticulitis who has child?
taken only clear liquids for the past week A) Using a moist soft brush or cloth to clean teeth and gums
D) A teenager with a history of falling off a bicycle without B) Swabbing teeth and gums with flavored mouthwash
hitting the handle bars C) Offering a bottle of water for the child to drink
D) Brushing with toothpaste and flossing each tooth
37. The nurse is assigned to care for 4 clients. Which of the
following should be assessed immediately after hearing the 5. The nurse is teaching the mother of a 5 month-old about
report? nutrition for her baby. Which statement by the mother indicates
A) The client with asthma who is now ready for discharge the need for further teaching?
B) The client with a peptic ulcer who has been vomiting all night A) "I'm going to try feeding my baby some rice cereal."
C) The client with chronic renal failure returning from dialysis B) "When he wakes at night for a bottle, I feed him."
D) The client with pancreatitis who was admitted yesterday C) "I dip his pacifier in honey so he'll take it."
D) "I keep formula in the refrigerator for 24 hours."
38. The nurse is teaching about nonsteroidal anti-inflammatory
drugs (NSAIDs) to a group of arthritic clients. To minimize the 6. A client with a fractured femur has been in Russell’s traction
side effects, the nurse should emphasize which of the following for 24 hours. Which nursing action is associated with this
actions? therapy?
A) Reporting joint stiffness in the morning A) Check the skin on the sacrum for breakdown
B) Taking the medication 1 hour before or 2 hours after meals B) Inspect the pin site for signs of infection
C) Using alcohol in moderation unless driving C) Auscultate the lungs for atelectasis
D) Continuing to take aspirin for short term relief D) Perform a neurovascular check for circulation

39. A client is prescribed warfarin sodium (Coumadin) to be 7. The nurse is teaching a parent about side effects of routine
continued at home. Which focus is critical to be included in the immunizations. Which of the following must be reported
nurse’s discharge instruction? immediately?
A) Maintain a consistent intake of green leafy foods A) Irritability
B) Report any nose or gum bleeds B) Slight edema at site
C) Take Tylenol for minor pains C) Local tenderness
D) Use a soft toothbrush D) Seizure activity

40. A pregnant client who is at 34 weeks gestation is diagnosed 8. Decentralized scheduling is used on a nursing unit. A chief
with a pulmonary embolism (PE). Which of these medications advantage of this management strategy is that it:
would the nurse anticipate the provider ordering? A) considers client and staff needs
A) Oral Coumadin therapy B) conserves time spent on planning
B) Heparin 5000 units subcutaneously B.I.D. C) frees the nurse manager to handle other priorities
C) Heparin infusion to maintain the PTT at 1.5-2.5 times the D) allows requests for special privileges
control value
D) Heparin by subcutaneous injection to maintain the PTT at 1.5 9. A couple trying to conceive asks the nurse when ovulation
times the control value occurs. The woman reports a regular 32 day cycle. Which
response by the nurse is correct?
Q&A Random Selection #4 A) Days 7-10 C) Days 14-16
B) Days 10-13 D) Days 17-19
10. The nurse is caring for a client with a myocardial infarction. 18. A newborn is having difficulty maintaining a temperature
Which finding requires the nurse's immediate action? above 98 degrees Fahrenheit and has been placed in an
A) Periorbital edema incubator. Which action is a nursing priority?
B) Dizzy spells A) Protect the eyes of the neonate from the heat lamp
C) Lethargy B) Monitor the neonate’s temperature
D) Shortness of breath C) Warm all medications and liquids before giving
D) Avoid touching the neonate with cold hands
11. At a senior citizens meeting a nurse talks with a client who
has Type 1 diabetes mellitus. Which statement by the client 19. What is the best way that parents of pre-schoolers can begin
during the conversation is most predictive of a potential for teaching their child about injury prevention?
impaired skin integrity? A) Set good examples themselves
A) "I give my insulin to myself in my thighs." B) Protect their child from outside influences
B) "Sometimes when I put my shoes on I don't know where my C) Make sure their child understands all the safety rules
toes are." D) Discuss the consequences of not wearing protective devices
C) "Here are my up and down glucose readings that I wrote on
my calendar." 20. A client complains of some discomfort after a below the
D) "If I bathe more than once a week my skin feels too dry." knee amputation. Which action by the nurse is most
appropriate initially?
12. Which client is at highest risk for developing a pressure A) Conduct guided imagery or distraction
ulcer? B) Ensure that the stump is elevated the first day post-op
A) 23 year-old in traction for fractured femur C) Wrap the stump snugly in an elastic bandage
B) 72 year-old with peripheral vascular disease, who is unable to D) Administer opioid narcotics as ordered
walk without assistance
C) 75 year-old with left sided paresthesia who is incontinent of 21. The nurse is caring for a client with extracellular fluid
urine and stool volume deficit. Which of the following assessments would the
D) 30 year-old who is comatose following a ruptured aneurysm nurse anticipate finding?
A) bounding pulse C) oliguria
13. A 16 year-old boy is admitted for Ewing's sarcoma of the B) rapid respirations D) neck veins are distended
tibia. In discussing his care with the parents, the nurse
understands that the initial treatment most often includes 22. The nurse is performing a gestational age assessment on a
A) amputation just above the tumor newborn delivered 2 hours ago. When coming to a conclusion
B) surgical excision of the mass using the Ballard scale, which of these factors may affect the
C) bone marrow graft in the affected leg score?
D) radiation and chemotherapy A) Birth weight C) Fetal distress in labor
B) Racial differences D) Birth trauma
14. The parents of a toddler ask the nurse how long their child
will have to sit in a car seat while in the automobile. What is the 23. Which oxygen delivery system would the nurse apply that
nurse’s best response to the parents? would provide the highest concentrations of oxygen to the
A) "Your child must use a care seat until he weighs at least 40 client?
pounds." A) Venturi mask C) Non-rebreather mask
B) "The child must be 5 years of age to use a regular seat belt." B) Partial rebreather mask D) Simple face mask
C) "Your child must reach a height of 50 inches to sit in a seat
belt." 24. Which of the following situations is most likely to produce
D) "The child can use a regular seat belt when he can sit still." sepsis in the neonate?
A) Maternal diabetes
15. A woman in her third trimester complains of severe B) Prolonged rupture of membranes
heartburn. What is appropriate teaching by the nurse to help C) Cesarean delivery
the woman alleviate these symptoms? D) Precipitous vaginal birth
A) Drink small amounts of liquids frequently
B) Eat the evening meal just before retiring 25. A 4 year-old hospitalized child begins to have a seizure while
C) Take sodium bicarbonate after each meal playing with hard plastic toys in the hallway. Of the following
D) Sleep with head propped on several pillows nursing actions, which one should the nurse do first?
A) Place the child in the nearest bed
16. A client is admitted with the diagnosis of pulmonary B) Administer IV medication to slow down the seizure
embolism. While taking a history, the client tells the nurse he C) Place a padded tongue blade in the child's mouth
was admitted for the same thing twice before, the last time just D) Remove the child's toys from the immediate area
3 months ago. The nurse would anticipate the provider ordering
A) pulmonary embolectomy 26. A 78 year-old client with pneumonia has a productive cough,
B) vena caval interruption but is confused. Safety protective devices (restraints) have been
C) increasing the Coumadin therapy to an INR of 3-4 ordered for this client. How can the nurse prevent aspiration?
D) thrombolytic therapy A) Suction the client frequently while restrained
B) Secure all 4 restraints to 1 side of bed
17. The nurse is caring for a 2 year-old who is being treated with C) Obtain a sitter for the client while restrained
chelation therapy, calcium disodium edetate, for lead D) Request an order for a cough suppressant
poisoning. The nurse should be alert for which of the following
side effects? 27. A client asks the nurse to explain the basic ideas of
A) Neurotoxicity C) Nephrotoxicity homeopathic medicine. The response that best explains this
B) Hepatomegaly D) Ototoxicity approach is that such remedies
A) destroy organisms causing disease
B) maintain fluid balance
C) boost the immune system 35. The nurse is teaching home care to the parents of a child
D) increase bodily energy with acute spasmodic croup. The most important aspects of this
care is/are
28. A newborn has hyperbilirubinemia and is undergoing A) sedation as needed to prevent exhaustion
phototherapy with a fiberoptic blanket. Which safety measure is B) antibiotic therapy for 10 to 14 days
most important during this process? C) humidified air and increased oral fluids
A) Regulate the neonate’s temperature using a radiant heater D) antihistamines to decrease allergic response
B) Withhold feedings while under the phototherapy
C) Provide water feedings at least every 2 hours 36. A nurse is performing the routine daily cleaning of a
D) Protect the eyes of neonate from the phototherapy lights tracheostomy. During the procedure, the client coughs and
displaces the tracheostomy tube. This negative outcome could
29. The nurse is assigned to care for a client who has a leaking have avoided by
intracranial aneurysm. To minimize the risk of rebleeding, the A) placing an obturator at the client’s bedside
nurse should plan to B) having another nurse assist with the procedure
A) restrict visitors to immediate family C) fastening clean tracheostomy ties before removing old ties
B) avoid arousal of the client except for family visits D) placing the client in a flat, supine position
C) keep client's hips flexed at no less than 90 degrees
D) apply a warming blanket for temperatures of 98 degrees 37. A client who is 12 hour post-op becomes confused and says:
Fahrenheit or less “Giant sharks are swimming across the ceiling.” Which
assessment is necessary to adequately identify the source of
30. A new nurse manager is responsible for interviewing this client's behavior?
applicants for a staff nurse position. Which interview strategy A) Cardiac rhythm strip
would be the best approach? B) Pupillary response
A) Vary the interview style for each candidate to learn different C) Pulse oximetry
techniques D) Peripheral glucose stick
B) Use simple questions requiring "yes" and "no" answers to
gain definitive information 38. A nurse assessing the newborn of a mother with diabetes
C) Obtain an interview guide from human resources for understands that hypoglycemia is related to what
consistency in interviewing each candidate pathophysiological process?
D) Ask personal information of each applicant to assure he/she A) Disruption of fetal glucose supply
can meet job demands B) Pancreatic insufficiency
C) Maternal insulin dependency
31. When suctioning a client's tracheostomy, the nurse should D) Reduced glycogen reserves
instill saline in order to
A) decrease the client's discomfort 39. A newborn delivered at home without a birth attendant is
B) reduce viscosity of secretions admitted to the hospital for observation. The initial temperature
C) prevent client aspiration is 95 degrees Fahrenheit (35 degrees Celsius) axillary. The nurse
D) remove a mucus plug recognizes that cold stress may lead to what complication?
A) Lowered BMR
32. A client returns from surgery after an open reduction of a B) Reduced PaO2
femur fracture. There is a small bloodstain on the cast. Four C) Lethargy
hours later, the nurse observes that the stain has doubled in D) Metabolic alkalosis
size. What is the best action for the nurse to take?
A) Call the health care provider 40. A nurse is caring for a client who had a closed reduction of a
B) Access the site by cutting a window in the cast fractured right wrist followed by the application of a fiberglass
C) Simply record the findings in the nurse's notes only cast 12 hours ago. Which finding requires the nurse’s
D) Outline the spot with a pencil and note the time and date on immediate attention?
the cast A) Capillary refill of fingers on right hand is 3 seconds
B) Skin warm to touch and normally colored
33. Included in teaching the client with tuberculosis taking C) Client reports prickling sensation in the right hand
isoniazid (INH) about follow-up home care, the nurse should D) Slight swelling of fingers of right hand
emphasize that a laboratory appointment for which of the
following lab tests is critical? Q&A Random Selection #5
A) Liver function
B) Kidney function 1. The nurse is caring for a client who had a total hip
C) Blood sugar replacement 4 days ago. Which assessment requires the nurse’s
D) Cardiac enzymes immediate attention?
34. The nurse is at the community center speaking with retired A) "I have bad muscle spasms in my lower leg of the affected
people about glaucoma. Which comment by one of the retirees extremity."
would the nurse support to reinforce correct information? B) "I just can't 'catch my breath' over the past few minutes and I
A) "I usually avoid driving at night since lights sometimes seem think I am in grave danger."
to make things blur." C) "I have to use the bedpan to pass my water at least every 1 to
B) "I take half of the usual dose for my sinuses to maintain my 2 hours."
blood pressure." D) "It seems that the pain medication is not working as well
C) "I have to sit at the side of the pool with the grandchildren today."
since I can't swim with this eye problem." 2. While assessing a 1 month-old infant, which finding should
D) "I take extra fiber and drink lots of water to avoid getting the nurse report immediately?
constipated." A) Abdominal respirations
B) Irregular breathing rate 10. While planning care for a toddler, the nurse teaches the
C) Inspiratory grunt parents about the expected developmental changes for this age.
D) Increased heart rate with crying Which statement by the mother shows that she understands
the child's developmental needs?
3. A client is receiving digoxin (Lanoxin) 0.25 mg. Daily. The A) "I want to protect my child from any falls."
health care provider has written a new order to give metoprolol B) "I will set limits on exploring the house."
(Lopressor) 25 mg. B.I.D. In assessing the client prior to C) "I understand our child’s need to use those new skills."
administering the medications, which of the following should D) "I intend to keep control over our child’s behavior."
the nurse report immediately to the health care provider?
A) Blood pressure 94/60 11. A client who is pregnant comes to the clinic for a first visit.
B) Heart rate 76 BPM The nurse gathers data about her obstetric history, which
C) Urine output 50 ml/hour includes 3 year-old twins at home and a miscarriage 10 years
D) Respiratory rate 16 ago at 12 weeks gestation. How would the nurse accurately
document this information?
4. In children suspected to have a diagnosis of diabetes, which A) Gravida 4 para 2
one of the following complaints would be most likely to prompt B) Gravida 2 para 1
parents to take their school age child for evaluation? C) Gravida 3 para 1
A) Polyphagia C) Bed wetting D) Gravida 3 para 2
B) Dehydration D) Weight loss
12. A client has been newly diagnosed with hypothyroidism and
5. During an assessment of a client with cardiomyopathy, the will take levothyroxine (Synthroid) 50 mcg/day by mouth. As
nurse finds that the systolic blood pressure has decreased from part of the teaching plan, the nurse emphasizes that this
145 to 110 mm Hg and the heart rate has risen from 72 to 96 medication:
beats per minute and the client complains of periodic dizzy A) Should be taken in the morning
spells. The nurse instructs the client to B) May decrease the client's energy level
A) increase fluids that are high in protein C) Must be stored in a dark container
B) restrict fluids D) Will decrease the client's heart rate
C) force fluids and reassess blood pressure
D) limit fluids to non-caffeine beverages 13. The nurse is performing a neurological assessment on a
client post right cerebral vascular accident (CVA). Which finding,
6. The nurse is speaking at a community meeting about personal if observed by the nurse, would warrant immediate attention?
responsibility for health promotion. A participant asks about A) Decrease in level of consciousness
chiropractic treatment for illnesses. What should be the focus of B) Loss of bladder control
the nurse’s response? C) Altered sensation of stimuli
A) Electrical energy fields D) Emotional lability
B) Spinal column manipulation
C) Mind-body balance 14. What would the nurse expect to see while assessing the
D) Exercise of joints growth of children during their school age years?
A) Decreasing amounts of body fat and muscle mass
7. A client is admitted to the emergency room with renal calculi B) Little change in body appearance from year to year
and is complaining of moderate to severe flank pain and nausea. C) Progressive height increase of 4 inches each year
The client’s temperature is 100.8 degrees Fahrenheit. The D) Yearly weight gain of about 5.5 pounds per year
priority nursing goal for this client is
A) Maintain fluid and electrolyte balance 15. The nurse is caring for a client with a venous stasis ulcer.
B) Control nausea Which nursing intervention would be most effective in
C) Manage pain promoting healing?
D) Prevent urinary tract infection A) Apply dressing using sterile technique
B) Improve the client's nutrition status
8. A nurse prepares to care for a 4 year-old newly admitted for C) Initiate limb compression therapy
rhabdomyosarcoma. The nurse should alert the staff to pay D) Begin proteolytic debridement
more attention to the function of which area of the body?
A) the muscles 16. Which of the following should the nurse implement to
B) the cerebellum prepare a client for a kidney, ureter, bladder (KUB) radiograph
C) the kidneys test?
D) the leg bones A) Client must be NPO before the examination
B) Enema to be administered prior to the examination
9. A triage nurse has these 4 clients arrive in the emergency C) Medicate client with Lasix 20 mg IV 30 minutes prior to the
department within a 15 minute period. Which client should the examination
triage nurse send back to be seen first? D) No special orders are necessary for this examination

A) A 2 month old infant with a history of rolling off the bed and 17. A nurse is to administer meperidine hydrochloride
has bulging fontanels with crying (Demerol) 100 mg, atropine sulfate (Atropisol) 0.4 mg, and
B) A teenager who got a singed beard while camping promethazine hydrochloride (Phenergan) 50 mg IM to a pre-
C) An elderly client with complaints of frequent liquid brown operative client. Which action should the nurse take first?
colored stools A) Raise the side rails on the bed
D) A middle aged client with intermittent pain behind the right B) Place the call bell within reach
scapula C) Instruct the client to remain in bed
D) Have the client empty bladder
18. The home health nurse visits a male client to provide wound D) Prominent "U" waves
care and finds the client lethargic and confused. His partner
states he fell down the stairs 2 hours ago. The nurse should 26. A 3 year-old child comes to the pediatric clinic after the
A) place a call to the client's provider for instructions sudden onset of findings that include irritability, thick muffled
B) send him to the emergency room for evaluation voice, croaking on inspiration, skin hot to touch, sits leaning
C) reassure the client's partner that the symptoms are transient forward, tongue protruding, drooling and suprasternal
D) instruct the client's partner to call the provider if his retractions. What should the nurse do first?
symptoms become worse A) Prepare the child for x-ray of upper airways
B) Examine the child's throat
19. A client comes to the clinic for treatment of recurrent pelvic C) Collect a sputum specimen
inflammatory disease (PID). The nurse recognizes that this D) Notify the healthcare provider of the child's status
condition most frequently follows which type of infection?
A) Trichomoniasis C) Staphylococcus 27. A nurse is evaluating the quality of home care for a client
B) Chlamydia D) Streptococcus with Alzheimer's disease. It would be a priority to reinforce
which statement by a family member?
20. A client has been taking furosemide (Lasix) for the past A) "At least 2 full meals a day should be eaten."
week. The nurse recognizes which finding may indicate the B) "We go to a group discussion every week at our community
client is experiencing a negative side effect from the center."
medication? C) "We have safety bars installed in the bathroom and have 24
A) Weight gain of 5 pounds hour alarms on the doors."
B) Edema of the ankles D) "Taking the medication 3 times a day is not a problem."
C) Gastric irritability
D) Decreased appetite 28. A child who has recently been diagnosed with cystic fibrosis
(CF) is being assessed by a pediatric clinic nurse. Which finding
21. The nurse anticipates that for a family who practices Chinese of this disease would the nurse not expect to see at this time?
medicine the priority therapeutic goal would be to A) Positive sweat test
A) achieve harmony B) Bulky greasy stools
B) maintain a balance of energy C) Moist, productive cough
C) respect life D) Meconium ileus
D) restore yin and yang
29. When teaching a client with coronary artery disease about
22. Which individual is at greatest risk for developing nutrition, the nurse should emphasize
hypertension? A) eating 3 balanced meals a day
A) 45 year-old African American attorney B) adding complex carbohydrates
B) 60 year-old Asian American shop owner C) avoiding very heavy meals
C) 40 year-old Caucasian nurse D) limiting sodium to 7 gms per day
D) 55 year-old Hispanic teacher
30. Which complication of cardiac catheterization should the
23. The hospital has sounded the call for a disaster drill on the nurse monitor for in the initial 24 hours after the procedure?
evening shift. Which of these clients would the nurse put first on A) Angina at rest
the discharge list in order to make room for a new admission? B) Thrombus formation
C) Dizziness
A) A middle aged client with a 7 year history of being ventilator D) Falling blood pressure
dependent and who was admitted with bacterial
pneumonia five days ago 31. Which of these statements best describes the characteristic
B) A young adult with Type 2 diabetes mellitus for over 10 years of an effective reward-feedback system?
and who was admitted with antibiotic-induced A) Specific feedback is given as close to the event as possible
diarrhea 24 hours ago B) Staff are given feedback in equal amounts over time
C) An elderly client with a history of hypertension, C) Positive statements precede a negative statement
hypercholesterolemia and lupus, and who was admitted with D) Performance goals should be higher than what is attainable
Stevens-Johnson syndrome that morning
D) An adolescent with a positive HIV test and who was admitted 32. A child who ingested 15 maximum strength acetaminophen
for acute cellulitis of the lower leg 48 hours ago tablets 45 minutes ago is seen in the emergency department.
Which of these orders should the registered nurse implement
24. A client has a Swan-Ganz catheter in place. The nurse first?
understands that this is intended to measure A) Gastric lavage PRN
A) right heart function B) Antidote N-acetylcysteine (NAC) (Mucomyst) for age per
B) left heart function pharmacy
C) renal tubule function C) Start a Dextrose 5% with 0.33% normal saline IV to keep vein
D) carotid artery function open
D) Activated charcoal per pharmacy
25. The nurse is caring for a client with a serum potassium level
of 3.5 mEq/L. The client is placed on a cardiac monitor and 33. Which of these findings indicate that a pump set to deliver a
receives 40 mEq KCL in 1000 ml of 5% dextrose in water IV. basal rate of 10 ml per hour plus PRN morphine drip for
Which of the following EKG patterns indicates to the nurse that breakthrough pain is not working?
the infusions should be discontinued? A) The client complains of discomfort at the IV insertion site
A) Narrowed QRS complex B) The client states "I just can't get relief from my pain"
B) Shortened "PR" interval C) The level of the drug is 100 ml at 8 AM and is 80 ml at noon
C) Tall peaked T waves D) The level of the drug is 100 ml at 8 AM and is 50 ml at noon
34. A nurse enters a client's room to discover that the client has Q &A Random Selection #6
no pulse or respirations. After calling for help, the first action
the nurse should take is 1. Which of these women in the labor and delivery unit would
A) start a peripheral IV the nurse check first when the water breaks (ROM) for all of
B) initiate closed-chest massage them within a 2 minute period?
C) establish an airway A) A multigravida with station at +2, contractions at 15 minutes
D) obtain the crash cart apart with duration of 30 seconds, cervix dilated at 7
cm, and 50% effacement
35. The nurse is preparing to administer an enteral feeding to a B) A multigravida with station at -1, contractions at 15 minutes
client via a nasogastric feeding tube. The most important action apart with duration of 30 seconds, cervix dilated at 3
of the nurse is to cm, and 10% effacement
A) verify correct placement of the tube C) A primipara with station at 0, contractions at 20 minutes
B) check that the feeding solution matches the dietary order apart with duration of 20 seconds, cervix dilated at 2 cm
C) aspirate abdominal contents to determine the amount of last and 10% effacement
feeding remaining in stomach D) A primipara with station at 1, contractions at 15 minutes
D) ensure that feeding solution is at room temperature apart with duration of 35 seconds, cervix dilated at 5 cm
and 50% effacement
36. A client with multiple sclerosis plans to begin an exercise
program. In addition to discussing the benefits of regular 2. The nurse is caring for an 87 year-old client with urinary
exercise, the nurse should caution the client to avoid activities retention. Which finding should be reported immediately?
which A) Fecal impaction
A) increase the heart rate B) Infrequent voiding
B) lead to dehydration C) Stress incontinence
C) are considered aerobic D) Burning with urination
D) may be competitive
3. A 36 year-old female client has a hemoglobin level of 14 g/dl
37. The nurse practicing in a maternity setting recognizes that and a hematocrit of 42% following a D&C. Which of the
the post mature fetus is at risk due to following would the nurse expect to find when assessing this
A) Excessive fetal weight client?
B) Low blood sugar levels A) Capillary refill less than 3 seconds
C) Depletion of subcutaneous fat B) Pale mucous membranes
D) Progressive placental insufficiency C) Respirations 36 breaths per minute
D) Complaints of fatigue when ambulating
38. At a community health fair the blood pressure of a 62 year- 4. Parents are concerned that their 11 year-old child is a very
old client is 160/96. The client states “My blood pressure is picky eater. The nurse suggests which of the following as the
usually much lower.” The nurse should tell the client to best initial approach?
A) go get a blood pressure check within the next 48 to 72 hours A) Consider a liquid supplement to increase calories
B) check blood pressure again in 2 months B) Discuss consequences of an unbalanced diet with the child
C) see the health care provider immediately C) Provide fruit, vegetable and protein snacks
D) visit the health care provider within 1 week for a BP check D) Encourage the child to keep a daily log of foods eaten

