1. A client as an obsessive-compulsive disorder manifested by the
Place chemical restraints
compulsion of handwashing. The nurse knows that which of the
following best describes the clients need for the repetitive acts
of handwashing?
a. Handwashing represents an attempt to manipulate the
environment to make it more comfortable.
b. Handwashing externalizes the anxiety from a source
within the bidy to an acceptable substitute outside the
body.
c. Handwashing assists the client to avoid undesirable
thoughts and maintain some control over guilt and