5. The nurse is assessing a pregnant client in her third trimester.

39. The nurse is giving discharge teaching to a client 7 days post The parents are informed that the ultrasound suggests that the
myocardial infarction. He asks the nurse why he must wait 6 baby is small for gestational age (SGA). An earlier ultrasound
weeks before having sexual intercourse. What is the best indicated normal growth. The nurse understands that this
response by the nurse to this question? change is most likely due to what factor?
A) "You need to regain your strength before attempting such A) Sexually transmitted infection
exertion. B) Exposure to teratogens
B) "When you can climb 2 flights of stairs without problems, it is C) Maternal hypertension
generally safe." D) Chromosomal abnormalities
C) "Have a glass of wine to relax you, then you can try to have
sex." 6. An 80 year-old nursing home resident has a temperature of
D) "If you can maintain an active walking program, you will have 101.6 degrees Fahrenheit rectally. This is a sudden change in an
less risk." otherwise healthy client. Which should the nurse assess first?
A) lung sounds C) level of alertness
40. An RN who usually works in a spinal rehabilitation unit is B) urine output D) appetite
floated to the emergency department. Which of these clients
should the charge nurse assign to this RN? 7. While giving care to a 2 year-old client, the nurse should
A) A middle-aged client who says "I took too many diet pills" remember that the toddler's tendency to say "no" to almost
and "my heart feels like it is racing out of my chest." everything is an indication of what psychosocial skill?
B) A young adult who says "I hear songs from heaven. I need
money for beer. I quit drinking 2 days ago for my family. A) Stubborn behavior C) Frustration with
Why are my arms and legs jerking?" adults
C) An adolescent who has been on pain medications for B) Rejection of parents D) Assertion of control
terminal cancer with an initial assessment finding of pinpoint
pupils and a relaxed respiratory rate of 10 8. The nurse is caring for a client suspected to have Tuberculosis
D) An elderly client who reports having taken a "large crack hit" (TB). Which of the following diagnostic tests is essential for
10 minutes prior to walking into the emergency room determining the presence of active TB?
A) Tuberculin skin testing 16. The recent increase in the reported cases of active
B) Sputum culture tuberculosis (TB) in the United States is attributed to which
C) White blood cell count factor?
D) Chest x-ray A) The increased homeless population in major cities
9. For which of the following mother-baby pairs should the B) The rise in reported cases of positive HIV infections
nurse review the Coombs' test in preparation for administering C) The migration patterns of people from foreign countries
Rho (D) immune globulin within 72 hours of birth? D) The aging of the population located in group homes
A) Rh negative mother with Rh positive baby 17. The nasogastric tube of a post-op gastrectomy client has
B) Rh negative mother with Rh negative baby stopped draining greenish liquid. The nurse should
C) Rh positive mother with Rh positive baby A) irrigate it as ordered with distilled water
D) Rh positive mother with Rh negative baby B) irrigate it as ordered with normal saline
C) place the end of the tube in water to see if the water bubbles
10. An unlicensed assistive staff member asks the nurse D) withdraw the tube several inches and reposition it
manager to explain the beliefs of a Christian Scientist who
refuses admission to the hospital after a motor vehicle accident. 18. A client arrived in the USA from a developing country 1
The best response of the nurse would be which of these week ago. The client is to be admitted to the medical surgical
statements? unit with a diagnosis of AIDS. There is a history of these findings:
A) "Spiritual healing is emphasized and the mind contributes to unintended weight loss, drug abuse, night sweats, productive
the cure." cough and a "feeling of being hot all the time." The nurse should
B) "The primary belief is that dietary practices result in health or assign the client to share a room with a client with the diagnosis
illness." of
C) "Fasting and prayer are initial actions to take in physical A) Acute tuberculosis with a productive cough of discolored
injury." sputum for over three months
D) "Meditation is intensive in the initial 48 hours and daily B) Lupus and vesicles on one side of the middle trunk from the
thereafter." back to the abdomen
C) Pseudomembranous colitis and C. difficile
11. The nurse has been teaching an apprehensive primipara D) Exacerbation of polyarthritis with severe pain
who has had initial difficulty in nursing the newborn. What
observation at the time of discharge suggests that initial breast 19. A 15 month-old child comes to the clinic for a follow-up visit
feeding is effective? after hospitalization for treatment of Kawasaki Disease. The
A) The mother feels calmer and talks to the baby while nursing nurse recognizes that which of the following scheduled
B) The mother awakens the newborn to feed whenever it falls immunizations will be delayed?
asleep A) MMR
C) The newborn falls asleep after 3 minutes at the breast B) Hib
D) The newborn refuses the supplemental bottle of glucose C) IPV
water D) DTaP

12. The nurse is caring for a client with congestive heart failure. 20. What is the major purpose of community health research?
Which finding requires the nurse's immediate attention? A) Describe the health conditions of populations
A) pulse oximetry of 85% B) Evaluate illness in the community
B) nocturia C) Explain the health conditions of families
C) crackles in lungs D) Identify the health conditions of the environment
D) diaphoresis
21. The nurse is taking a health history from a Native American
13. The nurse is taking a health history from parents of a child client. It is critical that the nurse must remember that eye
admitted with possible Reye's syndrome. Which recent illness contact with such clients is considered
would the nurse recognize as increasing the risk to develop A) Expected
Reye's syndrome? B) Rude
A) rubeola C) Professional
B) meningitis D) Enjoyable
C) varicella
D) hepatitis 22. The nurse discovers that the parents of a 2 year-old child
continue to use an apnea monitor each night. The parents state:
14. The nurse is caring for a client with end-stage heart failure. “We are concerned about the possible occurrence of sudden
The family members are distressed about the client's impending infant death syndrome (SIDS).” In order to take appropriate
death. What action should the nurse do first? action, the nurse must understand that
A) Explain the stages of death and dying to the family A) The child is within the age group most susceptible to SIDS
B) Recommend an easy-to-read book on grief B) The peak age for occurrence of SIDS is 8 to 12 months of age
C) Assess the family's patterns for dealing with death C) The apnea monitor is not effective on a child in this age group
D) Ask about their religious affiliations D) 95% of SIDS cases occur before 6 months of age

15. The nurse is teaching a mother who will breast feed for the 23. The parents of a child who has recently been diagnosed with
first time. Which of the following is a priority? asthma ask the nurse to explain the condition to them. The best
A) Show her films on the physiology of lactation response is "Asthma causes
B) Give the client several illustrated pamphlets A) the airway to become narrow and obstructs airflow."
C) Assist her to position the newborn at the breast B) air to be trapped in the lungs because the airways are
D) Give her privacy for the initial feeding dilated."
C) the nerves that control respiration to become hyperactive."
D) a decrease in the stress hormones which prevents the A) A middle aged woman with asthma and Type 1 diabetes
airways from opening." mellitus has a BP of 150/94
B) A middle aged woman with a history of two prior vaginal
24. When teaching parents about sickle cell disease, the nurse term births is 2 cm dilated
should tell them that their child's anemia is caused by C) A young woman who is a grand multipara has cervical dilation
A) Reduced oxygen capacity of cells due to lack of iron of 4 cm and is 50% effaced
B) An imbalance between red cell destruction and production D) An adolescent who is 18 weeks pregnant has a report of no
C) Depression of red and white cells and platelets fetal heart tones and coughing up frothy sputum
D) Inability of sickle shaped cells to regenerate
33. The nurse is assessing a child with suspected lead poisoning.
25. An adolescent client is admitted in respiratory alkalosis Which of the following assessments is the nurse most likely to
following aspirin overdose. The nurse recognizes that this find?
imbalance was caused by A) Complaints of numbness and tingling in feet
A) tachypnea B) Wheezing noted when lung sound auscultated
B) acidic byproducts C) Excessive perspiration
C) vomiting and dehydration D) Difficulty sleeping
D) hyperpyrexia
34. The nurse is attending a workshop about caring for persons
26. A nurse is teaching a class for new parents at a local infected with hepatitis. Which characteristic is most appropriate
community center. The nurse would stress that _______ is most when defining the incidence rate of hepatitis?
hazardous for an 8 month-old child. A) The number of persons in a population who develop hepatitis
A) riding in a car B during a specific period of time
B) falling off a bed B) The total number of persons in a population who have
C) an electrical outlet hepatitis B at a particular time
D) eating peanuts C) The percentage of deaths resulting from hepatitis B during a
specific time
27. The mother of a burned child asks the nurse to clarify what D) The occurrence of hepatitis B in the population at a particular
is meant by a third degree burn. The best response by the nurse time
is
A) "The top layer of the skin is destroyed." 35. The nurse is providing home care for a client with heart
B) "The skin layers are swollen and reddened." failure and pulmonary edema. Which nursing diagnosis should
C) "All layers of the skin were destroyed in the burn." have priority in planning care?
D) "Muscle, tissue and bone have been injured." A) Impaired skin integrity related to dependent edema
B) Activity intolerance related to oxygen supply and demand
8. The nurse is providing diet instruction to the parents of a imbalance
child with cystic fibrosis. The nurse would emphasize that the C) Constipation related to immobility
diet should be high D) Risk for infection related to ineffective mobilization of
A) calorie, low fat, low sodium secretions
B) protein, low fat, low carbohydrate
C) protein, high calorie, unrestricted fat 36. The nurse is assessing a newborn delivered at home by a
D) carbohydrate, low protein, moderate fat client addicted to heroin. Which of the following would the
nurse expect to observe?
29. The nurse is assessing a young child at a clinic visit for a mild A) Hypertonic neuro reflex
respiratory infection. Koplik spots are noted on the oral mucous B) Immediate CNS depression
membranes. The nurse should then assess which area of the C) Lethargy and sleepiness
body? D) Jitteriness at 24-48 hours
A) the skin
B) the lungs 37. Which action is most likely to ensure the safety of the nurse
C) the muscles while making a home visit?
D) bowel and bladder A) Observe no evidence of weapons in the home during the visit
B) Prior to the visit, review the client's record for any previous
30. A client's admission urinalysis shows the specific gravity entries about violence
value of 1.039. Which of the following assessment data would C) Remain alert at all times and leave if cues suggest the home is
the nurse expect to find when assessing this client? not safe
A) Moist mucous membranes D) Carry a cell phone, pager and/or hand held alarm for
B) Urinary frequency emergencies
C) Poor skin turgor
D) Increased blood pressure 38. As a client is being discharged following resolution of a
spontaneous pneumothorax, he tells the nurse that he is now
31. The nurse is caring for a client with Meniere's disease. When going to Hawaii for a vacation. The nurse would warn him to
teaching the client about the disease, the nurse should explain avoid
that the client should avoid foods high in A) surfing
A) calcium B) scuba diving
B) fiber C) parasailing
C) sodium D) swimming
D) carbohydrate
39. In order to be effective in administering cardiopulmonary
32. After the shift report in a labor and delivery unit which of resuscitation to a 5 year-old, the nurse must
these clients would the nurse check first? A) assess the brachial pulses
B) breathe once every 5 compressions D) Ask the health care provider to change the regimen to fewer
C) use both hands to apply chest pressure medications
D) compress 80-90 times per minute
40. A postpartum client admits to alcohol use throughout the 7. A client has been taking alprazolam (Xanax) for 3 days.
pregnancy. Which of the following newborn findings suggests to Nursing assessment should reveal which expected effect of the
the nurse that the infant has fetal alcohol syndrome? drug?
A) Growth retardation is evident A) Tranquilization, numbing of emotions
B) Multiple anomalies are identified B) Sedation, analgesia
C) Cranial facial abnormalities are noted C) Relief of insomnia and phobias
D) Prune belly syndrome is suspected D) Diminished tachycardia and tremors associated with anxiety

Q&A Random Selection #7

8. A woman who delivered 5 days ago and had been diagnosed
1. A nursing student asks the nurse manager to explain the with pregnancy induced hypertension (PIH) calls the hospital
forces that drive health care reform. The appropriate response triage nurse hotline to ask for advice. She states, “I have had the
by the nurse manager should include worst headache for the past 2 days. It pounds and by the middle
A) The escalation of fees with a decreased reimbursement of the afternoon everything I look at looks wavy. Nothing I have
percentage taken helps.” What should the nurse do next?
B) High costs of diagnostic and end-of-life treatment procedures
C) Increased numbers of elderly and of the chronically ill of all A) Advise the client that the swings in her hormones may have
ages that effect. However, suggest for her to call her
D) A steep rise in provider fees and in insurance premiums provider within the next day.
B) Advise the client to have someone bring her to the
2. The nurse manager identifies that time spent by staff in emergency room as soon as possible.
charting is excessive, requiring overtime for completion. The C) Ask the client to stay on the line, get the address and send an
nurse manager states that "staff will form a task force to ambulance to the home.
investigate and develop potential solutions to the problem, and D) Ask what the client has taken? How often? Ask about other
report on this at the next staff meeting." The nurse manager's specific complaints.
leadership style is best described as
A) Laissez-faire 9. A client on warfarin therapy following coronary artery stent
B) Autocratic placement calls the clinic to ask if he can take Alka-Seltzer for an
C) Participative upset stomach. What is the best response by the nurse?
D) Group A) Avoid Alka-Seltzer because it contains aspirin
B) Take Alka-Seltzer at a different time of day than the warfarin
3. The nurse is working with parents to plan home care for a 2 C) Select another antacid that does not inactivate warfarin
year-old with a heart problem. A priority nursing intervention D) Use on-half the recommended dose of Alka-Seltzer
would be to
A) encourage the parents to enroll in cardiopulmonary 10. The nurse notes an abrupt onset of confusion in an elderly
resuscitation (CPR) class patient. Which of the following recently-ordered medications
B) assist the parents to plan quiet play activities at home would most likely contribute to this change?
C) stress to the parents that they will need relief care givers A) Anticoagulant
D) instruct the parents to avoid contact with persons with B) Liquid antacid
infection C) Antihistamine
D) Cardiac glycoside
4. Which of these clients would the triage nurse request the
provider examine immediately? 11. The nurse is teaching a 27 year-old client with asthma about
A) A 5 month-old infant who has audible wheezing and grunting their therapeutic regime. Which statement would indicate the
B) An adolescent who has soot over the face and shirt need for additional instruction?
C) A middle-aged man with second degree burns over the right A) "I should monitor my peak flow every day."
hand B) "I should contact the clinic if I am using my medication more
D) A toddler with singed ends of long hair that extends to the often."
waist C) "I need to limit my exercise, especially activities such as
walking and running."
5. The nurse is caring for a client with Rheumatoid Arthritis. D) "I should learn stress reduction and relaxation techniques."
Which nursing diagnosis should receive priority in the plan of
care? 12. In assessing a post partum client, the nurse palpates a firm
A) Risk for injury fundus and observes a constant trickle of bright red blood from
B) Self care deficit the vagina. What is the most likely cause of these findings?
C) Alteration in comfort A) Uterine atony
D) Alteration in mobility B) Genital lacerations
C) Retained placenta
6. The nurse is caring for a client with active tuberculosis who D) Clotting disorder
has a history of noncompliance. Which of the following actions
by the nurse would represent appropriate care for this client? 13. The nurse is caring for a 75 year old client in congestive
A) Instruct the client to wear a high efficiency particulate air heart failure. Which finding suggests that digitalis levels should
mask in public places. be reviewed?
B) Ask a family member to supervise daily compliance A) Extreme fatigue
C) Schedule weekly clinic visits for the client B) Increased appetite
C) Intense itching 22. While caring for a child with Reye's syndrome, the nurse
D) Constipation should give which action the highest priority?
A) monitor intake and output
14. The nurse is teaching a client with atrial fibrillation about the B) provide good skin care
use of Coumadin (warfarin) at home. The need to avoid which of C) assess level of consciousness
these should be emphasized to the client? D) assist with range of motion
A) Large indoor gatherings
B) Exposure to sunlight 23. A 70 year-old post-operative client has elevated serum BUN,
C) Active physical exercise HCT, Cl, and Na+. Creatinine and K+ are within normal limits.
D) Foods rich in vitamin K The nurse should perform additional assessments to confirm
that an actual problem is:
A) Impaired gas exchange
B) Metabolic acidosis
15. A nurse who is a native English speaker admits an elderly C) Renal insufficiency
Mexican-American migrant worker after an accident that D) Fluid volume deficit
occurred during work. To facilitate communication the nurse
should initially 24. A 67 year-old client with non-insulin dependent diabetes
A) Request a Spanish interpreter should be instructed to contact the out-patient clinic
B) Speak through the family or co-workers immediately if the following findings are present
C) Use pictures, letter boards, or monitoring A) Temperature of 99.5 degrees Fahrenheit with painful
D) Assess the client's ability to speak English urination
B) An open, reddened wound on the heel
16. To prevent keratitis in an unconscious client, the nurse C) Insomnia and daytime fatigue
should apply moisturizing ointment to the D) Nausea with 2 episodes of vomiting
A) finger and toenail quicks
B) eyes 25. A confused client has been placed in physical restraints by
C) perianal area order of the provider. Which task could be assigned to an
D) external ear canals unlicensed assistive personnel (UAP)?
A) Assist the client with activities of daily living
17. The nurse is caring for a 5 year-old child whose left leg is in B) Monitor the clients physical safety
skeletal traction. Which of the following activities would be an C) Evaluate for basic comfort needs
appropriate diversional activity? D) Document mental status and muscle strength
A) Kicking balloons with right leg
B) Playing "Simon Says" 26. The nurse is providing foot care instructions to a client with
C) Playing hand held games arterial insufficiency. The nurse would identify the need for
D) Throw bean bags additional teaching if the client stated
A) "I can only wear cotton socks."
18. The nurse is teaching a group of adults about modifiable B) "I cannot go barefoot around my house."
cardiac risk factors. Which of the following should the nurse C) "I will trim corns and calluses regularly."
focus on first? D) "I should ask a family member to inspect my feet daily."
A) Weight reduction C) Physical exercise
B) Stress management D) Smoking cessation 27. A client is scheduled to have a blood test for cholesterol and
triglycerides the next day. The nurse would tell the client
19. The nurse is assessing a client with portal hypertension. A) "Be sure and eat a fat-free diet until the test."
Which of the following findings would the nurse expect? B) "Do not eat or drink anything but water for 12 hours before
A) Expiratory wheezes the blood test."
B) Blurred vision C) "Have the blood drawn within 2 hours of eating breakfast."
C) Ascites D) "Stay at the laboratory so 2 blood samples can be drawn an
D) Dilated pupils hour apart."

20. The nurse is caring for an acutely ill 10 year-old client. Which 28. A client who is terminally ill has been receiving high doses of
of the following assessment findings would require the nurses an opioid analgesic for the past month. As death approaches
immediate attention? and the client becomes unresponsive to verbal stimuli, what
A) Rapid bounding pulse orders would the nurse expect from the health care provider?
B) Temperature of 101.3 degrees Fahrenheit (38.5 degrees A) Decrease the analgesic dosage by half
Celsius) B) Discontinue the analgesic
C) Profuse diaphoresis C) Continue the same analgesic dosage
D) Slow, irregular respirations D) Prescribe a less potent drug

21. A parent tells the nurse that their 6 year-old child who 29. The nurse is caring for a child with cystic fibrosis. The nurse
normally enjoys school, has not been doing well since the would anticipate that the child would be deficient in which
grandmother died 2 months ago. Which statement most vitamins?
accurately describes thoughts on death and dying at this age? A) B, D, and K
A) Death is personified as the bogeyman or devil B) A, D, and K
B) Death is perceived as being irreversible C) A, C, and D
C) The child feels guilty for the grandmother's death D) A, B, and C
D) The child is worried that he, too, might die
30. A child is diagnosed with poison ivy. The mother tells the
nurse that she does not know how her child contracted the rash
since he had not been playing in wooded areas. As the nurse D) "Let’s move to the ‘what if…’ as related to these objections
asks questions about possible contact, which of the following and explore spin off ideas."
would the nurse recognize as highest risk for exposure?
A) Playing with toys in a back yard flower garden 38. A pre-term baby develops nasal flaring, cyanosis and
B) Eating small amounts of grass while playing "farm" diminished breath sounds on one side. The provider's diagnosis
C) Playing with cars on the pavement near burning leaves is spontaneous pneumothorax. Which procedure should the
D) Throwing a ball to a neighborhood child who has poison ivy nurse prepare for first?
A) Cardiopulmonary resuscitation
31. The nurse observes a staff member caring for a client with a B) Insertion of a chest tube
left unilateral mastectomy. The nurse would intervene if she C) Oxygen therapy
notices the staff member is D) Assisted ventilation
A) advising client to restrict sodium intake
B) taking the blood pressure in the left arm 39. A newborn presents with a pronounced cephalhematoma
C) elevating her left arm above heart level following a birth in the posterior position. Which nursing
D) compressing the drainage device diagnosis should guide the plan of care?
A) Pain related to periosteal injury
32. The nurse has identified what appears to be ventricular B) Impaired mobility related to bleeding
tachycardia on the cardiac monitor of a client being evaluated C) Parental anxiety related to knowledge deficit
for possible myocardial infarction. The first action the nurse D) Injury related to intracranial hemorrhage
would perform is to
A) begin cardiopulmonary resuscitation 40. A nurse caring for premature newborns in an intensive care
B) prepare for immediate defibrillation setting carefully monitors oxygen concentration. What is the
C) notify the "Code" team and provider most common complication of this therapy?
D) assess airway breathing and circulation A) Intraventricular hemorrhage
B) Retinopathy of prematurity
33. The primary teaching for a client following an extracorporeal C) Bronchial pulmonary dysplasia
shock-wave lithotripsy (ESWL) procedure is D) Necrotizing enterocolitis
A) "Drink 3000 to 4000 cc of fluid each day for one month."
B) "Limit fluid intake to 1000 cc each day for one month." Q&A Random Selection #8
C) "Increase intake of citrus fruits to three servings per day."
D) "Restrict milk and dairy products for one month." 1. While assessing an Rh positive newborn whose mother is Rh
negative, the nurse recognizes the risk for hyperbilirubinemia.
34. An infant has just returned from surgery for placement of a Which of the following should be reported immediately?
gastrostomy tube as an initial treatment for tracheoesophageal A) Jaundice evident at 26 hours
fistula. The mother asks: ”When can the tube can be used for B) Hematocrit of 55%
feeding?” The nurse's best response would be which of these C) Serum bilirubin of 12mg
comments? D) Positive Coombs' test
A) "Feedings can begin in 5 to 7 days."
B) "The feeding tube can be used immediately." 2. A young adult male has been diagnosed with testicular
C) "The stomach contents and air must be drained first." cancer. Which of these statements by this client would need to
D) "Healing of the incision must be complete before feeding." be explored by the nurse to clarify his understanding?
A) "This surgical procedure involves removing one or both
35. The community health nurse has been caring for an testicles through a cut in the groin. My lymph nodes in
adolescent with a history of morbid obesity, asthma, and my lower belly also may be removed."
hypertension, and is 22 weeks pregnant. Which of these lab B) "I have a good chance to regain my fertility later. However if I
reports need to be called to the teen’s provider within the next am concerned, I can have my sperm frozen and
hour? preserved (cryopreserved) before chemotherapy."
A) hemoglobin 11 g/L and calcium 6 mg/dl C) "If I have cancer at stage 3 it means I have less involvement
B) magnesium 0.8 mEq/L and creatinine 3 mg/dl of the cancer."
C) blood urea nitrogen 28 and glucose 225 mg/dl D) "After the surgical removal of a testicle, I can have an
D) hematocrit 33% and platelets 200,000 artificial testicle (prosthesis) placed inside my scrotum. This
artificial implant has the weight and feel of a normal testicle."
36. A client with hepatitis A (HAV) is newly admitted to the unit.
Which action would be the priority to include in this client’s 3. During the beginning shift assessment of a client with asthma
plan of care within the initial 24 hours? who is receiving oxygen per nasal cannula at 2 liters per minute,
A) Wear masks with shields if there is potential for fluid splash the nurse would be most concerned about which unreported
B) Use disposable utensils and plates for meals finding?
C) Wear gown and gloves during client contact A) Pulse oximetry reading of 89%
D) Provide soft easily digested food with frequent snacks B) Crackles at the base of the lungs on auscultation
C) Rapid shallow respirations with intermittent wheezes
37. A nurse manager is using the technique of brainstorming to D) Excessive thirst with a dry cracked tongue
help solve a problem. One nurse criticizes another nurse’s
contribution and begins to find objections to the suggestion. 4. A Hispanic client confides in the nurse that she is concerned
The nurse manager's best response is: that staff may give her newborn the "evil eye." The nurse should
A) "Let’s move on to a new action that deals with the problem." communicate to other personnel that the appropriate approach
B) "I think you need to reserve judgment until after all is to
suggestions are offered." A) touch the baby after looking at him
C) "Very well thought out. Your analytic skills and interest are B) talk very slowly while speaking to him
incredible." C) avoid touching the child
D) look only at the parents C) Muscle spasm and a bent over posture
D) Intention tremor and jerky movement of the elbows
5. The nurse is caring for a client on mechanical ventilation.
When performing endotracheal suctioning, the nurse will avoid 12. During the care of a client with Legionnaire's disease, which
hypoxia by finding would require the nurse's immediate attention?
A) inserting a fenestrated catheter with a whistle tip without A) Pleuritic pain on inspiration
suction B) Dry mucus membranes in the mouth
B) completing suction pass in 30 seconds with pressure of 150 C) A decrease in respiratory rate from 34 to 24
mm Hg D) Decrease in chest wall expansion
C) hyperoxygenation with 100% O2 for 1 to 2 minutes before
and after each suction pass 13. Which finding would be the most characteristic of an acute
D) minimizing suction pass to 60 seconds while slowly rotating episode of reactive airway disease?
the lubricated catheter A) auditory gurgling
B) inspiratory laryngeal stridor
C) auditory expiratory wheezing
D) frequent dry coughing

6. A client is admitted for COPD. Which findings would require 14. The school nurse is called to the playground for an episode
the nurse's immediate attention? of mouth trauma. The nurse finds that the front tooth of a 9
A) Nausea and vomiting year old child has been avulsed ("knocked out"). After
B) Restlessness and confusion recovering the tooth, the initial response should be to
C) Low-grade fever and cough A) rinse the tooth in water before placing it in the socket
D) Irritating cough and liquefied sputum B) place the tooth in a clean plastic bag for transport to the
dentist
7. A hospitalized child suddenly has a seizure while his family is C) hold the tooth by the roots until reaching the emergency
visiting. The nurse notes whole body rigidity followed by general room
jerking movements. The child vomits immediately after the D) ask the child to replace the tooth even if the bleeding
seizure. A priority nursing diagnosis for the child is continues
A) high risk for infection related to vomiting
B) altered family processes related to chronic illness 15. At a routine health assessment, a client tells the nurse that
C) fluid volume deficit related to vomiting she is planning a pregnancy in the near future. She asks about
D) risk for aspiration related to loss of consciousness preconception diet changes. Which of the statements made by
the nurse is best?
8. A 6 month-old infant who is being treated for developmental A) "Include fibers in your daily diet."
dysplasia of the hip has been placed in a hip spica cast. The B) "Increase green leafy vegetable intake."
nurse should teach the parents to C) "Drink a glass of milk with each meal."
A) gently rub the skin with a cotton swab to relieve itching D) "Eat at least 1 serving of fish weekly."
B) place the favorite books and push-pull toys in the crib
C) check every few hours for the next day or 2 for swelling in the 16. A 67 year-old client is admitted with substernal chest pain
baby's feet with that radiates to the jaw. The admitting diagnosis is acute
D) turn the baby with the abduction stabilizer bar every 2 hours myocardial infraction (MI). The priority nursing diagnosis for
this client during the first 24 hours is
9. The nurse is teaching a client with cardiac disease about the A) constipation related to immobility
anatomy and physiology of the heart. Which is the correct B) high risk for infection
pathway of blood flow through the heart? C) impaired gas exchange
A) Right ventricle, left ventricle, right atrium, left atrium D) fluid volume deficit
B) Left ventricle, right ventricle, left atrium, right atrium
C) Right atrium, right ventricle, left atrium, left ventricle 17. The nurse is caring for a client with status epilepticus. The
D) Right atrium, left atrium, right ventricle, left ventricle most important nursing assessment(s) of this client is/are
A) intravenous drip rate
10. Which of these tests would the nurse expect to monitor for B) level of consciousness
the evaluation of clients aged 18 and older with poor glycemic C) pulse and respiration
control? D) injuries to the extremities
A) A glycosylated hemoglobin (A1c) should be performed during
an initial assessment and during follow-up 18. Which tasks, if delegated by the new charge nurse to a
assessments, which should occur at no longer than 3-month unlicensed assistive personnel (UAP), would require
intervals intervention by the nurse manager?
B) A glycosylated hemoglobin is to be obtained at least twice a A) To help an elderly client to the bathroom
year B) To empty a Foley catheter bag
C) A fasting glucose and a glycosylated hemoglobin is to be C) To bathe a woman with internal radon seeds
obtained at 3 months intervals after the initial assessment D) To feed a 2 year-old with a broken arm
D) A glucose tolerance test, a fasting glucose and a glycosylated
hemoglobin should be obtained at 6-monthintervals 19. The nurse is assessing a newborn the day after birth. A high
after the initial assessment pitched cry, irritability and lack of interest in feeding are noted.
The mother signed her own discharge against medical advice.
11. The nurse is assigned to a client with Parkinson's disease. What intervention is appropriate nursing care?
Which findings would the nurse anticipate? A) Reduce the environmental stimuli
A) Non-intention tremors and urgency with voiding B) Offer formula every 2 hours
B) Echolalia and a shuffling gait C) Talk to the newborn while feeding
D) Rock the baby frequently C) "Compression of porous bones produces a buckle or torus
type break."
20. An 82 year-old client is prescribed eye drops for treatment D) "Bone fragments often remain attached by a periosteal
of glaucoma. What assessment is needed before the nurse hinge."
begins teaching proper administration of the medication?
A) Determine third party payment plan for this treatment 26. While caring for a client with infective endocarditis, the
B) The client’s manual dexterity nurse must be alert for signs of pulmonary embolism. Which of
C) Proximity to health care services the following assessment findings suggests this complication?
D) Ability to use visual assistive devices A) Positive Homan's sign
B) Fever and chills
21. A child and his family were exposed to Mycobacterium C) Dyspnea and cough
tuberculosis about 2 months ago, to confirm the presence or D) Sensory impairment
absence of an infection, it is most important for all family
members to have a 27. The nurse uses the DRG (Diagnosis Related Group) manual
A) chest x-ray to
B) blood culture A) classify nursing diagnoses from the client's health history
C) sputum culture B) identify findings related to a medical diagnosis
D) PPD intradermal test C) determine reimbursement for a medical diagnosis
D) implement nursing care based on case management protocol
22. A client comes into the community health center upset and
crying stating “I will die of cancer now that I have this disease.” 28. The nurse would teach a client with Raynaud's phenomenon
And then the client hands the nurse a paper with one word that, after smoking cessation, it is most important to
written on it: "Pheochromocytoma." Which response should the A) avoid caffeine C) reduce stress
nurse state initially? B) keep feet dry D) wear gloves
A) "Pheochromocytomas usually aren't cancerous (malignant).
But they may be associated with cancerous tumors in 29. A client returned from surgery for a perforated appendix
other endocrine glands such as the thyroid (medullary with localized peritonitis. In view of this diagnosis, how would
carcinoma of the thyroid)" the nurse position the client?
B) This problem is diagnosed by blood and urine tests that A) Prone C) Semi-Fowler
reveal elevated levels of adrenaline and noradrenaline B) Dorsal recumbent D) Supine
C) "Computerized tomography (CT) or magnetic resonance
imaging (MRI) are used to detect an adrenal tumor"
D) "You probably have had episodes of sweating, heart 30. A 4 month-old child taking digoxin (Lanoxin) has a blood
pounding and headaches" pressure of 92/78; resting pulse of 78 BPM; respirations 28 and
a potassium level of 4.8 mEq/L. The client is irritable and has
23. On admission to the hospital a client with an acute asthma vomited twice since the morning dose of digoxin. Which finding
episode has intermittent nonproductive coughing and a pulse is most indicative of digoxin toxicity?
oximeter reading of 88%. The client states, “I feel like this is A) Bradycardia C) Irritability
going to be a bad time this admission. I wish I would not have B) Lethargy D) Vomiting
gone into that bar with all those people who smoke last night.”
Which nursing diagnoses would be most important for this 31. The hospital is planning to downsize and eliminate a number
client? of staff positions as a cost-saving measure. To assist staff in this
A) Anxiety related to hospitalization change process, the nurse manager is preparing for the
B) Ineffective airway clearance related to potential thick "unfreezing" phase of change. With this approach the nurse
secretions manager should:
C) Altered health maintenance related to preventative A) discuss with the staff how to deal with any defensive
behaviors associated with asthma behavior
D) Impaired gas exchange related to bronchoconstriction and B) explain to the unit staff why change is necessary
mucosal edema C) assist the staff during the acceptance of the new changes
D) clarify what the changes mean to the community and
24. A newly appointed nurse manager is having difficulties with hospital
time management. Which advice from an experienced manager
should the new manager implement initially? 32. Which of these statements by the nurse is incorrect if the
A) Set daily goals and establish priorities for each hour and each nurse has the goal to reinforce information about cancers to a
day. group of young adults?
B) Ask for additional assistance when you feel overwhelmed. A) "You can reduce your risk of this serious type of stomach
C) Keep a time log of your day in hourly blocks for at least 1 cancer by eating lots of fruits and vegetables, limiting
week. all meat, and avoiding nitrate-containing foods."
D) Complete each task before beginning another activity in B) "Prostate cancer is the most common cancer in American
selected instances. men with results to threaten sexuality and life."
C) "Colorectal cancer is the second-leading cause of cancer-
25. The nurse is caring for a 4 year-old child with a greenstick related deaths in the United States."
fracture. In explaining this type of fracture to the parents, the D) "Lung cancer is the leading cause of cancer deaths in the
best statement by the nurse should be that, United States. Yet it's the most preventable of all
A) "A child's bone is more flexible and can be bent 45 degrees cancers."
before breaking."
B) "Bones of children are more porous than adults’ and often 33. The nurse and a student nurse are discussing the specific
have incomplete breaks." points about infants born to HBsAg-positive mothers. Which of
these comments by the student indicates a need for clarification A) "I may experience seizures if I stop the medication abruptly."
of information? B) "I may experience an increase in my heart rate for a few
A) "The infant will get the hepatitis B vaccine and the hepatitis B weeks."
immune globulin within 12 hours at birth at separate C) ”I can expect to feel nervousness the first few weeks."
injection sites." D) “I can have a heart attack if I stop this medication suddenly."
B) "The second dose can be given at 1 to 2 months of age."
C) "The third dose should be given at least 16 weeks from the Q&A Random Selection #9
second dose."
D) "The last dose in the series is not to be given before age 24 1. The nurse is teaching a client about the healthy use of ego
weeks." defense mechanisms. An appropriate goal for this client would
be
34. A female client diagnosed with genital herpes simplex virus A) Reduce fear and protect self-esteem
2 (HSV 2) complains of dysuria, dyspareunia, leukorrhea and B) Minimize anxiety and delay apprehension
lesions on the labia and perianal skin. A primary nursing action C) Avoid conflict and leave unpleasant situations
with the focus of comfort should be to D) Increase independence and communicate more often
A) suggest 3 to 4 warm sitz baths per day
B) cleanse the genitalia twice a day with soap and water 2. A child with tetralogy of Fallot visits the clinic several weeks
C) spray warm water over genitalia after urination before planned surgery. The nurse should give priority
D) apply heat or cold to lesions as desired attention to
A) assessment of oxygenation
35. The nurse manager has a nurse employee who is suspected B) observation for developmental delays
of a problem with chemical dependency. Which intervention C) prevention of infection
would be the best approach by the nurse manager? D) maintenance of adequate nutrition
A) Confront the nurse about the suspicions in a private meeting
B) Schedule a staff conference, without the nurse present, to 3. The registered nurse (RN) is planning care at a team meeting
collect information for a 2 month-old child in bilateral leg casts for congenital
C) Consult the human resources department about the issue clubfoot. Which of these outcomes suggested by the practical
and needed actions nurse (PN) should be considered the priority nursing goal
D) Counsel the employee to resign to avoid investigation following cast application?
36. A client has been admitted for meningitis. In reviewing the A) The infant will experience minimal pain
laboratory analysis of cerebrospinal fluid (CSF), the nurse would B) Muscle spasms will be relieved
expect to note C) Mobility will be managed as tolerated
A) high protein C) elevated sed rate D) Tissue perfusion will be maintained
B) clear color D) increased glucose
4. At a nursing staff meeting, there is discussion of perceived
37. A client with chronic congestive heart failure should be inequities in weekend staff assignments. As a follow-up, the
instructed to contact the home health nurse if which finding nurse manager should initially
occurs? A) Allow the staff to change assignments
A) Weight gain of 2 pounds or more in a 48 hour period B) Clarify reasons for current assignments
B) Urinating 4 to 5 times each day C) Help staff see the complexity of issues
C) A significant decrease in appetite D) Facilitate creative thinking on staffing
D) Appearance of non-pitting ankle edema
5. A client is admitted with a distended bladder due to the
38. A 74 year-old male is admitted due to inability to void. He inability to void. The nurse obtains an order to catheterize the
has a history of an enlarged prostate and has not voided in 14 client, and is aware that gradual emptying is preferred over
hours. When assessing for bladder distention, the best method complete emptying because it reduces the
for the nurse to use is to assess for A) potential for renal collapse
A) rebound tenderness B) potential for shock
B) left lower quadrant dullness C) intensity of bladder spasms
C) rounded swelling above the pubis D) chance of bladder atrophy
D) urinary discharge
6. The nurse is assessing a 12 year-old who has hemophilia A.
39. With an alert of an internal disaster and the need for beds, Which finding would the nurse anticipate?
the charge nurse is asked to list clients who are potential A) An excess of red blood cells
discharges within the next hour. Which client should the charge B) An excess of white blood cells
nurse select? C) A deficiency of clotting factor VIII
A) An elderly client who has had type 2 diabetes for over 20 D) A deficiency of clotting factors VIII and IX
years, admitted with diabetic ketoacidosis 24 hours ago
B) An adolescent admitted the prior night with Tylenol 7. The nurse is caring for a client with left ventricular heart
intoxication failure. Which one of the following assessments is an early
C) A middle-aged client with an internal automatic defibrillator indication of inadequate oxygen transport?
and complaints of “passing out at unknown times” A) crackles in the lungs
admitted yesterday B) confusion and restlessness
D) A school-aged child diagnosed with suspected bacterial C) distended neck veins
meningitis and was admitted at the change of shifts D) use of accessory muscles

40. Which one of the following statements, if made by the 8. A 6 year-old female is diagnosed with recurrent urinary tract
client, indicates teaching about Inderal (propranolol) has been infections (UTIs). Which one of the following instructions
effective? would be best for the nurse to tell the caregiver?
A) Increase bladder tone by delaying voiding A) Determine that adequate mist is supplied
B) When laundering clothing, rinse several times B) Inspect the nares and ears for skin breakdown
C) Use plain water for the bath, shampooing hair last C) Lubricate the tips of the cannula before insertion
D) Have the child use antibacterial soaps while bathing D) Maintain sterile technique when handling cannula

9. While performing an initial assessment on a newborn 17. The nurse is providing instructions for a client with asthma
following a breech delivery, the nurse suspects hip dislocation. who is sensitive to house dust-mites. Which information about
Which of the following is most suggestive of the abnormality? prevention of asthma episodes would be the most helpful to
A) Flexion of lower extremities include during the teaching?
B) Negative Ortolani response A) Change the pillow covers every month
C) Lengthened leg of affected side B) Wash bed linens in warm water with a cold rinse
D) Irregular hip symmetry C) Wash and rinse the bed linens in hot water
D) Use air filters in the furnace system
10. In reviewing the assessment data of a client suspected of
having diabetes insipidus, the nurse expects which of the 18. A client tells the nurse he is fearful of planned surgery
following after a water deprivation test? because of evil thoughts about a family member. What is the
A) Increased edema and weight gain best initial response by the nurse?
B) Unchanged urine specific gravity A) Call a chaplain
C) Rapid protein excretion B) Deny the feelings
D) Decreased blood potassium C) Cite recovery statistics
D) Listen to the client
11. The nurse is caring for a client with Parkinson's disease. The
client spends over 1 hour to dress for scheduled therapies. 19. The nurse is performing a physical assessment on a client
What is the most appropriate action for the nurse to take in this with insulin dependent diabetes mellitus. Which client finding
situation? calls for immediate nursing action?
A) Ask family members to dress the client A) Diaphoresis and shakiness
B) Encourage the client to dress more quickly B) Reduced lower leg sensation
C) Allow the client the time needed to dress C) Intense thirst and hunger
D) Demonstrate methods on how to dress more quickly D) Painful hematoma on thigh

12. When caring for a client with advanced cirrhosis of the liver, 20. A Hispanic client refuses emergency room treatment until a
which nursing diagnosis should take priority? curandero is called. The nurse understands that this person
A) risk for injury: hemorrhage brings what to situations of illness?
B) risk for injury related to peripheral neuropathy A) Holistic healing
C) altered nutrition: less than body requirements B) Spiritual advising
D) fluid volume excess: ascites C) Herbal preparations
D) Witchcraft potions
13. A client is admitted with a diagnosis of myocardial infarction
(MI). The client is complaining of chest pain. The nurse 21. You are teaching a client about the patient controlled
knows that pain related to an MI is due to analgesia (PCA) planned for post-operative care. Which
A) insufficient oxygenation of the cardiac muscle statement indicates further teaching may be needed by the
B) potential circulatory overload client?
C) left ventricular overload A) "I will be receiving continuous doses of medication."
D) electrolyte imbalance B) "I should call the nurse before I take additional doses."
C) "I will call for assistance if my pain is not relieved."
14. On initial examination of a 15 month-old child with D) "The machine will prevent an overdose."
suspected otitis media, which group of findings would the
registered nurse (RN) anticipate? 22. The nurse is teaching childbirth preparation classes. One
A) Periorbital edema, absent light reflex and translucent woman asks about her rights to develop a birthing plan. Which
tympanic membrane response made by the nurse would be best?
B) Irritability, rhinorrhea, and bulging tympanic membrane A) "What is your reason for wanting such a plan?"
C) Diarrhea, retracted tympanic membrane and enlarged B) "Have you talked with your provider about this?"
parotid gland C) "Let us discuss your rights as a couple"
D) Vomiting, pulling at ears and pearly white tympanic D) "Write your ideal plan for the next class"
membrane
23. The nurse is caring for a client admitted to the hospital with
15. Postoperative orders for a client undergoing a mitral valve right lower lobe (RLL) pneumonia. On assessment, the nurse
replacement include monitoring pulmonary artery pressure notes crackles over the RLL. The client has significant pleuritic
together with pulmonary capillary wedge pressure with a pain and is unable to take in a deep breath in order to cough
pulmonary artery catheter. The purpose of these actions by the effectively. Which nursing diagnosis would be most appropriate
nurse is to assess for this client based on this assessment data?
A) right ventricular pressure A) Impaired gas exchange related to acute infection and sputum
B) left ventricular end-diastolic pressure production
C) acid-base balance B) Ineffective airway clearance related to sputum production
D) coronary artery stability and ineffective cough
C) Ineffective breathing pattern related to acute infection
16. A client is receiving oxygen therapy via a nasal cannula. D) Anxiety related to hospitalization and role conflict
When providing nursing care, which of the following
interventions would be appropriate?
24. A woman comes to the antepartum clinic for a routine C) Peanut butter and jelly sandwich, chips, pudding, milk
prenatal examination. She is 12 weeks pregnant with her second D) Baked chicken, applesauce, cookie, milk
child. Which of the following shows proper documentation of
the client's obstetric history by the nurse? 33. In addition to disturbances in mental awareness and
A) Para 2, Gravida 1 orientation, a client with cognitive impairment is also likely to
B) Nulligravida 2, Para 1 show loss of ability in
C) Primigravida 1, Para 1 A) Hearing, speech, and sight
D) Gravida 2, Para 1 B) Endurance, strength, and mobility
C) Learning, creativity, and judgment
25. When planning the care for a young adult client diagnosed D) Balance, flexibility, and coordination
with anorexia nervosa which of these concerns should the nurse
determine to be the priority for long term mobility? 34. A client was re-admitted to the hospital following a recent
A) digestive problems skull fracture. Which finding requires the nurse's immediate
B) amenorrhea attention?
C) Electrolyte imbalance A) Lethargy
D) blood disorders B) Agitation
C) Ataxia
26. A client was admitted with a diagnosis of pneumonia. When D) Hearing loss
auscultating the client's breath sounds, the nurse hears
inspiratory crackles in the right base. Temperature is 102.3 35. A young child is admitted for treatment of lead poisoning.
degrees Fahrenheit orally. What other finding would the nurse The nurse recognizes that the most serious effect of chronic
expect? lead poisoning is
A) Flushed skin C) Mental confusion A) central nervous system damage
B) Bradycardia D) Hypotension B) moderate anemia
C) renal tubule damage
27. The nurse is evaluating the growth and development of a D) growth impairment
toddler with AIDS. The nurse would anticipate finding that the
child has 36. The new graduate nurse interviews for a position in a
A) achieved developmental milestones at an erratic rate nursing department of a large health care agency, described by
B) delay in musculoskeletal development the interviewer as having shared governance. Which of these
C) displayed difficulty with speech development statements best illustrates the shared governance model?
D) delay in achievement of most developmental milestones A) An appointed board oversees any administrative decisions
B) Nursing departments share responsibility for client outcomes
28. The nurse would expect which eating disorder to cause the C) Staff groups are appointed to discuss nursing practice and
greatest fluctuations in potassium? client education issues
A) binge eating disorder D) Non-nurse managers supervise nursing staff in groups of
B) anorexia nervosa units
C) bulimia
D) purge syndrome 37. In a long term rehabilitation care unit, a client with spinal
cord injury complains of a pounding headache. The client is
29. The nurse is planning care for a client with increased sitting in a wheelchair watching television. Further assessment
intracranial pressure. The best position for this client is by the nurse reveals excessive sweating, a splotchy rash,
A) Trendelenburg pilomotor erection, facial flushing, congested nasal passages
B) Prone and a heart rate of 50. The nurse should perform which action
C) Semi-Fowlers next?
D) Side-lying with head flat A) Take the client's respirations, blood pressure (BP),
temperature and then pupillary responses
30. The nurse is assessing a client with a deep vein thrombosis. B) Place the client into the bed and administer the ordered PRN
Which of the following signs and/or symptoms would the nurse analgesic
anticipate finding? C) Check the client for bladder distention and the client's urinary
A) Rapid respirations catheter for kinks
B) Diaphoresis D) Turn the television off and then assist client to use relaxation
C) Swelling of lower extremity techniques
D) Positive Babinski's sign
38. A 2 month-old infant has both a cleft lip and palate which
31. The nurse is assessing a newborn infant and observes low will be repaired in stages. In the immediate postoperative
set ears, short palpebral fissures, flat nasal bridge and indistinct period for a cleft lip repair, which nursing approach should be
philtrum. A priority maternal assessment by the nurse should the priority?
be to ask about A) Remove protective arm devices one at a time for short
A) alcohol use during pregnancy periods with supervision
B) usual nutritional intake B) Initiate by mouth feedings when alert, with the return of the
C) family genetic disorders gag reflex
D) maternal and paternal ages C) Introduce to the parents how to cleanse the suture line with
the prescribed protocol
32. A 14 month-old had cleft palate surgical repair several days D) Position the infant on the back after feedings throughout the
ago. The parents ask the nurse about feedings after discharge. day
Which lunch is the best example of an appropriate meal?
A) Hot dog, carrot sticks, gelatin, milk
B) Soup, blenderized soft foods, ice cream, milk
39. When teaching new parents prevention of sudden infant
death syndrome (SIDS) what is the most important practice the 8. A nurse is caring for a 2 year-old child after corrective surgery
nurse should instruct them to do? for Tetralogy of Fallot. The mother reports that the child has
A) Place the infant in a supine or side lying position for sleep suddenly begun seizing. The nurse recognizes this problem is
B) Do not allow anyone to smoke in the home probably due to
C) Follow recommended immunization schedule A) a cerebral vascular accident
D) Be sure to check infant every one hour B) postoperative meningitis
C) medication reaction
40. A client is admitted with the diagnosis of myocardial D) metabolic alkalosis
infarction (MI). Which of the following lab values would be
consistent with this diagnosis 9. A client with asthma has low pitched wheezes present on the
A) Low serum albumin final half of exhalation. One hour later the client has high
B) High serum cholesterol pitched wheezes extending throughout exhalation. This change
C) Abnormally low white blood cell count in assessment indicates to the nurse that the client
D) Elevated creatinine phosphokinase (CPK) A) has increased airway obstruction
B) has improved airway obstruction
Q&A Random Selection #10 C) needs to be suctioned
1. A home health nurse is at the home of a client with diabetes D) exhibits hyperventilation
and arthritis. The client has difficulty drawing up insulin. It
would be most appropriate for the nurse to refer the client to 10. Following a diagnosis of acute glomerulonephritis (AGN) in
A) A social worker from the local hospital their 6 year-old child, the parents remark: “We just don’t know
B) A physical therapist to improve fine motor coordination how he caught the disease!” The nurse's response is based on
C) An activity therapist from the community center an understanding that
D) Another client with diabetes mellitus and takes insulin A) AGN is a streptococcal infection that involves the kidney
tubules
2. A couple asks the nurse about risks of several birth control B) the disease is easily transmissible in schools and camps
methods. What is the most appropriate response by the nurse? C) the illness is usually associated with chronic respiratory
A) Norplant is safe and may be removed easily infections
B) Oral contraceptives should not be used by smokers D) it is not "caught" but is a response to a previous B-hemolytic
C) Depo-Provera is convenient with few side effects strep infection
D) The IUD gives protection from pregnancy and infection
11. During the admission assessment on a client with chronic
3. The nurse is caring for a client with a long leg cast. During bilateral glaucoma, which statement by the client would the
discharge teaching about appropriate exercises for the affected nurse anticipate since it is associated with this problem?
extremity, the nurse should recommend _________ exercises A) "I have constant blurred vision."
A) isometric B) "I can't see on my left side."
B) range of motion C) "I have to turn my head to see my room."
C) aerobic D) "I have specks floating in my eyes."
D) isotonic
4. Which behavioral characteristic describes the domestic 12. A 19 year-old client is paralyzed in a car accident. Which
abuser? statement used by the client would indicate to the nurse that
A) Alcoholic the client is using the mechanism of "suppression"?
B) Over confident A) "I don't remember anything about what happened to me."
C) High tolerance for frustrations B) "I'd rather not talk about it right now."
D) Low self-esteem C) "It's all the other guy's fault! He was going too fast."
D) "My mother is heartbroken about this."
5. A client asks the nurse about including her 2 and 12 year-old
sons in the care of their newborn sister. Which of the following 13. A client was admitted to the psychiatric unit after
is an appropriate initial statement by the nurse? complaining to her friends and family that neighbors have
A) "Focus on your sons' needs during the first days at home." bugged her home in order to hear all of her business. She
B) "Tell each child what he can do to help with the baby." remains aloof from other clients, paces the floor and believes
C) "Suggest that your husband spend more time with the boys." that the hospital is a house of torture. Nursing interventions for
D) "Ask the children what they would like to do for the the client should appropriately focus on efforts to
newborn." A) convince the client that the hospital staff is trying to help
6. The nurse is caring for a post-surgical client at risk for B) help the client to enter into group recreational activities
developing deep vein thrombosis. Which intervention is an C) provide interactions to help the client learn to trust staff
effective preventive measure? D) arrange the environment to limit the client’s contact with
A) Place pillows under the knees other clients
B) Use elastic stockings continuously
C) Encourage range of motion and ambulation 14. A client with schizophrenia is receiving haloperidol (Haldol) 5
D) Massage the legs twice daily mg T.I.D. The client’s family is alarmed and calls the clinic when
"his eyes rolled upward." The nurse recognizes this as what type
7. A client is scheduled for a percutaneous transluminal of side effect?
coronary angioplasty (PTCA). The nurse knows that a PTCA is the A) Oculogyric crisis
A) surgical repair of a diseased coronary artery B) Tardive dyskinesia
B) placement of an automatic internal cardiac defibrillator C) Nystagmus
C) procedure that compresses plaque against the wall of the D) Dysphagia
diseased coronary artery to improve blood flow
D) non-invasive radiographic examination of the heart
15. The parents of a newborn male with hypospadias want their 22. A client is scheduled for an Intravenous Pyelogram (IVP). In
child circumcised. The best response by the nurse would be to order to prepare the client for this test, the nurse would
inform them that A) instruct the client to maintain a regular diet the day prior to
A) circumcision is delayed so the foreskin can be used for the the examination
surgical repair B) restrict the client's fluid intake 4 hours prior to the
B) this procedure is contraindicated because of the permanent examination
defect C) administer a laxative to the client the evening before the
C) there is no medical indication for performing a circumcision examination
on any child D) inform the client that only 1 x-ray of his abdomen is
D) the procedure should be performed as soon as the infant is necessary
stable
23. The nurse is caring for a client in the late stages of
16. A mother brings her 26 month-old to the well-child clinic. amyotrophic lateral sclerosis (ALS). Which finding would the
She expresses frustration and anger due to her child's nurse expect?
constantly saying "no" and his refusal to follow her directions. A) confusion C) shallow respirations
The nurse explains this is normal for his age, as negativism is B) loss of half of visual field D) tonic-clonic seizures
attempting to meet which developmental need?
A) Trust 24. The nurse is caring for a 13 year-old following spinal fusion
B) Initiative for scoliosis. Which of the following interventions is
C) Independence appropriate in the immediate post-operative period?
D) Self-esteem A) Raise the head of the bed at least 30 degrees
B) Encourage ambulation within 24 hours
17. Following mitral valve replacement surgery a client develops C) Maintain in a flat position, logrolling as needed
PVC’s. The health care provider orders a bolus of Lidocaine D) Encourage leg contraction and relaxation after 48 hours
followed by a continuous Lidocaine infusion at a rate of 2
mg/minute. The IV solution contains 2 grams of Lidocaine in 500 25. An infant weighed 7 pounds 8 ounces at birth. If growth
cc’s of D5W. The infusion pump delivers 60 microdrops/cc. occurs at a normal rate, what would be the expected weight
What rate would deliver 4 mg of Lidocaine/minute? change at 6 months of age?
A) 60 microdrops/minute A) Double the birth weight
B) 20 microdrops/minute B) Triple the birth weight
C) 30 microdrops/minute C) Gain 6 ounces each week
D) 40 microdrops/minute D) Add 2 pounds each month

18. To prevent a Valsalva maneuver in a client recovering from 26. A client complained of nausea, a metallic taste in her mouth,
an acute myocardial infarction, the nurse would and fine hand tremors 2 hours after her first dose of lithium
A) assist the client to use the bedside commode carbonate (Lithane). What is the nurse’s best explanation of
B) administer stool softeners every day as ordered these findings?
C) administer antidysrhythmics prn as ordered A) These side effects are common and should subside in a few
D) maintain the client on strict bed rest days
B) The client is probably having an allergic reaction and should
19. A 16 year-old client is admitted to a psychiatric unit with a discontinue the drug
diagnosis of attempted suicide. The nurse is aware that the C) Taking the lithium on an empty stomach should decrease
most frequent cause for suicide in adolescents is these symptoms
A) Progressive failure to adapt D) Decreasing dietary intake of sodium and fluids should
B) Feelings of anger or hostility minimize the side effects
C) Reunion wish or fantasy
D) Feelings of alienation or isolation 27. Which response by the nurse would best assist the
chemically impaired client to deal with issues of guilt?
A) "Addiction usually causes people to feel guilty. Don’t worry, it
20. The nurse is caring for a woman 2 hours after a vaginal is a typical response due to your drinking
delivery. Documentation indicates that the membranes were behavior."
ruptured for 36 hours prior to delivery. What is the priority B) "What have you done that you feel most guilty about and
nursing diagnoses at this time? what steps can you begin to take to help you lessen this
A) Altered tissue perfusion guilt?"
B) Risk for fluid volume deficit C) "Don’t focus on your guilty feelings. These feelings will only
C) High risk for hemorrhage lead you to drinking and taking drugs."
D) Risk for infection D) "You’ve caused a great deal of pain to your family and close
friends, so it will take time to undo all the things
21. The nurse is caring for a 20 lbs (9 kg) 6 month-old with a 3 you’ve done."
day history of diarrhea, occasional vomiting and fever.
Peripheral intravenous therapy has been initiated, with 5% 28. Which statement by the client with chronic obstructive lung
dextrose in 0.33% normal saline with 20 mEq of potassium per disease indicates an understanding of the major reason for the
liter infusing at 35 ml/hr. Which finding should be reported to use of occasional pursed-lip breathing
the health care provider immediately?
A) 3 episodes of vomiting in 1 hour A) "This position of my lips helps to keep my airway open."
B) Periodic crying and irritability B) "I can expel more when I pucker up my lips to breathe out."
C) Vigorous sucking on a pacifier C) "My mouth doesn't get as dry when I breathe with pursed
D) No measurable voiding in 4 hours lips."
D) "With prolonging breathing out with pursed lips the little B) Do not use occlusive ointments on the rash
areas in my lungs don't collapse." C) Use commercial baby wipes with each diaper change
D) Discontinue a new food that was added to the infant's diet
29. A 57 year-old male client has a hemoglobin of 10 mg/dl and just prior to the rash
a hematocrit of 32%. What would be the most appropriate
follow-up by the home care nurse? 36. An adolescent client comes to the clinic 3 weeks after the
A) Ask the client if he has noticed any bleeding or dark stools birth of her first baby. She tells the nurse she is concerned
B) Tell the client to call 911 and go to the emergency because she has not returned to her pre-pregnant weight.
department immediately Which action should the nurse perform first?
C) Schedule a repeat Hemoglobin and Hematocrit in 1 month A) Review the client's weight pattern over the year
D) Tell the client to schedule an appointment with a B) Ask the mother to record her diet for the last 24 hours
hematologist C) Encourage her to talk about her view of herself
D) Give her several pamphlets on postpartum nutrition
30. A client experiences post partum hemorrhage eight hours
after the birth of twins. Following administration of IV fluids and 37. The nurse is assessing an infant with developmental
500 ml of whole blood, her hemoglobin and hematocrit are dysplasia of the hip. Which finding would the nurse anticipate?
within normal limits. She asks the nurse whether she should A) unequal leg length
continue to breast feed the infants. Which of the following is B) limited adduction
based on sound rationale? C) diminished femoral pulses
A) "Nursing will help contract the uterus and reduce your risk of D) symmetrical gluteal folds
bleeding."
B) "Breastfeeding twins will take too much energy after the 38. A newborn has been diagnosed with hypothyroidism. In
hemorrhage." discussing the condition and treatment with the family, the
C) "The blood transfusion may increase the risks to you and the nurse should emphasize
babies." A) they can expect the child will be mentally retarded
D) "Lactation should be delayed until the "real milk" is B) administration of thyroid hormone will prevent problems
secreted." C) this rare problem is always hereditary
D) physical growth/development will be delayed
31. On admission to the psychiatric unit, the client is trembling
and appears fearful. The nurse’s initial response should be to 39. The nurse understands that a priority goal of involuntary
A) Give the client orientation materials and review the unit rules hospitalization of the severely mentally ill client is
and regulations A) re-orientation to reality
B) Introduce him/herself and accompany the client to the B) elimination of symptoms
client’s room C) protection from harm to self or others
C) Take the client to the day room and introduce her to the D) return to independent functioning
other clients
D) Ask the nursing assistant to get the client’s vital signs and 40. A 3 year-old had a hip spica cast applied two hours ago. In
complete the admission search order to facilitate drying, the nurse should
A) Expose the cast to air and turn the child frequently
32. While caring for the client during the first hour after B) Use a heat lamp to reduce the drying time
delivery, the nurse determines that the uterus is boggy and C) Handle the cast with the abductor bar
there is vaginal bleeding. What should be the nurse's first D) Turn the child as little as possible
action?
A) Check vital signs Q&A Random Selection #11
B) Massage the fundus
C) Offer a bedpan 1. While assessing a client in an outpatient facility with a panic
D) Check for perineal lacerations disorder, the nurse completes a thorough health history and
33. The nurse is teaching parents about the treatment plan for a physical exam. Which finding is most significant for this client?
2 weeks-old infant with Tetralogy of Fallot. While awaiting A) Compulsive behavior
future surgery, the nurse instructs the parents to immediately B) Sense of impending doom
report C) Fear of flying
A) loss of consciousness D) Predictable episodes
B) feeding problems
C) poor weight gain 2. A client has just been admitted with portal hypertension.
D) fatigue with crying Which nursing diagnosis would be a priority in planning care?
A) Altered nutrition: less than body requirements
34. For a 6 year-old child hospitalized with moderate edema and B) Potential complication hemorrhage
mild hypertension associated with acute glomerulonephritis C) Ineffective individual coping
(AGN), which one of the following nursing interventions would D) Fluid volume excess
be appropriate?
A) Institute seizure precautions 3. A client has just returned to the medical-surgical unit
B) Weigh the child twice per shift following a segmental lung resection. After assessing the client,
C) Encourage the child to eat protein-rich foods the first nursing action would be to
D) Relieve boredom through physical activity A) administer pain medication
B) suction excessive tracheobronchial secretions
35. A nurse is teaching the parent of a nine month-old infant C) assist client to turn, deep breathe and cough
about diaper dermatitis. Which of the following measures would D) monitor oxygen saturation
be appropriate for the nurse to include?
A) Use only cloth diapers that are rinsed in bleach
4. Which playroom activities should the nurse organize for a A) Administration of cough suppressants
small group of 7 year-old hospitalized children? B) Increasing oral fluid intake to 3000 cc per day
A) Sports and games with rules C) Maintaining bed rest with bathroom privileges
B) Finger paints and water play D) Performing chest physiotherapy twice a day
C) "Dress-up" clothes and props
D) Chess and television programs 13. Which of these variations in the newborn results from the
presence of maternal hormones?
5. The nurse is caring for a client with cirrhosis of the liver with A) Engorgement of the breasts
ascites. When instructing nursing assistants in the care of the B) Mongolian spots
client, the nurse should emphasize that the client C) Edema of the scrotum
A) should remain on bed rest in a semi-Fowler's position D) Lanugo
B) should alternate ambulation with bed rest with legs elevated
C) may ambulate and sit in chair as tolerated 14. A 23 year-old single client is in the 33rd week of her first
D) may ambulate as tolerated and remain in semi-Fowlers pregnancy. She tells the nurse that she has everything ready for
position in bed the baby and has made plans for the first weeks together at
home. Which normal emotional reaction does the nurse
6. The nurse is discussing dietary intake with an adolescent who recognize?
has acne. The most appropriate statement for the nurse is A) Acceptance of the pregnancy
A) "Eat a balanced diet for your age." B) Focus on fetal development
B) "Increase your intake of protein and Vitamin A." C) Anticipation of the birth
C) "Decrease fatty foods from your diet." D) Ambivalence about pregnancy
D) "Do not use caffeine in any form, including chocolate."
15. The nurse is reviewing a depressed client's history from an
7. A client is in the third month of her first pregnancy. During earlier admission. Documentation of anhedonia is noted. The
the interview, she tells the nurse that she has several sex nurse understands that this finding refers to
partners and is unsure of the identity of the baby's father. A) reports of difficulty falling and staying asleep
Which of the following nursing interventions is a priority? B) expression of persistent suicidal thoughts
A) Counsel the woman to consent to HIV screening C) lack of enjoyment in usual pleasures
B) Perform tests for sexually transmitted diseases D) reduced senses of taste and smell
C) Discuss her high risk for cervical cancer
D) Refer the client to a family planning clinic 16. A 2 month-old child has had a cleft lip repair. The selection
of which restraint would require no further action by the charge
8. The nurse enters the room as a 3 year-old is having a nurse?
generalized seizure. Which intervention should the nurse A) elbow
perform first? B) mummy
A) Clear the area of any hazards C) jacket
B) Place the child on its side D) clove hitch
C) Restrain the child
D) Give the prescribed anticonvulsant 17. The nurse is caring for a client with trigeminal neuralgia (tic
douloureux). To assist the client with nutrition needs, the nurse
9. Upon examining the mouth of a 3 year-old child, the nurse should
discovers that the teeth have chalky white-to-yellowish staining A) Offer small meals of high calorie soft food
with pitting of the enamel. Which of the following conditions B) Assist the client to sit in a chair for meals
would most likely explain these findings? C) Provide additional servings of fruits and raw vegetables
A) Ingestion of tetracycline D) Encourage the client to eat fish, liver and chicken
B) Excessive fluoride intake
C) Oral iron therapy 18. A nurse from the surgical department is reassigned to the
D) Poor dental hygiene pediatric unit. The charge nurse should recognize that the child
at highest risk for cardiac arrest and is the least likely to be
assigned to this nurse is which child?
10. A client has developed thrombophlebitis of the left leg. A) congenital cardiac defects
Which nursing intervention should be given the highest B) an acute febrile illness
priority? C) prolonged hypoxemia
A) Elevate the leg on 2 pillows D) severe multiple trauma
B) Apply support stockings
C) Apply warm compresses
D) Maintain complete bed rest 19. Which of the following should the nurse teach the client to
avoid when taking chlorpromazine HCL (Thorazine)?
11. The nurse is caring for a child who has just returned from A) Direct sunlight
surgery following a tonsillectomy and adenoidectomy. Which B) Foods containing tyramine
action by the nurse is appropriate? C) Foods fermented with yeast
A) Offer ice cream every 2 hours D) Canned citrus fruit drinks
B) Place the child in a supine position
C) Allow the child to drink through a straw 20. A nurse who is evaluating a developmentally challenged 2
D) Observe swallowing patterns year-old should stress which goal when talking to the child's
mother?
12. The nurse is planning care for a client with pneumococcal A) Teaching the child self care skills
pneumonia. Which of the following would be most effective in B) Preparing for independent toileting
removing respiratory secretions? C) Promoting the child's optimal development
D) Helping the family decide on long term care
 28. While explaining an illness to a 10 year-old, what should the
21. A 16 month-old child has just been admitted to the hospital. nurse keep in mind about the cognitive development at this
As the nurse assigned to this child enters the hospital room for age?
the first time, the toddler runs to the mother, clings to her and A) They are able to make simple association of ideas
begins to cry. What would be the initial action by the nurse? B) They are able to think logically in organizing facts
A) Arrange to change client care assignments C) Interpretation of events originate from their own perspective
B) Explain that this behavior is expected D) Conclusions are based on previous experiences
C) Discuss the appropriate use of "time-out"
D) Explain that the child needs extra attention 29. The initial response by the nurse to a delusional client who
refuses to eat because of a belief that the food is poisoned is
22. The nurse in a well-child clinic examines many children on a A) "You think that someone wants to poison you?"
daily basis. Which of the following toddlers requires further B) "Why do you think the food is poisoned?"
follow up? C) "These feelings are a symptom of your illness."
A) A 13 month-old unable to walk D) "You’re safe here. I won’t let anyone poison you."
B) A 20 month-old only using 2 and 3 word sentences
C) A 24 month-old who cries during examination 30. The registered nurse has just admitted a client with severe
D) A 30 month-old only drinking from a sippy cup depression. What domain should be the priority focus as the
nurse identifies the nursing diagnoses?
23. The nurse is caring for a client with acute pancreatitis. After A) Nutrition
pain management, which intervention should be included in the B) Elimination
plan of care? C) Activity
A) Encourage the client to cough and deep breathe every 2 D) Safety
hours
B) Place the client in contact isolation 31. The nurse is caring for a client in the coronary care unit. The
C) Provide a diet high in protein display on the cardiac monitor indicates ventricular fibrillation.
D) Institute seizure precautions What should the nurse do first?
A) perform defibrillation
24. When using an interpreter to teach a client about a B) administer epinephrine as ordered
procedure to do in the home, the nurse should take which C) assess for presence of pulse
approach? D) institute CPR
A) Speak directly to the interpreter while presenting
information and use pauses for questions 32. A client is discharged following hospitalization for congestive
B) Talk to the interpreter in advance and leave the client and heart failure. The nurse teaching the family suggests they
interpreter alone encourage the client to rest frequently in which of the following
C) Include a family member and direct communications to that positions?
person A) High Fowler's
D) Face the client while presenting the information as the B) Supine
interpreter talks in the native language C) Left lateral
D) Low Fowler's
25. A registered nurse (RN) is assigned to work at the Poison
Control Center telephone hotline. In which of these cases of 33. Which of the following conditions assessed by the nurse
childhood poisoning would the nurse suggest that parents have would contraindicate the use of benztropine (Cogentin)?
the child drink orange juice? A) Neuro malignant syndrome
A) An 18 month-old who ate an undetermined amount of crystal B) Acute extrapyramidal syndrome
drain cleaner C) Glaucoma, prostatic hypertrophy
B) A 14 month-old who chewed 2 leaves of a philodendron plant D) Parkinson's disease, atypical tremors
C) A 20 month-old who is found sitting on the bathroom floor
beside an empty bottle of diazepam (Valium) 34. The nurse is assigned to a newly delivered woman with
D) A 30 month-old who has swallowed a mouthful of charcoal HIV/AIDS. The student asks the nurse about how it is
lighter fluid determined that a person has AIDS other than a positive HIV
test. The nurse responds:
A) "The complaints of at least 3 common findings."
26. While planning care for a 2 year-old hospitalized child, which B) "The absence of any opportunistic infection."
situation would the nurse expect to most likely affect the C) "CD4 lymphocyte count is less than 200."
behavior? D) "Developmental delays in children."
A) Strange bed and surroundings
B) Separation from parents 35. A client treated for depression tells the nurse at the mental
C) Presence of other toddlers health clinic that he recently purchased a handgun because he is
D) Unfamiliar toys and games thinking about suicide. The first nursing action should be to
A) Notify the primary care provider immediately
27. The nursing care plan for a client with decreased adrenal B) Suggest in-patient psychiatric care
function should include C) Respect the client's confidential disclosure
A) encouraging activity D) Phone the family to warn them of the risk
B) placing client in reverse isolation
C) limiting visitors 36. The nurse is performing physical assessments on
D) measures to prevent constipation adolescents. What finding would the nurse anticipate
concerning female growth spurts?
A) They occur about 2 years earlier than for males.
B) They begin about the same time for males.
C) They begin just prior to the onset of puberty. B) "Children ask many questions, but are not looking for
D) They are characterized by an increase in height of 4 inches answers."
each year. C) "This question indicates interest in sex beyond this age."
D) "Full and detailed answers should be given to all questions."
37. Which of the following would be the best strategy for the
nurse to use when teaching insulin injection techniques to a 5. The nurse is assessing a 4 year-old for possible developmental
newly diagnosed client with diabetes? dysplasia of the right hip. Which finding would the nurse
A) Give written pre and post tests expect?
B) Ask questions during practice A) Pelvic tip downward
C) Allow another diabetic to assist B) Right leg lengthening
D) Observe a return demonstration C) Ortolani sign
D) Characteristic limp
38. A 15 year-old client with a lengthy confining illness is most
at risk for altered psycho-emotional growth and development 6. At a routine clinic visit, parents express concern that their 4
due to year-old is wetting the bed several times a month. What is the
A) loss of control C) dependence nurse's best response?
B) insecurity D) lack of trust A) "This is normal at this time of day."
B) "How long has this been occurring?"
39. The nurse is assessing a 2 year-old client with a possible C) "Do you offer fluids at night?"
diagnosis of congenital heart disease. Which of these is most D) "Have you tried waking her to urinate?"
likely to be seen with this diagnosis?
A) Several otitis media episodes in the last year 7. The charge nurse on the eating disorder unit instructs a new
B) Weight and height in the 10th percentile since birth staff member to weigh each client in his or her hospital gown
C) Takes frequent rest periods while playing only. What is the rationale for this nursing intervention?
D) Changing food preferences and dislikes A) To reduce the risk of the client feeling cold due to decreased
fat and subcutaneous tissue
40. The nurse is caring for a 10 year-old on admission to the B) To cover the bony prominence and areas where there is skin
burn unit. One assessment parameter that will indicate that the breakdown
child has adequate fluid replacement is C) The client knows what type of clothing to wear when
A) urinary output of 30 ml per hour weighed
B) no complaints of thirst D) To reduce the tendency of the client to hide objects under his
C) increased hematocrit or her clothing
D) good skin turgor around burn
8. The nurse is caring for a client with benign prostatic
Q&A Random Selection #12 hypertrophy (BPH). Which of the following assessments would
the nurse anticipate finding?
1. The nurse is caring for a post-op colostomy client. The client A) Large volume of urinary output with each voiding
begins to cry, saying "I'll never be attractive again with this ugly B) Involuntary voiding with coughing and sneezing
red thing." What should be the first action taken by the nurse? C) Frequent urination
A) Arrange a consultation with a sex therapist experienced in D) Urine is dark and concentrated
working with colostomy clients
B) Suggest sexual positions that hide the colostomy 9. A client complaining of severe shortness of breath is
C) Invite the partner to participate in colostomy care after diagnosed with congestive heart failure. The nurse observes a
viewing an instructional video falling pulse oximetry. The client's color changes to gray and she
D) Encourage the client to discuss her feelings about the expectorates large amounts of pink frothy sputum. The first
colostomy action of the nurse would be which of the following?
A) Call the health care provider
2. A schizophrenic client talks animatedly but the staff are B) Check vital signs
unable to understand what the client is communicating. The C) Position in high Fowler's
client is observed mumbling to herself and speaking to the D) Administer oxygen
radio. A desirable outcome for this client’s care will be
A) expresses feelings appropriately through verbal interactions 10. A school nurse is advising a class of unwed pregnant high
B) accurately interprets events and behaviors of others school students. What is the most important action they can
C) demonstrates improved social relationships perform to deliver a healthy child?
D) engages in meaningful and understandable verbal A) Maintain good nutrition
communication B) Stay in school
3. The nurse is caring for a 7 year-old child who is being C) Keep in contact with the child's father
discharged following a tonsillectomy. Which of the following D) Get adequate sleep
instructions is appropriate for the nurse to teach the parents?
A) Report a persistent cough to the health care provider 11. Which of the following nursing assessment findings require
B) The child can return to school in 4 days immediate discontinuance of an antipsychotic medication?
C) Administer chewable aspirin for pain A) Involuntary rhythmic stereotypic movements and tongue
D) The child may gargle with saline as necessary for discomfort protrusion
B) C eek puffing, involuntary movements of extremities and
4. An anxious parent of a 4 year-old consults the nurse for trunk
guidance in how to answer the child's question, "Where do C) Agitation, constant state of motion
babies come from?" What is the nurse's best response to the D) Hyperpyrexia, severe muscle rigidity, malignant hypertension
parent?
A) "When a child asks a question, give a simple answer."
12. A parent has numerous questions regarding normal growth
and development of a 10 month-old infant. Which of the 21. The nurse is teaching parents of an infant about introduction
following parameters is of most concern to the nurse? of solid food to their baby. What is the first food they can add to
A) 50% increase in birth weight the diet?
B) Head circumference greater than chest A) Vegetables C) Fruit
C) Crying when the parents leave B) Cereal D) Meats
D) Able to stand up briefly in play pen
22. During seizure activity which observation is the priority to
13. A 3 year-old child is treated in the emergency department enhance further direction of treatment?
after ingestion of 1 ounce of a liquid narcotic. What action A) Observe the sequence or types of movement
should the nurse perform first? B) Note the time from beginning to end
A) Provide the ordered humidified oxygen via mask C) Identify the pattern of breathing
B) Suction the mouth and the nose D) Determine if loss of bowel or bladder control occurs
C) Check the mouth and radial pulse 23. The nurse is caring for a client with a sigmoid colostomy who
D) Start the ordered intravenous fluids requests assistance in removing the flatus from a 1 piece
drainable ostomy pouch. Which is the correct intervention?
14. A client continually repeats phrases that others have just A) Piercing the plastic of the ostomy pouch with a pin to vent
said. The nurse recognizes this behavior as the flatus
A) autistic C) echolalic B) Opening the bottom of the pouch, allowing the flatus to be
B) echopraxis D) catatonic expelled
C) Pulling the adhesive seal around the ostomy pouch to allow
15. Which of the following statements describes what the nurse the flatus to escape
must know in order to provide anticipatory guidance to parents D) Assisting the client to ambulate to reduce the flatus in the
of a toddler about readiness for toilet training? pouch
A) The child learns voluntary sphincter control through
repetition 24. A nurse who travels with an agency is uncertain about what
B) Myelination of the spinal cord is completed by this age tasks can be performed when working in a different state. It
C) Neuronal impulses are interrupted at the base of the ganglia would be best for the nurse to check which resource?
D) The toddler can understand cause and effect A) The state nurse practice act in which the assignment is made
B) With a nurse colleague who has worked in that state 2 years
16. In teaching parents to associate prevention with the lifestyle ago
of their child with sickle cell disease, the nurse should C) The policies and procedures of the assigned agency in that
emphasize that a priority for their child is to state
A) avoid overheating during physical activities D) The Nursing Social Policy Statement within the United States
B) maintain normal activity with some restrictions
C) be cautious of others with viruses or temperatures 25. The parents of a 7 year-old tell the nurse their child has
D) maintain routine immunizations started to "tattle" on siblings. In interpreting this new behavior,
how should the nurse explain the child's actions to the parents?
17. The nurse is performing an assessment on a client with A) The ethical sense and feelings of justice are developing
pneumococcal pneumonia. Which finding would the nurse B) Attempts to control the family use new coping styles
anticipate? C) Insecurity and attention getting are common motives
A) bronchial breath sounds in outer lung fields D) Complex thought processes help to resolve conflicts
B) decreased tactile fremitus
C) hacking, nonproductive cough 26. Which of these principles should the nurse apply when
D) hyper-resonance of areas of consolidation performing a nutritional assessment on a 2 year-old client?
A) An accurate measurement of intake is not reliable
18. When teaching a client with chronic obstructive pulmonary B) The food pyramid is not used in this age group
disease about oxygen by cannula, the nurse should also instruct C) A serving size at this age is about 2 tablespoons
the client's family to D) Total intake varies greatly each day
A) avoid smoking near the client
B) turn off oxygen during meals 27. A client with HIV infection has a secondary herpes simplex
C) adjust the liter flow to 10 as needed type 1 (HSV-1) infection. The nurse knows that the most likely
D) remind the client to keep mouth closed reason for the HSV-1 infection in this client is
A) immunosuppression
19. The nurse is caring for a 14 month-old just diagnosed with B) emotional stress
cystic fibrosis. The parents state this is the first child in either C) unprotected sexual activities
family with this disease, and ask about the risk to future D) contact with saliva
children. What is the best response by the nurse?
A) 1in 4 chance for each child to carry that trait 28. The nurse is preparing to perform a physical examination on
B) 1in 4 risk for each child to have the disease an 8 month-old who is sitting contentedly on his mother's lap.
C) 1in 2 chance of avoiding the trait and disease Which of the following should the nurse do first?
D) 1in 2 chance that each child will have the disease A) Elicit reflexes C) Auscultate heart and lungs
B) Measure height and weight D) Examine the ears
20. In providing care to a 14 year-old adolescent with scoliosis,
which of the following will be most difficult for this client? 29. A client is unconscious following a tonic-clonic seizure. What
A) Compliance with treatment regimens should the nurse do first?
B) Looking different from their peers A) check the pulse
C) Lacking independence in activities B) administer Valium
D) Reliance on family for their social support C) place the client in a side-lying position
D) place a tongue blade in the mouth D) Do not cross your legs

30. The nurse has been assigned to four clients in the 38. The nurse is assessing a client with delayed wound healing.
emergency room, each experiencing one of these conditions. Which of the following risk factors is most important in this
Which client condition would the nurse check first? situation?
A) Viral pneumonia with atelectasis A) Glucose level of 120
B) Spontaneous pneumothorax with a respiratory rate of 38 B) History of myocardial infarction
C) Tension pneumothorax with slight tracheal deviation to the C) Long term steroid usage
right D) Diet high in carbohydrates
D) Acute asthma with episodes of bronchospasm
39. A 7 year-old child is hospitalized following a major burn to
31. The nurse measures the head and chest circumferences of a the lower extremities. A diet high in protein and carbohydrates
20 month-old infant. After comparing the measurements, the is recommended. The nurse informs the child and family that
nurse finds that they are approximately the same. What action the most important reason for this diet is to
should the nurse take? A) Promote healing and strengthen the immune system
A) Notify the provider B) Provide a well balanced nutritional intake
B) Palpate the anterior fontanel C) Stimulate increased peristalsis absorption
C) Feel the posterior fontanel D) Spare protein catabolism to meet metabolic needs
D) Record these normal findings
40. A client was admitted to the psychiatric unit after refusing to
32. A 2 year-old child has recently been diagnosed with cystic get out of bed. In the hospital the client talks to unseen people
fibrosis. The nurse is teaching the parents about home care for and voids on the floor. The nurse could best handle the problem
the child. Which of the following information is appropriate for of voiding on the floor by
the nurse to include? A) requiring the client to mop the floor
A) Allow the child to continue normal activities B) restricting the client’s fluids throughout the day
B) Schedule frequent rest periods C) withholding privileges each time the voiding occurs
C) Limit exposure to other children D) toileting the client more frequently with supervision
D) Restrict activities to inside the house
Q&A Random Selection #13
33. The nurse understands that during the "tension building"
phase of a violent relationship, when the batterer makes 1. The primary nursing diagnosis for a client with congestive
unreasonable demands, the battered victim may experience heart failure with pulmonary edema is
feelings of A) pain
A) anger B) impaired gas exchange
B) helplessness C) cardiac output altered: decreased
C) calm D) fluid volume excess
D) explosiveness
2. In assessing the healing of a client's wound during a home
34. When counseling parents of a child who has recently been visit, which of the following is the best indicator of good
diagnosed with hemophilia, what must the nurse know about healing?
the offspring of a normal father and a carrier mother? A) White patches
A) It is likely that all sons are affected B) Green drainage
B) There is a 50% probability that sons will have the disease C) Reddened tissue
C) Every daughter is likely to be a carrier D) Eschar development
D) There is a 25% chance a daughter will be a carrier
3. The nurse is caring for 2 children who have had surgical repair
35. The nurses on a unit are planning for stoma care for clients of congenital heart defects. For which defect is it a priority to
who have a stoma for fecal diversion. Which stomal diversion assess for findings of heart conduction disturbance?
poses the highest risk for skin breakdown A) Arterial septal defect
A) Ileostomy B) Patent ductus arteriosus
B) Transverse colostomy C) Aortic stenosis
C) Ileal conduit D) Ventricular septal defect
D) Sigmoid colostomy
4. When an autistic client begins to eat with her hands, the
36. A client is admitted for hemodialysis. Which abnormal lab nurse can best handle the problem by
value would the nurse anticipate not being improved by A) placing the spoon in the client’s hand and stating, "Use the
hemodialysis? spoon to eat your food."
A) Low hemoglobin B) commenting, "I believe you know better than to eat with
B) Hypernatremia your hand."
C) High serum creatinine C) jokingly stating, "Well I guess fingers sometimes work better
D) Hyperkalemia than spoons."
D) removing the food and stating, "You can’t have anymore
food until you use the spoon."
37. The nurse is teaching a client who has a hip prosthesis
following total hip replacement. Which of the following should 5. A depressed client who has recently been acting suicidal is
be included in the instructions for home care? now more social and energetic than usual. Smilingly he tells the
A) Avoid climbing stairs for 3 months nurse "I’ve made some decisions about my life." What should be
B) Ambulate using crutches only the nurse’s initial response?
C) Sleep only on your back A) "You’ve made some decisions."
B) "Are you thinking about killing yourself?" D) elevate the head of the bed
C) "I’m so glad to hear that you’ve made some decisions."
D) "You need to discuss your decisions with your therapist." 14. The nursing intervention that best describes treatment to
deal with the behaviors of clients with personality disorders
6. The nurse is participating in a community health fair. As part include
of the assessments, the nurse should conduct a mental status A) pointing out inconsistencies in speech patterns to correct
examination when thought disorders
A) an individual displays restlessness B) accepting client and the client's behavior unconditionally
B) there are obvious signs of depression C) encouraging dependency in order to develop ego controls
C) conducting any health assessment D) consistent limit-setting enforced 24 hours per day
D) the resident reports memory lapses
15. After talking with her partner, a client voluntarily admitted
7. The nurse asks a client with a history of alcoholism about herself to the substance abuse unit. After the second day on the
recent drinking behavior. The client states "I didn’t hurt anyone. unit the client states to the nurse, "My husband told me to get
I just like to have a good time, and drinking helps me to relax." treatment or he would divorce me. I don’t believe I really need
The client is using which defense mechanism? treatment, but I don’t want my husband to leave me." Which
A) Denial response by the nurse would assist the client?
B) Projection A) "In early recovery, it's quite common to have mixed feelings,
C) Intellectualization but unmotivated people can’t get well."
D) Rationalization B) "In early recovery, it’s quite common to have mixed feelings,
but I didn’t know you had been pressured to come."
8. When assessing a client who has just undergone a C) "In early recovery it’s quite common to have mixed feelings,
cardioversion, the practical nurse (LPN) finds the respirations perhaps it would be best to seek treatment on an
are 12/minute. Which action should the nurse take first? outpatient basis."
A) Try to vigorously stimulate normal breathing D) "In early recovery, it’s quite common to have mixed feelings.
B) Ask the RN to assess the vital signs Let’s discuss the benefits of sobriety for you."
C) Measure the pulse oximetry
D) Continue to monitor respirations 16. The nurse understands that one reason domestic violence
remains extensively undetected is
9. A client has been receiving lithium (Lithane) for the past two A) few battered victims seek medical care
weeks for the treatment of bipolar illness. When planning B) there is typically a series of minor, vague complaints
client teaching, what is most important for the nurse to C) expenses due to police and court costs are prohibitive
emphasize? D) very little knowledge is currently known about batterers and
A) Maintain a low sodium diet battering relationships
B) Take a diuretic with lithium and avoid excessive fluids
C) Don't be overly concerned if feelings of depression occur 17. The nurse is caring for a client 2 hours after a right lower
D) Come in for evaluation of serum lithium levels regularly lobectomy. During the evaluation of the water-seal chest
drainage system, it is noted that the fluid level bubbles
10. Following a cocaine high, the user commonly experiences an constantly in the water seal chamber. On inspection of the chest
extremely unpleasant feeling called dressing and tubing, the nurse does not find any air leaks in the
A) craving system. The next best action for the nurse is to
B) crashing A) check for subcutaneous emphysema in the upper torso
C) outward bound B) reposition the client to improve the level of comfort
D) nodding out C) call the provider as soon as possible
D) check for any increase in the amount of thoracic drainage
11. What is the best way for the nurse to obtain the health
history of a 14 year-old client? 18. While teaching a client about their medications, the client
A) Have the mother present to verify information asks how long it will take before the therapeutic effects of
B) Allow an opportunity for the teen to express feelings lithium occur. What is the best response of the nurse?
C) Use the same type of language as the adolescent A) Immediately C) 2 weeks
D) Focus the discussion of risk factors in the peer group B) Several days D) 1 month

12. The nurse is caring for a post myocardial infarction client in 19. A client develops volume overload from an IV that has
an intensive care unit. It is noted that urinary output has infused too rapidly. What assessment would the nurse expect to
dropped from 60 -70 ml per hour to 30 ml per hour. This change find?
is most likely due to A) S3 heart sound
A) dehydration B) Thready pulse
B) diminished blood volume C) Flattened neck veins
C) decreased cardiac output D) Hypoventilation
D) renal failure
20. The nurse is performing a developmental assessment on an
8 month-old. Which finding should be reported to the provider?
A) Lifts head from the prone position
B) Rolls from abdomen to back
13. When a client is having a general tonic clonic seizure, the C) Responds to parents' voices
nurse should D) Falls forward when sitting
A) hold the client's arms at their side 21. Clients with mitral stenosis would likely manifest findings
B) place the client on their side associated with congestion in the
C) insert a padded tongue blade in client's mouth A) pulmonary circulation C) superior vena cava
B) descending aorta D) bundle of His 30. Clients taking which of the following drugs are at risk for
depression?
22. The nurse is assessing a client on admission to a community A) Steroids C) Folic acid
mental health center. The client discloses that she has been B) Diuretics D) Aspirin
thinking about ending her life. The nurse's best response would
be 31. The nurse is teaching a client with dysrhythmia about the
A) "Do you want to discuss this with your pastor?" electrical pathway of an impulse as it travels through the heart.
B) "We will help you deal with those thoughts." Which of these describes the normal pathway?
C) "Is your life so terrible that you want to end it?" A) AV node, SA node, Bundle of His, Purkinje fibers
D) "Have you thought about how you would do it?" B) Purkinje fibers, SA node, AV node, Bundle of His
C) Bundle of His, Purkinje fibers, SA node , AV node
23. The nurse is caring for a newborn who has just been D) SA node, AV node, Bundle of His, Purkinje fibers
diagnosed with hypospadias. When discussing the defect with
the parents, the nurse should communicate that 32. A neonate born 12 hours ago to a methadone maintained
A) circumcision can be performed at any time woman is exhibiting a hyperactive MORO reflex and slight
B) initial repair is delayed until 6-8 years of age tremors. The newborn passed one loose, watery stool. Which of
C) post-operative appearance will be normal these is a nursing priority?
D) surgery will be performed in stages A) Hold the infant at frequent intervals.
B) Assess for neonatal withdrawal syndrome
24. A 2 year-old child is being treated with Amoxicillin C) Offer fluids to prevent dehydration
suspension, 200 milligrams per dose, for acute otitis media. The D) Administer paregoric to stop diarrhea
child weighs 30 lb. (15 kg) and the daily dose range is 20-40
mg/kg of body weight, in three divided doses every 8 hours. 33. A client has received her first dose of fluphenazine (Prolixin)
Using 2 hours ago. She suddenly experiences torticollis and
principles of safe drug administration, what should the nurse do involuntary spastic muscle movement. In addition to
next? administering the ordered anticholinergic drug, what other
A) Give the medication as ordered measure
B) Call the provider to clarify the dose should the nurse implement?
C) Recognize that antibiotics are over-prescribed A) Have respiratory support equipment available
D) Hold the medication as the dosage is too low B) Immediately place her in the seclusion room
C) Assess the client for anxiety and agitation
25. While planning care for a preschool aged child, the nurse D) Administer prn dose of IM antipsychotic medication
takes developmental needs into consideration. Which of the
following would be of the most concern to the nurse? 34. What principle of HIV disease should the nurse keep in mind
A) Playing imaginatively C) Identifying with family when planning care for a newborn who was infected in utero?
B) Expressing shame D) Exploring the playroom A) The disease will incubate longer and progress more slowly in
this infant
26. The nurse is teaching a smoking cessation class and notices B) The infant is very susceptible to infections
there are 2 pregnant women in the group. Which information is C) Growth and development patterns will proceed at a normal
a priority for these women? rate
A) Low tar cigarettes are less harmful during pregnancy D) Careful monitoring of renal function is indicated
B) There is a relationship between smoking and low birth weight
C) The placenta serves as a barrier to nicotine 35. The nurse is caring for a 12 year-old with an acute illness.
D) Moderate smoking is effective in weight control Which of the following indicates the nurse understands
common
27. In order to enhance a client's response to medication for sibling reactions to hospitalization?
chest pain from acute angina, the nurse should emphasize A) Younger siblings adapt very well
A) learning relaxation techniques B) Visitation is helpful for both
B) limiting alcohol use C) The siblings may enjoy privacy
C) eating smaller meals D) Those cared for at home cope better
D) avoiding passive smoke
36. Parents of a 7 year-old child call the clinic nurse because
28. When making a home visit to a client with chronic their daughter was sent home from school because of a rash.
pyelonephritis, which nursing action has the highest priority? The child had been seen the day before by the provider and
A) follow-up on lab values before the visit diagnosed with Fifth Disease (erythema infectiosum). What is
B) observe client findings for the effectiveness of antibiotics the most appropriate action by the nurse?
C) ask for a log of urinary output A) Tell the parents to bring the child to the clinic for further
D) ask for the log of the oral intake evaluation
B) Refer the school officials to printed materials about this viral
29. A new nurse on the unit notes that the nurse manager illness
seems to be highly respected by the nursing staff. The new C) Inform the teacher that the child is receiving antibiotics for
nurse is surprised when one of the nurses states: "The manager the rash
makes all decisions and rarely asks for our input." The best D) Explain that this rash is not contagious and does not require
description of the nurse manager's management style is isolation
A) Participative or democratic
B) Ultraliberal or communicative 37. Which therapeutic communication skill used by the nurse is
C) Autocratic or authoritarian most likely to encourage a depressed client to vent feelings?
D) Laissez faire or permissive A) Direct confrontation
B) Reality orientation
C) Projective identification nutritional disorder in this age group?
D) Active listening A) Bulimia C) Obesity
38. The nurse walks into a client's room and finds the client lying B) Anorexia D) Malnutrition
still and silent on the floor. The nurse should first 6. A pre-term newborn is to be fed breast milk through
A) assess the client's airway nasogastric tube. Breast milk is preferred over formula for
B) call for help premature infants because it
C) establish that the client is unresponsive A) contains less lactose
D) see if anyone saw the client fall B) is higher in calories/ounce
C) provides antibodies
D) has less fatty acid
39. The nurse is caring for a client with end stage renal disease.
What action should the nurse take to assess for patency in a 7. A mother wants to switch her 9 month-old infant from an
fistula used for hemodialysis? iron-fortified formula to whole milk because of the expense.
A) observe for edema proximal to the site Upon further assessment, the nurse finds that the baby eats
B) irrigate with 5 ml of 0.9% Normal Saline table foods well, but drinks less milk than before. What is the
C) palpate for a thrill over the fistula best advice by the nurse?
D) check color and warmth in the extremity A) Change the baby to whole milk
B) Add chocolate syrup to the bottle
40. The nurse caring for a 14 year-old boy with severe C) Continue with the present formula
Hemophilia A, who was admitted after a fall while playing D) Offer fruit juice frequently
basketball. In understanding his behavior and in planning care
for this client, the nurse should understand that adolescents 8. Which of the following nursing assessments for an infant is
with hemophilia most valuable in identifying serious visual defects?
_______. A) Red reflex test
A) must have structured activities B) Visual acuity
B) often take part in active sports C) Pupil response to light
C) explain limitations to peer groups D) Cover test
D) avoid risks after bleeding episodes
9. A 38 year-old female client is admitted to the hospital with an
Q&A Random Selection #14 acute exacerbation of asthma. This is her third admission for
asthma in 7 months. She describes how she doesn't really like
1. The nurse is caring for a client who is in the late stage of having to use her medications all the time. Which explanation
multiple myeloma. Which of the following should be included in by the nurse best describes the long-term consequence of
the plan of care? uncontrolled airway inflammation?
A) Monitor for hyperkalemia A) The alveoli will degenerate
B) Place in protective isolation B) Chronic bronchoconstriction of the large airways will occur
C) Precautions with position changes C) Lung remodeling and permanent changes in lung function will
D) Administer diuretics as ordered result
D) The client will experience frequent bouts of pneumonia
2. A 2 year-old child has just been diagnosed with cystic fibrosis.
The child's father asks the nurse "What is our major concern 10. Which nursing action is a priority as the plan of care is
now, and what will we have to deal with in the future?" Which developed for a 7 year-old child hospitalized for acute
of the following is the best response? glomerulonephritis?
A) "There is a probability of life-long complications." A) Assess for generalized edema
B) "Cystic fibrosis results in nutritional concerns that can be B) Monitor for increased urinary output
dealt with." C) Encourage rest during hyperactive periods
C) "Thin, tenacious secretions from the lungs are a constant D) Note patterns of increased blood pressure
struggle in cystic fibrosis."
D) "You will work with a team of experts and also have access to 11. A nurse is to present information about Chinese folk
a support group that the family can attend." medicine to a group of student nurses. Based on this cultural
belief system, the nurse would explain that illness is attributed
3. The nurse is caring for residents in a long term care setting for to the
the elderly. Which of the following activities will be most A) Yang, the positive force that represents light, warmth, and
effective in meeting the growth and development needs for fullness
persons in this age group? B) Yin, the negative force that represents darkness, cold, and
A) Aerobic exercise classes emptiness
B) Transportation for shopping trips C) use of improper hot foods, herbs and plants
C) Reminiscence groups D) a failure to keep life in balance with nature and others
D) Regularly scheduled social activities
12. A 65-year-old Hispanic-Latino client with prostate cancer
4. A 30 month-old child is admitted to the hospital unit. Which rates his pain as a 6 on a 0-to-10 scale. The client refuses all
of the following toys would be appropriate for the nurse to pain medication other than Motrin, which does not relieve his
select from the toy room for this child? pain. The next action for the nurse to take is to
A) Cartoon stickers A) ask the client about the refusal of certain pain medications
B) Large wooden puzzle B) talk with the client's family about the situation
C) Blunt scissors and paper C) report the situation to the primary care provider
D) Beach ball D) document the situation in the notes

5. The nurse is talking to parents about nutrition in school aged

children. Which of the following is the most common
13. A client is experiencing hallucinations that are markedly A) Maintaining and preserving function
increased at night. The client is very frightened by the B) Anticipating side effects of therapy
hallucinations. The client’s partner asked to stay a few hours C) Supporting coping with limitations
beyond the visiting time, in the client’s private room. What D) Ensuring compliance with medications
would be the best response by the nurse demonstrating
emotional support for the client?
A) "No, it would be best if you brought the client some reading 20. During an examination of a 2 year-old child with a tentative
material that she could read at night." diagnosis of Wilm's tumor, the nurse would be most concerned
B) "No, your presence may cause the client to become more about which statement by the mother?
anxious." A) "My child has lost 3 pounds in the last month."
C) "Yes, staying with the client and orienting her to her B) "Urinary output seemed to be less over the past 2 days."
surroundings may decrease her anxiety." C) "All the pants have become tight around the waist."
D) "Yes, would you like to spend the night when the client’s D) "The child prefers some salty foods more than others."
behavior indicates that she is frightened?"
21. The nurse is caring for a client who has developed cardiac
14. The nurse is caring for a child receiving chest physiotherapy tamponade. Which finding would the nurse anticipate?
(CPT). Which of the following actions by the nurse would be A) Widening pulse pressure
appropriate? B) Pleural friction rub
A) Schedule the therapy thirty minutes after meals C) Distended neck veins
B) Teach the child not to cough during the treatment D) Bradycardia
C) Confine the percussion to the rib cage area
D) Place the child in a prone position for the therapy 22. At the geriatric day care program a client is crying and
repeating "I want to go home. Call my daddy to come for me."
15. A client is admitted with a pressure ulcer in the sacral area. The nurse should
The partial thickness wound is 4 cm by 7 cm, the wound base is A) Inform the client that she must wait until the program ends
red and moist with no exudate and the surrounding skin is at 5:00 pm to leave
intact. Which of the following coverings is most appropriate for B) Give the client simple information about what she will be
this wound? doing
A) transparent dressing C) Tell the client you will call someone to come for her and
B) dry sterile dressing with antibiotic ointment suggest joining the exercise group while she waits
C) wet to dry dressing D) Firmly direct the client to her assigned group activity
D) occlusive moist dressing
23. The nurse assesses a client who has been re-admitted to the
16. A mother asks the nurse if she should be concerned about psychiatric inpatient unit for schizophrenia. His symptoms have
her child’s tendency to stutter. What assessment data will be been managed for several months with fluphenazine (Prolixin).
most useful in counseling the parent? Which should be a focus of the first assessment?
A) Age of the child A) Stressors in the home
B) Sibling position in family B) Medication compliance
C) Stressful family events C) Exposure to hot temperatures
D) Parental discipline strategies D) Alcohol use

17. The nurse is making a home visit to a client with chronic 24. Which type of accidental poisoning would the nurse expect
obstructive pulmonary disease (COPD). The client tells the nurse to occur in children under age 6?
that he used to be able to walk from the house to the mailbox A) Oral ingestion
without difficulty. Now, he has to pause to catch his breath B) Topical contact
halfway through the trip. Which diagnosis would be most C) Inhalation
appropriate for this client based on this assessment? D) Eye splashes
A) Activity intolerance caused by fatigue related to chronic
tissue hypoxia 25. The parents of a 15 month-old child asks the nurse to
B) Impaired mobility related to chronic obstructive pulmonary explain their child's lab results and how they show the child has
disease iron deficiency anemia. The nurse's best response is
C) Self care deficit caused by fatigue related to dyspnea A) "Although the results are here, your doctor will explain them
D) Ineffective airway clearance related to increased bronchial later."
secretions B) "Your child has fewer red blood cells that carry oxygen."
C) "The blood cells that carry nutrients to the cells are too
18. At the day treatment center a client diagnosed with large."
schizophrenia - paranoid type sits alone alertly watching the D) "There are not enough blood cells in your child's circulation."
activities of clients and staff. The client is hostile when
approached and asserts that the doctor gives her medication to 26. At a well baby clinic the nurse is assigned to assess an 8
control her mind. The client's behavior most likely indicates month-old child. Which of these developmental achievements
A) Feelings of increasing anxiety related to paranoia would the nurse anticipate that the child would be able to
B) Social isolation related to altered thought processes perform?
C) Sensory perceptual alteration related to withdrawal from A) Say 2 words
environment B) Pull up to stand
D) Impaired verbal communication related to impaired C) Sit without support
judgment D) Drink from a cup

19. What is the most important aspect to include when

developing a home care plan for a client with severe arthritis?
27. The nurse assesses delayed gross motor development in a 3 35. A victim of domestic violence states to the nurse, "If only I
year-old child. The inability of the child to do which action could change and be how my companion wants me to be, I
confirms this finding? know things would be different." Which would be the best
A) Stand on 1 foot response by the nurse?
B) Catch a ball A) "The violence is temporarily caused by unusual
C) Skip on alternate feet circumstances, don’t stop hoping for a change."
D) Ride a bicycle B) "Perhaps, if you understood the need to abuse, you could
stop the violence."
28. A client was admitted to the psychiatric unit with major C) "No one deserves to be beaten. Are you doing anything to
depression after a suicide attempt. In addition to feeling sad and provoke your spouse into beating you?"
hopeless, the nurse would assess for D) "Batterers lose self-control because of their own internal
A) Anxiety, unconscious anger, and hostility reasons, not because of what their partner did or did not
B) Guilt, indecisiveness, poor self-concept do."
C) Psychomotor retardation or agitation
D) Meticulous attention to grooming and hygiene 36. In a child with suspected coarctation of the aorta, the nurse
would expect to find
29. The nurse is caring for a client with an unstable spinal cord A) strong pedal pulses
injury at the T7 level. Which intervention should take priority in B) diminishing carotid pulses
planning care? C) normal femoral pulses
A) Increase fluid intake to prevent dehydration D) bounding pulses in the arms
B) Place client on a pressure reducing support surface
C) Use skin care products designed for use with incontinence 37. First-time parents bring their 5 day-old infant to the
D) Increase caloric intake to aid healing pediatrician's office because they are extremely concerned
about its breathing pattern. The nurse assesses the baby and
30. A nurse is conducting a community wide seminar on finds that the breath sounds are clear with equal chest
childhood safety issues. Which of these children is at the highest expansion. The respiratory rate is 38-42 breaths per minute
risk for poisoning? with occasional periods of apnea lasting 10 seconds in length.
A) 9 month-old who stays with a sitter 5 days a week What is the correct analysis of these findings?
B) 20 month-old who has just learned to climb stairs A) The pediatrician must examine the baby
C) 10 year-old who occasionally stays at home unattended B) Emergency equipment should be available
D) 15 year-old who likes to repair bicycles C) This breathing pattern is normal
D) A future referral may be indicated
31. A polydrug user has been in recovery for 8 months. The
client has began skipping breakfast and not eating regular 38. A client was admitted to the psychiatric unit with a diagnosis
dinners. The client has also started frequenting bars to "see old of bipolar disorder. He constantly “bothers” other clients, tries
buddies." The nurse understands that the client’s behaviors are to help the housekeeping staff, demonstrates pressured speech
warning signs to indicate that the client may be and demands constant attention from the staff. Which activity
A) headed for relapse would be best for the client?
B) feeling hopeless A) Reading
C) approaching recovery B) Checkers
D) in need of increased socialization C) Cards
D) Ping-pong
32. Privacy and confidentiality of all client information is legally
protected. In which of these situations would the nurse make an 39. When teaching adolescents about sexually transmitted
exception to this practice? diseases, what should the nurse emphasize that is the most
A) When a family member offers information about their loved common infection?
one A) Gonorrhea
B) When the client threatens self-harm and harm to others B) Chlamydia
C) When the provider decides the family has a right to know the C) Herpes
client's diagnosis D) HIV
D) When a visitor insists that the visitor has been given
permission by the client 40. Post-procedure nursing interventions for electroconvulsive
therapy include
33. The nurse admits a client newly diagnosed with A) applying hard restraints if seizure occurs
hypertension. What is the best method for assessing the blood B) permitting client to sleep for 4 to 6 hours
pressure? C) remaining with client until oriented
A) Standing and sitting D) expecting long-term memory loss
B) In both arms
C) After exercising Q&A Random Selection #15
D) Supine position
1. The nurse enters a 2 year-old child's hospital room in order to
34. A client is admitted with the diagnosis of meningitis. Which administer an oral medication. When the child is asked if he is
finding would the nurse expect when assessing this client? ready to take his medicine, he immediately says, "No!". What
A) Hyperextension of the neck with passive shoulder flexion would be the most appropriate next action?
B) Flexion of the hip and knees with passive flexion of the neck A) Leave the room and return five minutes later and give the
C) Flexion of the legs with rebound tenderness medicine
D) Hyperflexion of the neck with rebound flexion of the legs B) Explain to the child that the medicine must be taken now
C) Give the medication to the father and ask him to give it
D) Mix the medication with ice cream or applesauce
 9. A home health nurse is caring for a client with a pressure sore
2. During the evaluation phase for a client, the nurse should that is red, with serous drainage, is 2 inches in diameter with
focus on loss of subcutaneous tissue. The appropriate dressing for this
A) All finding of physical and psychosocial stressors of the client wound is
and in the family A) transparent film dressing
B) The client's status, progress toward goal achievement, and B) wet dressing with debridement granules
ongoing re-evaluation C) wet to dry with hydrogen peroxide
C) Setting short and long-term goals to insure continuity of care D) moist saline dressing
from hospital to home
D) Select interventions that are measurable and achievable 10. The school nurse suspects that a third grade child might
within selected timeframes have attention deficit hyperactivity disorder (ADHD). Prior to
referring the child for further evaluation, the nurse should
3. The nurse is providing instructions to a new mother on the A) observe the child's behavior on at least 2 occasions
proper techniques for breast feeding her infant. Which B) consult with the teacher about how to control impulsivity
statement by the mother indicates the need for additional C) compile a history of behavior patterns and developmental
instruction? accomplishments
A) "I should position my baby completely facing me with my D) compare the child's behavior with classic signs and symptoms
baby's mouth in front of my nipple." 11. A client is admitted with a diagnosis of hepatitis B. In
B) "The baby should latch onto the nipple and areola areas." reviewing the initial laboratory results, the nurse would expect
C) "There may be times that I will need to manually express to find elevation in which of the following values?
milk." A) Blood urea nitrogen
D) " I can switch to a bottle if I need to take a break from breast B) Acid phosphatase
feeding." C) Bilirubin
D) Sedimentation rate
4. The nurse is planning to give a 3 year-old child oral digoxin.
Which of the following is the best approach by the nurse? 12. The nurse is assessing a child for clinical manifestations of
A) "Do you want to take this pretty red medicine?" iron deficiency anemia. Which factor would the nurse recognize
B) "You will feel better if you take your medicine." as the cause of the findings?
C) "This is your medicine, and you must take it all right now." A) Decreased cardiac output
D) "Would you like to take your medicine from a spoon or a B) Tissue hypoxia
cup?" C) Cerebral edema
D) Reduced oxygen saturation
5. A 4 year-old child is recovering from chicken pox (varicella).
The parents would like to have the child return to day care as 13. A recovering alcoholic asked the nurse, "Will it be ok for me
soon as possible. In order to ensure that the illness is no longer to just drink at special family gatherings?" Which initial
communicable, what should the nurse assess for in this child? response by the nurse would be best?
A) All lesions crusted A) "A recovering person has to be very careful not to lose
B) Elevated temperature control, therefore, confine your drinking only to family
C) Rhinorrhea and coryza gatherings."
D) Presence of vesicles B) "At your next AA meeting discuss the possibility of limited
drinking with your sponsor."
6. The nurse is performing an assessment on a child with severe C) "A recovering person needs to get in touch with their
airway obstruction. Which finding would the nurse anticipate? feelings. Do you want a drink?"
A) Retractions in the intercostal tissues of the thorax D) "A recovering person cannot return to drinking without
B) Chest pain aggravated by respiratory movement starting the addiction process over."
C) Cyanosis and mottling of the skin
D) Rapid, shallow respirations 14. The nurse would expect the cystic fibrosis client to receive
supplemental pancreatic enzymes along with a diet
7. A nurse is assigned to a client who is newly admitted for A) high in carbohydrates and proteins
treatment of a frontal lobe brain tumor. Which history offered B) low in carbohydrates and proteins
by the family members would be recognized by the nurse as C) high in carbohydrates, low in proteins
associated with the diagnosis, and communicated to the D) low in carbohydrates, high in proteins
provider?
A) "My partner's breathing rate is usually below 12." 15. A Hispanic client in the postpartum period refuses the
B) "I find the mood swings and the change from a calm person hospital food because it is "cold." The best initial action by the
to being angry all the time hard to deal with." nurse is to
C) "It seems our sex life is nonexistent over the past 6 months." A) have the unlicensed assistive personnel (UAP) reheat the
D) "In the morning and evening I hear complaints that reading is food if the client wishes
next to impossible from blurred print." B) ask the client what foods are acceptable or are unacceptable
C) encourage her to eat for healing and strength
8. A client is receiving nitroprusside IV for the treatment of D) schedule the dietitian to meet with the client as soon as
acute heart failure with pulmonary edema. What diagnostic lab possible
value should the nurse monitor when a client is receiving this
medication? 16. The nurse is assigned to a client who has heart failure .
A) Potassium level During the morning rounds the nurse sees the client develop
B) Arterial blood gasses sudden anxiety, diaphoresis and dyspnea. The nurse
C) Blood urea nitrogen auscultates, crackles bilaterally. Which nursing intervention
D) Thiocyanate should be performed first?
A) Take the client's vital signs
B) Place the client in a sitting position with legs dangling A) Discuss with the mother sharing parenting responsibilities
C) Contact the health care provider B) Set time aside to get the mother to express her feelings and
D) Administer the PRN antianxiety agent concerns
C) Arrange for the parents to attend infant care classes
17. Based on principles of teaching and learning, what is the D) Talk with the father and help him accept the wife's decision
best initial approach to pre-op teaching for a client scheduled
for coronary artery bypass? 25. The nurse is talking with a client. The client abruptly says to
A) Touring the coronary intensive unit the nurse, "The moon is full. Astronauts walk on the moon.
B) Mailing a video tape to the home Walking is a good health habit." The client’s remarks most likely
C) Assessing the client's learning style indicate
D) Administering a written pre-test A) neologisms C) loose associations
B) flight of ideas D) word salad
18. In evaluating the growth of a 12 month-old child, which of
these findings would the nurse expect to be present in the 26. A mother asks about expected motor skills for a 3 year-old
infant? child. Which of the following would the nurse emphasize as
A) Increased 10% in height normal at this age?
B) 2 deciduous teeth A) Jumping rope
C) Tripled the birth weight B) Tying shoelaces
D) Head > chest circumference C) Riding a tricycle
19. A nurse is doing preconception counseling with a woman D) Playing hopscotch
who is planning a pregnancy. Which of the following statements 27. The nurse is monitoring the contractions of a woman in
suggests that the client understands the connection between labor. A contraction is recorded as beginning at 10:00 A.M. and
alcohol consumption and fetal alcohol syndrome? ending at 10:01 A.M. Another begins at 10:15 A.M. What is the
A) "I understand that a glass of wine with dinner is healthy." frequency of the contractions?
B) "Beer is not really hard alcohol, so I guess I can drink some." A) 14 minutes
C) "If I drink, my baby may be harmed before I know I am B) 10 minutes
pregnant." C) 15 minutes
D) "Drinking with meals reduces the effects of alcohol." D) Nine minutes

20. In planning care for a child diagnosed with minimal change 28. A client who has been drinking for five years states that he
nephrotic syndrome, the nurse should understand the drinks when he gets upset about "things" such as being
relationship between edema formation and unemployed or feeling like life is not leading anywhere. The
A) increased retention of albumin in the vascular system nurse understands that the client is using alcohol as a way to
B) decreased colloidal osmotic pressure in the capillaries deal with
C) fluid shift from interstitial spaces into the vascular space A) recreational and social needs
D) reduced tubular reabsorption of sodium and water B) feelings of anger
C) life’s stressors
21. Which of these parents’ comments about a newborn would D) issues of guilt and disappointment
most likely reveal an initial finding of a suspected pyloric
stenosis? 29. The nurse is preparing a 5 year-old for a scheduled
A) "I noticed a little lump a little above the belly button." tonsillectomy and adenoidectomy. The parents are anxious and
B) "The baby seems hungry all the time." concerned about the child's reaction to impending surgery.
C) "Mild vomiting turned into vomiting that shot across the Which nursing intervention would best prepare the child?
room." A) Introduce the child to all staff the day before surgery
D) "We notice irritation and spitting up immediately after B) Explain the surgery 1 week prior to the procedure
feedings." C) Arrange a tour of the operating and recovery rooms
D) Encourage the child to bring a favorite toy to the hospital
22. Which of the actions suggested to the registered nurse (RN)
by the practical nurse (PN) during a planning conference for a 10 30. The nurse should recognize that physical dependence is
month-old infant admitted 2 hours ago with bacterial meningitis accompanied by what findings when alcohol consumption is
would be acceptable to add to the plan of care? first reduced or ended?
A) measure head circumference A) Seizures
B) place in airborne isolation B) Withdrawal
C) provide passive range of motion C) Craving
D) provide an over-the-crib protective top D) Marked tolerance

23. The nurse is discussing nutritional requirements with the 31. The client who is receiving enteral nutrition through a
parents of an 18 month-old child. Which of these statements gastrostomy tube has had 4 diarrhea stools in the past 24 hours.
about milk consumption is correct? The nurse should
A) May drink as much milk as desired A) review the medications the client is receiving
B) Can have milk mixed with other foods B) increase the formula infusion rate
C) Will benefit from fat-free cow's milk C) increase the amount of water used to flush the tube
D) Should be limited to 3-4 cups of milk daily D) attach a rectal bag to protect the skin

24. A postpartum mother is unwilling to allow the father to 32. The nurse, assisting in applying a cast to a client with a
participate in the newborn's care, although he is interested in broken arm, knows that the
doing so. She states, "I am afraid the baby will be confused A) cast material should be dipped several times into the warm
about who the mother is. Baby raising is for mothers, not water
fathers." The nurse's initial intervention should be what focus? B) cast should be covered until it dries
C) wet cast should be handled with the palms of hands
D) casted extremity should be placed on a cloth-covered surface 40. The father of an 8 month-old infant asks the nurse if his
child's vocalizations are normal for his age. Which of the
33. In taking the history of a pregnant woman, which of the following would the nurse expect at this age?
following would the nurse recognize as the primary A) Cooing
contraindication for breast feeding? B) Imitation of sounds
A) Age 40 years C) Throaty sounds
B) Lactose intolerance D) Laughter
C) Family history of breast cancer
D) Use of cocaine on weekends Q&A Random Selection #16

34. Immediately following an acute battering incident in a 1. Which statement by a parent would alert the nurse to assess
violent relationship, the batterer may respond to the partner’s for iron deficiency anemia in a 14 month-old child?
injuries by A) "I know there is a problem since my baby is always
A) seeking medical help for the victim's injuries constipated."
B) minimizing the episode and underestimating the victim’s B) "My child doesn't like many fruits and vegetables, but she
injuries really loves her milk."
C) contacting a close friend and asking for help C) "I can't understand why my child is not eating as much as she
D) being very remorseful and assisting the victim with medical did 4 months ago."
care D) "My child doesn't drink a whole glass of juice or water at 1
time."
35. A client with emphysema visits the clinic. While teaching
about proper nutrition, the nurse should emphasize that the 2. When counseling a 6 year-old who is experiencing enuresis,
client should what must the nurse understand about the pathophysiological
A) eat foods high in sodium to increase sputum liquefaction basis of this disorder?
B) use oxygen during meals to improve gas exchange A) It has no clear etiology
C) perform exercise after respiratory therapy to enhance B) Enuresis may be associated with sleep phobia
appetite C) It has a definite genetic link
D) cleanse the mouth of dried secretions to reduce risk of D) Enuresis is a sign of willful misbehavior
infection 3. Following surgery for placement of a ventriculoperitoneal
(VP) shunt as treatment for hydrocephalus, the parents
36. A victim of domestic violence tells the batterer she needs a question why the infant has a small abdominal incision. The best
little time away. How would the nurse expect that the batterer response by the nurse would be to explain that the incision was
might respond? made in order to
A) With acceptance and views the victim’s comment as an A) pass the catheter into the abdominal cavity
indication that their marriage is in trouble B) place the tubing into the urinary bladder
B) With fear of rejection causing increased rage toward the C) visualize abdominal organs for catheter placement
victim D) insert the catheter into the stomach
C) With a new commitment to seek counseling to assist with
their marital problems 4. A client with bipolar disorder is reluctant to take lithium
D) With relief, and welcomes the separation as a means to have (Lithane) as prescribed. The most therapeutic response by the
some personal time nurse to his refusal is
A) "You need to take your medicine, this is how you get well."
37. An 18 month-old has been brought to the emergency room B) "If you refuse your medicine, we’ll just have to give you a
with irritability, lethargy over 2 days, dry skin, and increased shot."
pulse. Based upon the evaluation of these initial findings, the C) "What is it about the medicine that you don’t like?"
nurse would assess the child for additional findings of D) "I can see that you are uncomfortable right now, I’ll wait until
A) septicemia tomorrow."
B) dehydration
C) hypokalemia 5. Delirium tremens could best be described as
D) hypercalcemia A) disorganized thinking, feelings of terror and non-purposeful
behavior
38. The nurse prepares for a Denver Screening of a 3 year-old B) a generalized shaking of the body accompanied by repetitive
child in the clinic. The mother asks the nurse to explain the thoughts
purpose of the test. What is the nurse’s best response about the C) an excited state accompanied by disorientation, hallucination
purpose of the Denver? and tachycardia
A) "It measures a child’s intelligence." D) single or multiple jerks caused by rapid contracting muscles
B) "It assesses a child's development."
C) "It evaluates psychological responses." 6. When providing nursing measures to relieve a 102-degree
D) " It helps to determine problems." Fahrenheit fever in a toddler with an infection, what is the most
effective intervention?
39. The nurse is caring for a toddler with atopic dermatitis. The A) Use medications to lower the temperature set point
nurse should instruct the parents to B) Apply extra layers of clothing to prevent shivering
A) Dress the child warmly to avoid chilling C) Immerse the child in a tub containing cool water
B) Keep the child away from other children for the duration of D) Give a tepid sponge bath prior to giving an antipyretic
the rash
C) Clean the affected areas with tepid water and detergent 7. In planning care for a 6 month-old infant, what must the
D) Wrap the child's hand in mittens or socks to prevent nurse provide to assist in the development of trust?
scratching A) Food
B) Warmth B) Heat intolerance
C) Security C) Diarrhea
D) Comfort D) Skin eruptions

8. Alcohol and drug abuse impairs judgment and increases risk 16. A child is sent to the school nurse by a teacher who has a
taking behavior. What nursing diagnosis best applies? written note that fifth disease is suspected. Which characteristic
A) Risk for injury would the nurse expect to find?
B) Risk for knowledge deficit A) Macule that rapidly progresses to papule and then vesicles
C) Altered thought process B) Erythema on the face, primarily on cheeks giving a "slapped
D) Disturbance in self-esteem face" appearance
C) Discrete rose pink macules will appear first on the trunk and
9. The nurse sees a substance abusing client occasionally in the fade when pressure is applied
outpatient clinic. In evaluating the client's progress, the nurse D) Koplik spots appear first followed by a rash that appears first
recognizes that the most revealing resistant behavior is on the face and spreads downward
A) recurring crises
B) continuing drug use 17. While working with an obese adolescent, it is important for
C) rationalizing comments the nurse to recognize that obesity in adolescence is most often
D) missing appointments associated with what other finding?
A) Sexual promiscuity
10. A client has been admitted with complaints of lower B) Poor body image
abdominal pain, difficulty swallowing, nausea, dizziness, C) Dropping out of school
headache and fatigue. The client is agitated, fearful, tachycardic D) Drug experimentation
and complains of being "too sick to return to work." The client is
diagnosed as having somatoform disorder. In formulating a plan
of care, the nurse must consider that the client's behavior 18. The emergency room nurse admits a child who experienced
A) is controlled by their subconscious mind a seizure at school. The parent comments that this is the first
B) is manipulative to avoid work responsibilities occurrence and denies any family history of epilepsy. What is
C) would respond to psychoeducational strategies the best response by the nurse?
D) could be modified through reality therapy A) "Do not worry. Epilepsy can be treated with medications."
B) "The seizure may or may not mean your child has epilepsy."
11. The nurse is providing instructions for a client with C) "Since this was the first convulsion, it may not happen again."
pneumonia. What is the most important information to convey D) "Long term treatment will prevent future seizures."
to the client?
A) "Take at least 2 weeks off from work." 19. A nurse is eating in the hospital cafeteria when a toddler at a
B) "You will need another chest x-ray in 6 weeks." nearby table chokes on a piece of food and appears slightly
C) "Take your temperature every day." blue. The appropriate initial action should be to
D) "Complete all of the antibiotic even if your findings A) begin mouth to mouth resuscitation
decrease." B) give the child water to help in swallowing
C) perform 5 abdominal thrusts
12. The nurse is caring for a pre-adolescent client in skeletal D) call for the emergency response team
Dunlop traction. Which nursing intervention is appropriate for
this child? 20. The parents of a 2 year-old child report that he has been
A) Make certain the child is maintained in correct body holding his breath whenever he has temper tantrums. What is
alignment. the best action by the nurse?
B) Be sure the traction weights touch the end of the bed. A) Teach the parents how to perform cardiopulmonary
C) Adjust the head and foot of the bed for the child's comfort resuscitation
D) Release the traction for 15-20 minutes every 6 hours PRN. B) Recommend that the parents give in when he holds his
breath to prevent anoxia
13. A victim of domestic violence states, "If I were better, I C) Advise the parents to ignore breath holding because
would not have been beat." Which feeling best describes what breathing will begin as a reflex
the victim may be experiencing? D) Instruct the parents on how to reason with the child about
A) Fear possible harmful effects
B) Helplessness
C) Self-blame 21. The nurse is teaching a client with metastatic bone disease
D) Rejection about measures to prevent hypercalcemia. It would be
important for the nurse to emphasize
14. A nurse and client are talking about the client’s progress A) the need for at least 5 servings of dairy products daily
toward understanding his behavior under stress. This is typical B) restriction of fluid intake to less than 1 liter per day
of which phase in the therapeutic relationship? C) the importance of walking as much as possible
A) Pre-interaction D) early recognition of findings associated with tetany
B) Orientation
C) Working 22. The nurse is talking by telephone with a parent of a 4 year-
D) Termination old child who has chickenpox. Which of the following
demonstrates appropriate teaching by the nurse?
15. A client is admitted with low T3 and T4 levels and an A) Chewable aspirin is the preferred analgesic
elevated thyroid stimulating hormone (TSH) level. On initial B) Topical cortisone ointment relieves itching
assessment, the nurse would anticipate which of the following C) Papules, vesicles, and crusts will be present at one time
findings? D) The illness is only contagious prior to lesion eruption
A) Lethargy
23. An ambulatory client reports edema during the day in his
feet and ankles that disappears while sleeping at night. What is 32. The nurse is assessing the mental status of a client admitted
the most appropriate follow-up question for the nurse to ask? with possible organic brain disorder. Which of these questions
A) "Have you had a recent heart attack?" will best assess the functioning of the client's recent memory?
B) "Do you become short of breath during your normal daily A) "Name the year." "What season is this?" (pause for answer
activities?" after each question)
C) "How many pillows do you use at night to sleep B) "Subtract 7 from 100 and then subtract 7 from that." (pause
comfortably?" for answer) "Now continue to subtract 7 from the new
D) "Do you smoke?" number."
C) "I am going to say the names of three things and I want you
24. A 35 year-old client with sickle cell crisis is talking on the to repeat them after me: blue, ball, pen."
telephone but stops as the nurse enters the room to request D) "What is this on my wrist?" (point to your watch) Then ask,
something for pain. The nurse should "What is the purpose of it?"
A) administer a placebo
B) encourage increased fluid intake 33. The nursing care plan for a toddler diagnosed with Kawasaki
C) administer the prescribed analgesia disease (mucocutaneous lymph node syndrome) should be
D) recommend relaxation exercises for pain control based on the high risk for development of which problem?
A) Chronic vessel plaque formation
25. The nurse should initiate discharge planning for a client B) Pulmonary embolism
A) when the client or family demonstrate readiness to learn self C) Occlusions at the vessel bifurcations
care modalities D) Coronary artery aneurysms
B) when informed that a date for discharge has been
determined 34. The nurse auscultates bibasilar inspiratory crackles in a
C) upon admission to a hospital unit or the emergency room newly admitted 68 year-old client with a diagnosis of congestive
D) when the client's condition is stabilized on the assigned unit heart disease. Which other finding is most likely to occur?
A) Chest pain C) Nail clubbing
26. A new nurse manager is seeking a mentor in the B) Peripheral edema D) Lethargy
administrative realm. Which of these characteristics is a priority 35. The nurse is discussing negativity with the parents of a 30
for the outcome of a positive experience with a mentor? month-old child. How should the nurse tell the parents to best
A) Information is clarified as needed respond to this behavior?
B) A teacher-coach role is taken by the mentor A) Reprimand the child and give a 15 minute "time out"
C) The mentee accepts feedback objectively B) Maintain a permissive attitude for this behavior
D) The mentor is randomly assigned by administration C) Use patience and a sense of humor to deal with this behavior
D) Assert authority over the child through limit setting
27. The nurse is assessing a client in the emergency room.
Which statement suggests that the problem is acute angina? 36. What is the most important consideration when teaching
A) "My pain is deep in my chest behind my breast bone." parents how to reduce risks in the home?
B) "When I sit up the pain gets worse." A) Age and knowledge level of the parents
C) "As I take a deep breath the pain gets worse." B) Proximity to emergency services
D) "The pain is right here in my stomach area." C) Number of children in the home
D) Age of children in the home
28. While caring for a toddler with croup, which initial sign of
croup requires the nurse's immediate attention? 37. A nurse has just received a medication order which is not
A) Respiratory rate of 42 legible. Which statement best reflects assertive
B) Lethargy for the past hour communication?
C) Apical pulse of 54 A) "I cannot give this medication as it is written. I have no idea
D) Coughing up copious secretions of what you mean."
B) "Would you please clarify what you have written so I am sure
29. Parents of a 6 month-old breast fed baby ask the nurse I am reading it correctly?"
about increasing the baby's diet. Which of the following should C) "I am having difficulty reading your handwriting. It would
be added first? save me time if you would be more careful."
A) Cereal C) Meat D) "Please print in the future so I do not have to spend extra
B) Eggs D) Juice time attempting to read your writing."

30. The nurse is planning care for a client during the acute phase 38. Hospital staff requests that the parents with a Greek
of a sickle cell vaso-occlusive crisis. Which of the following heritage of a hospitalized infant remove the amulet from
actions would be most appropriate? around the child's neck. The parents refuse. The nurse
A) Fluid restriction 1000cc per day understands that the parents may be concerned about
B) Ambulate in hallway 4 times a day A) mental development delays
C) Administer analgesic therapy as ordered B) evil eye or envy of others
D) Encourage increased caloric intake C) fright from spiritual beings
D) balance in body systems
31. The nurse is caring for a client with a pressure ulcer on the
heel that is covered with black hard tissue. Which would be an 39. A nurse admits a 3 week-old infant to the special care
appropriate goal in planning care for this client? nursery with a diagnosis of bronchopulmonary dysplasia. As the
A) Protection for the granulation tissue nurse reviews the birth history, which data would be most
B) Heal infection consistent with this diagnosis?
C) Debride eschar A) Gestational age assessment suggested growth retardation
D) Keep the tissue intact B) Meconium was cleared from the airway at delivery
C) Phototherapy was used to treat Rh incompatibility 8. A client calls the nurse with a complaint of sudden deep
D) The infant received mechanical ventilation for 2 weeks throbbing leg pain. What is the appropriate first action by the
nurse?
40. The nurse is assessing a healthy child at the 2 year check up. A) Suggest isometric exercises
Which of the following should the nurse report immediately to B) Maintain the client on bed rest
the health care provider? C) Ambulate for several minutes
A) Height and weight percentiles vary widely D) Apply ice to the extremity
B) Growth pattern appears to have slowed
C) Recumbent and standing height are different 9. The nurse will administer liquid medicine to a 9 month-old
D) Short term weight changes are uneven child. Which of the following methods is appropriate?
A) Allow the infant to drink the liquid from a medicine cup
Q&A Random Selection #17 B) Administer the medication with a syringe next to the tongue
1. A client refuses to take the medication prescribed because C) Mix the medication with the infant's formula in the bottle
the client prefers to take self-prescribed herbal preparations. D) Hold the child upright and administer the medicine by spoon
What is the initial action the nurse should take?
A) Report the behavior to the charge nurse 10. A mother telephones the clinic and says “I am worried
B) Talk with the client to find out about the preferred herbal because my breast-fed 1 month-old infant has soft, yellow
preparation stools after each feeding.” The nurse's best response would be
C) Contact the client's primary care provider which of these?
D) Explain the importance of the medication to the client A) "This type of stool is normal for breast fed infants. Keep
doing as you have."
2. During the two-month well-baby visit, the mother complains B) "The stool should have turned to light brown by now. We
that formula seems to stick to her baby's mouth and tongue. need to test the stool."
Which of the following would provide the most valuable data C) "Formula supplements might need to be added to increase
for nursing assessment? the bulk of the stools."
A) Inspect the baby's mouth and throat D) "Water should be offered several times each day in addition
B) Obtain cultures of the mucous membranes to the breast feeding."
C) Flush both sides of the mouth with normal saline
D) Use a soft cloth to attempt to remove the patches
3. Dual diagnosis indicates that there is a substance abuse
problem as well as a
A) cross addiction 11. A nurse manager considers changing staff assignments from
B) mental disorder 8 hour shifts to 12 hour shifts. A staff-selected planning
C) disorder of any type committee has approved the change, yet the staff are not
D) medical problem receptive to the plan. As a change agent, the nurse manager
should first
4. A client admits to benzodiazepine dependence for several A) support the planning committee and post the new schedule
years. She is now in an outpatient detoxification program. The B) explore how the planning committee evaluated barriers to
nurse must understand that a priority during withdrawal is the plan
A) avoiding alcohol use during this time C) design a different approach to deliver care with fewer staff
B) observing the client for hypotension D) retain the previous staffing pattern for another 6 months
C) abrupt discontinuation of the drug
D) assessing for mild physical symptoms 12. What is the major developmental task that the mother must
accomplish during the first trimester of pregnancy?
5. To obtain data for the nursing assessment, the nurse should: A) Acceptance of the pregnancy
A) observe carefully the client’s nonverbal behaviors B) Acceptance of the termination of the pregnancy
B) adhere to pre-planned interview goals and structure C) Acceptance of the fetus as a separate and unique being
C) allow clients to talk about whatever they want D) Satisfactory resolution of fears related to giving birth
D) elicit clients' description of their experiences, thoughts and
behaviors 13. The nurse is assigned to care for a client newly diagnosed
with angina. As part of discharge teaching, it is important to
6. A client with a history of heart disease takes prophylactic remind the client to remove the nitroglycerine patch after 12
aspirin daily. The nurse should monitor which of the following to hours in order to prevent what condition?
prevent aspirin toxicity? A) Skin irritation
A) Serum potassium B) Drug tolerance
B) Protein intake C) Severe headaches
C) Lactose tolerance D) Postural hypotension
D) Serum albumin
14. The most common reason for an Apgar score of 8 and 9 in a
7. The nurse is teaching diet restrictions for a client with newborn is an abnormality of what parameter?
Addison's disease. The client would indicate an understanding A) Heart rate
of the diet by stating B) Muscle tone
A) "I will increase sodium and fluids and restrict potassium." C) Cry
B) "I will increase potassium and sodium and restrict fluids." D) Color
C) "I will increase sodium, potassium and fluids."
D) "I will increase fluids and restrict sodium and potassium." 15. The nurse is caring for a depressed client with a new
prescription for a selective serotonin reuptake inhibitor (SSRI)
antidepressant. In reviewing the admission history and physical, glucose reading was just performed. You will explain to the
which of the following should prompt questions about the client that the HbA test:
safety of this medication? A) Provides a more precise blood glucose value than self-
A) History of obesity monitoring
B) Prescribed use of a monoamine oxidase (MAO) inhibitor B) Is performed to detect complications of diabetes
C) Diagnosis of vascular disease C) Measures circulating levels of insulin
D) Takes antacids frequently D) Reflects an average blood sugar for several months

16. The nurse is caring for several 70 to 80 year-old clients on 23. The nurse is caring for a client with a deep vein thrombosis.
bed rest. What is the most important measure to prevent skin Which finding would require the nurse's immediate attention?
breakdown? A) Temperature of 102 degrees Fahrenheit
A) Massage legs frequently B) Pulse rate of 98 beats per minute
B) Frequent turning C) Respiratory rate of 32
C) Moisten skin with lotions D) Blood pressure of 90/50
D) Apply moist heat to reddened areas
24. The nurse is planning care for a 2 year-old hospitalized child.
17. A nurse aide is taking care of a 2 year-old child with Wilm's Which of the following will produces the most stress at this age?
tumor. The nurse aide asks the nurse why there is a sign above A) Separation anxiety
the bed that says DO NOT PALPATE THE ABDOMEN? The best B) Fear of pain
response by the nurse would be which of these statements? C) Loss of control
A) "Touching the abdomen could cause cancer cells to spread." D) Bodily injury
B) "Examining the area would cause difficulty to the child."
C) "Pushing on the stomach might lead to the spread of 25. During the initial physical assessment on a client who is a
infection." Vietnamese immigrant, the nurse notices small, circular,
D) "Placing any pressure on the abdomen may cause an ecchymotic areas on the client's knees. The best action for the
abnormal experience." nurse to take is to
A) Ask the client for more information about the nature of the
18. In preparing medications for a client with a gastrostomy bruises
tube, the nurse should contact the health care provider before B) Ask the client and then the family about the findings
administering which of the following drugs through the tube? C) Report the bruising to social services to follow-up
A) Cardizem SR tablet (diltiazem) D) Document the findings on the admission sheet
B) Lanoxin liquid
C) Os-cal tablet (calcium carbonate) 26. Which type of traction can the nurse expect to be used on a
D) Tylenol liquid (acetaminophen) 7 year-old with a fractured femur and extensive skin damage?
19. A nurse arranges for a interpreter to facilitate A) Ninety-ninety C) Bryant
communication between the health care team and a non- B) Buck's D) Russell
English speaking client. To promote therapeutic communication, 27. A client with considerable pain asks, “What is your opinion
the appropriate action for the nurse to remember when regarding acupuncture as a drug-free method for alleviating
working with an interpreter is to pain?” The nurse responds, "I'd forget about it as those weird
A) promote verbal and nonverbal communication with both the non-Western treatments can be scary." The nurse's response is
client and the interpreter an example of
B) speak only a few sentences at a time and then pause for a A) prejudice C) ethnocentrism
few moments B) discrimination D) cultural insensitivity
C) plan that the encounter will take more time than if the client
spoke English 28. The nurse is speaking to a group of parents and elementary
D) ask the client to speak slowly and to look at the person school teachers about care for children with rheumatic fever. It
spoken to is a priority to emphasize that
A) home schooling is preferred to classroom instruction
20. A nurse has asked a second staff nurse to sign for a wasted B) children may remain strep carriers for years
narcotic, which was not witnessed by another person. This C) most play activities will be restricted indefinitely
seems to be a recent pattern of behavior. What is the D) clumsiness and behavior changes should be reported
appropriate initial action?
A) Report this immediately to the nurse manager 29. A 6 year-old child diagnosed with acute glomerulonephritis
B) Confront the nurse about the suspected drug use (AGN) is experiencing anorexia, moderate edema and elevated
C) Sign the narcotic sheet and document the event in an blood urea nitrogen (BUN) levels. The child requests a peanut
incident report butter sandwich for lunch. What would the nurse's best
D) Counsel the colleague about the risky behaviors response to this request?
A) "That's a good choice, and I know it is your favorite. You can
21. A mother calls the clinic, concerned that her 5 week-old have it today."
infant is "sleeping more than her brother did." What is the best B) "I'm sorry, that is not a good choice, but you could have
initial response? pasta."
A) "Do you remember his sleep patterns?" C) "I know that is your favorite, but let me help you pick another
B) "How old is your other child?" lunch."
C) "Why do you think this a concern?" D) "You cannot have the peanut butter until you are feeling
D) "Does the baby sleep after feeding?" better."

22. A diabetic client asks the nurse why the provider ordered a 30. A 24 year-old male is admitted with a diagnosis of testicular
glycosylated hemoglobin (HbA) measurement, since a blood cancer. The nurse would expect the client to have
A) scrotal discoloration
B) sustained painful erection
C) inability to achieve erection 1. The nurse is caring for a child immediately after surgical
D) heaviness in the affected testicle correction of a ventricular septal defect. Which of the following
nursing assessments should be a priority?
31. Which statement describes factors that help build personal A) Blanch nail beds for color and refill
power in an organization? B) Assess for post-operative arrhythmias
A) Longevity in an organization, social ties to people in power, C) Auscultate for pulmonary congestion
and a history as someone who does not back down in D) Monitor equality of peripheral pulses
conflict ends with success
B) Goals are met with the use of networking, mentoring, and 2. A client is receiving external beam radiation to the
coalition building mediastinum for treatment of bronchial cancer. Addressing
C) High visibility and formal power are maintained with a which of the following should take priority in planning care?
confrontational style A) Esophagitis C) Fatigue
D) Credibility to one's position is enhanced when professional B) Leukopenia D) Skin irritation
dress and demeanor are employed
3. A nurse is to collect a sputum specimen for acid-fast bacillus
32. Which statement describes the advantage of using a (AFB) from a client. Which action should the nurse take first?
decision grid for decision making? A) Ask client to cough sputum into container
A) It is both a visual and a quantitative method of decision B) Have the client take several deep breaths
making C) Provide a appropriate specimen container
B) It is the fastest way for group decision making D) Assist with oral hygiene
C) It allows the data to be graphed for easy interpretation
D) It is the only truly objective way to make a decision in a group 4. A client has a history of chronic obstructive pulmonary
disease (COPD). As the nurse enters the client's room, his
33. A nurse is caring for a client with peripheral arterial oxygen is running at 6 liters per minute, his color is flushed and
insufficiency of the lower extremities. Which intervention his respirations are 8 per minute. What should the nurse do
should be included in the plan of care to reduce leg pain? first?
A) elevate the legs above the heart A) Obtain a 12-lead EKG
B) increase ingestion of caffeine products B) Place client in high Fowler's position
C) apply cold compresses C) Lower the oxygen rate
D) lower the legs to a dependent position D) Take baseline vital signs

34. The nurse is caring for a client with COPD who becomes 5. A 4 year-old has been hospitalized for 24 hours with skeletal
dyspneic. The nurse should traction for treatment of a fracture of the right femur. The
A) instruct the client to breathe into a paper bag nurse finds that the child is now crying and the right foot is pale
B) place the client in a high Fowler's position with the absence of a pulse. What should the nurse do first?
C) assist the client with pursed lip breathing A) Notify the health care provider
D) administer oxygen at 6L/minute via nasal cannula B) Readjust the traction
C) Administer the ordered prn medication
35. After successful alcohol detoxification, a client remarked to D) Reassess the foot in fifteen minutes
a friend, "I’ve tried to stop drinking but I just can’t. I can’t even
work without having a drink." The client’s belief that he needs 6. A nurse checks a client who is on a volume-cycled ventilator.
alcohol indicates his dependence is primarily Which finding indicates that the client may need suctioning?
A) psychological C) biological A) Drowsiness C) Pulse rate of 82
B) physical D) social-cultural B) Complaint of nausea D) Restlessness

36. The nurse is caring for several hospitalized children with the 7. A client has returned from a cardiac catheterization. Which
following diagnoses. Which disorder is likely to result in one of the following findings would indicate the client is
metabolic acidosis? experiencing a complication from the procedure?
A) Severe diarrhea for 24 hours A) Increased blood pressure
B) Nausea with anorexia B) Increased heart rate
C) Alternating constipation and diarrhea C) Loss of pulse in the extremity
D) Vomiting for over 48 hours D) Decreased urine output

37. The nurse detects blood-tinged fluid leaking from the nose 8. The nurse is assessing a client 2 hours postoperatively after a
and ears of a head trauma client. What is the appropriate femoral popliteal bypass. The upper leg dressing becomes
nursing action? saturated with blood. The nurse's first action should be to
A) Pack the nose and ears with sterile gauze A) wrap the leg with elastic bandages
B) Apply pressure to the injury site B) apply pressure at the bleeding site
C) Apply bulky, loose dressing to nose and ears C) reinforce the dressing and elevate the leg
D) Apply an ice pack to the back of the neck D) remove the dressings and re-dress the incision
38. Which of the following should the nurse obtain from a client
prior to having electroconvulsive therapy (ECT)? 9. The most effective nursing intervention to prevent atelectasis
A) Permission to videotape from developing in a post-operative client is to
B) Salivary pH A) maintain adequate hydration
C) Mini-mental status exam B) assist client to turn, deep breathe, and cough
D) Pre-anesthesia work-up C) ambulate client within 12 hours
D) splint incision
Reduction of Risk Potential
10. The nurse is reviewing laboratory results on a client with repositioning the client, the nurse notices 200 cc of dark, red
acute renal failure. Which one of the following should be fluid flows into the collection chamber of the chest drain. What
reported immediately? is the most appropriate nursing action?
A) Blood urea nitrogen 50 mg/dl A) Clamp the chest tube
B) Hemoglobin of 10.3 mg/dl B) Call the surgeon immediately
C) Venous blood pH 7.30 C) Prepare for blood transfusion
D) Serum potassium 6 mEq/L D) Continue to monitor the rate of drainage

11. The nurse is caring for a client undergoing the placement of 19. The nurse is preparing a client who will undergo a
a central venous catheter line. Which of the following would myelogram. Which of the following statements by the client
require the nurse’s immediate attention? indicates a contraindication for this test?
A) Pallor A) "I can't lie in one position for more than thirty minutes."
B) Increased temperature B) "I am allergic to shrimp."
C) Dyspnea C) "I suffer from claustrophobia."
D) Involuntary muscle spasms D) "I developed a severe headache after a spinal tap."

12. The nurse is caring for a client who requires a mechanical 20. The nurse is performing a physical assessment on a client
ventilator for breathing. The high pressure alarm goes off on the who just had an endotracheal tube (ET) inserted. Which finding
ventilator. What is the first action the nurse should perform? would call for immediate action by the nurse?
A) Disconnect the client from the ventilator and use a manual A) Breath sounds can be heard bilaterally
resuscitation bag B) Mist is visible in the T-Piece
B) Perform a quick assessment of the client's condition C) Pulse oximetry of 88 BPM
C) Call the respiratory therapist for help D) Client is unable to speak
D) Press the alarm re-set button on the ventilator
Safety and Infection Control
13. A 60 year-old male client had a hernia repair in an
outpatient surgery clinic. He is awake and alert, but has not 1. After an explosion at a factory one of the employees
been able to void since he returned from surgery 6 hours ago. approaches the nurse and says “I am an unlicensed assistive
He received 1000 mL of IV fluid. Which action would be most personnel (UAP) at the local hospital.” Which of these tasks
likely to help him void? should the nurse assign first to this worker who wants to help
A) Have him drink several glasses of water care for the wounded workers?
B) Perform Credé's method on the bladder from the bottom to A) Get temperatures
the top B) Take blood pressure
C) Assist him to stand by the side of the bed to void C) Palpate pulses
D) Wait 2 hours and have him try to void again D) Check alertness

14. The provider order reads "Aspirate nasogastric (NG) feeding 2. A client is diagnosed with methicillin resistant staphylococcus
tube every 4 hours and check pH of aspirate." The pH of the aureus pneumonia (MRSA). What type of isolation is most
aspirate is 10. Which action should the nurse take? appropriate for this client?
A) Hold the tube feeding and notify the provider A) Reverse
B) Administer the tube feeding as scheduled B) Airborne
C) Irrigate the tube with diet cola soda C) Standard precautions
D) Apply intermittent suction to the feeding tube D) Contact
15. When caring for a client with a post-right thoracotomy who
has undergone an upper lobectomy, the nurse focuses on pain
management to promote
A) relaxation and sleep 3. A newly admitted adult client has a diagnosis of hepatitis A.
B) deep breathing and coughing The charge nurse should reinforce to the staff members that the
C) incisional healing most significant routine infection control strategy, in addition to
D) range of motion exercises handwashing, is which of these?
16. A client is diagnosed with a spontaneous pneumothorax A) Place appropriate signs outside and inside the room
necessitating the insertion of a chest tube. What is the best B) Use a mask with a shield if there is a risk of fluid splash
explanation for the nurse to provide this client? C) Wear a gown to change soiled linens from incontinence
A) "The tube will drain fluid from your chest." D) Have gloves on while handling bedpans with feces
B) "The tube will remove excess air from your chest."
C) "The tube controls the amount of air that enters your chest." 4. The nurse is assigned to a client newly diagnosed with active
D) "The tube will seal the hole in your lung." tuberculosis. Which of these interventions would be a priority
for the nurse to implement?
17. To prevent unnecessary hypoxia during suctioning of a A) Have the client cough into a tissue and dispose in a separate
tracheostomy, the nurse must bag
A) apply suction for no more than 10 seconds B) Instruct the client to cover the mouth with a tissue when
B) maintain sterile technique coughing
C) lubricate 3 to 4 inches of the catheter tip C) Reinforce that everyone should wash their hands before and
D) withdraw catheter in a circular motion after entering the room
D) Place client in a negative pressure private room and have all
18. A client has a chest tube inserted following a left lower who enter the room use masks with shields
lobectomy required by a stab wound to the chest. While
5. A nurse who is assigned to the emergency department needs
to understand that gastric lavage is a priority in which
situation? D) Verify the client's allergies on the admission sheet and order.
A) An infant who has been identified as suffering from botulism Verify the client's name on the nameplate outside the
B) A toddler who has eaten a number of ibuprofen tablets room then as the nurse enters the room ask the client "What is
C) A preschooler who has swallowed powdered plant food your first, middle and last name?"
D) A school aged child who has taken a handful of vitamins
12. The school nurse is teaching the faculty the most effective
6. The parents of a toddler who is being treated for pesticide methods to prevent the spread of lice (Pediculus Humanus
poisoning ask: “Why is activated charcoal used? What does it Capitis) in the school. The information that would be most
do?” What is the nurse's best response? important to include is reflected in which of these statements?
A) "Activated charcoal decreases the body’s absorption of the A) "The treatment medication requires reapplication in 8 to 10
poison from the stomach." days."
B) "The charcoal absorbs the poison and forms a compound that B) "Bedding and clothing can be boiled or steamed to kill lice."
doesn't hurt your child." C) "Children should not share hats, scarves and combs."
C) "This substance helps to get the poison out of the body D) "Nit combs are necessary to comb lice eggs (nits) out of
through the gastrointestinal system." children's hair."
D) "The action may bind or inactivate the toxins or irritants that
are ingested by children and adults." 13. Which approach is the best way to prevent infections when
providing care to clients in the home setting?
7. Which of these nursing diagnoses, appropriate for elderly A) Handwashing before and after examination of clients
clients, would indicate the client is at greatest risk for falls? B) Wearing nonpowdered latex-free gloves to examine the
A) Sensory perceptual alterations related to decreased vision client
B) Alteration in mobility related to fatigue C) Using a barrier between the client's furniture and the nurse's
C) Impaired gas exchange related to retained secretions bag
D) Altered patterns of urinary elimination related to nocturia D) Wearing a mask with a shield during any eye/mouth/nose
8. A child is admitted to the pediatric unit with a diagnosis of examination
suspected meningococcal meningitis. Which admission orders
should the nurse implement first? 14. A nurse is reinforcing teaching with a client about
A) Institute seizure precautions compromised host precautions. The client is receiving filgrastim
B) Monitor neurologic status every hour (Neupogen) for neutropenia. Which lunch selection suggests the
C) Place in respiratory/secretion precautions client has learned about necessary dietary changes?
D) Cefotaxime IV 50 mg/kg/day divided q6h A) grilled chicken sandwich and skim milk
B) roast beef, mashed potatoes, and green beans
9. Several clients are admitted to an adult medical unit. For C) peanut butter sandwich, banana, and iced tea
which client condition(s) would the nurse institute airborne D) barbeque beef, baked beans, and cole slaw
precautions?
A) Autoimmune deficiency syndrome (AIDS) with 15. A school nurse has a 10 year-old child with a history of
cytomegalovirus (CMV) epilepsy with tonic-clonic seizures attending classes regularly.
B) A positive purified protein derivative (PPD) test with an The school nurse should inform the teacher that if the child
abnormal chest x-ray experiences a seizure in the classroom, the most important
C) A tentative diagnosis of viral pneumonia with productive action to take during the seizure would be to
brown sputum A) move any chairs or desks at least 3 feet away from the child
D) Advanced carcinoma of the lung with hemoptysis B) note the sequence of movements with the time lapse of the
event
10. A client is scheduled to receive an oral solution of C) provide privacy as much as possible to minimize frightening
radioactive iodine (131I). In order to reduce hazards, the priority the other children
information for the nurse to include in client teaching is which D) place the hands or a folded blanket under the head of the
of these statements? child
A) "In the initial 48 hours, avoid contact with children and
pregnant women, and flush the commode twice after
urination or defecation."
B) "Use disposable utensils for 2 days and if vomiting occurs 16. A parent calls the hospital hot line and is connected to the
within 10 hours of the dose, do so in the toilet and flush triage nurse. The caller proclaims: “I found my child with odd
it twice." stuff coming from the mouth and an unmarked bottle nearby.”
C) "Your family can use the same bathroom that you use Which of these comments would be the best tool for the nurse
without any special precautions." to determine if the child has swallowed a corrosive substance?
D) "Drink plenty of water and empty your bladder often during A) "Ask the child if the mouth is burning or throat pain is
the initial 3 days of therapy." present."
B) "Take the child’s pulse at the wrist and see if the child is has
11. The nurse is to administer a new medication to a client. trouble breathing lying flat."
Which of these actions best demonstrate awareness of safe, C) "What color is the child’s lips and nails and has the child
proficient nursing practice? voided today?"
A) Verify the order for the medication. Prior to giving the D) "Has the child had vomiting, diarrhea or stomach cramps?"
medication the nurse should say, "Please state your name."
B) Upon entering the room the nurse should ask: "What is your 17. Which of these clients would the nurse recommend keeping
name? What allergies do you have?" and then check in the hospital during an internal disaster at that facility?
the client's name band and allergy band. A) An adolescent diagnosed with sepsis 7 days ago and whose
C) As the room is entered say "What is your name?" then check vital signs are maintained within low normal limits.
the client's name band. B) A middle-aged woman known to have had an uncomplicated
myocardial infarction 4 days ago
C) An elderly man admitted 2 days ago with an acute
exacerbation of ulcerative colitis
D) A young adult in the second day of treatment for an overdose
of acetometaphen

18. When an infant car seat is properly installed, the infant

should face
A) forward, so child may look out window
B) backward, so child faces the seat
C) the side window, to increase sensory stimulation
D) upward, as child lies on back with seat installed sideways

19. Which of these clients is the priority for the nurse to report
to the public health department within the next 24 hours?
A) An infant with a positive culture of stool for Shigella
B) An elderly factory worker with a lab report that is positive for
acid-fast bacillus smear
C) A young adult commercial pilot with a positive
histopathological examination from an induced sputum for
Pneumocystis carinii
D) A middle-aged nurse with a history of varicella zoster virus
and with crops of vesicles on an erythematous base that
appear on the skin

20. Which of these actions is the primary nursing intervention

designed to limit transmission of a client’s Salmonella infection?
A) Wash hands thoroughly before and after client contact
B) Wear gloves when in contact with body secretions
C) Double glove when in contact with feces or vomitus
D) Wear gloves when disposing of contaminated linens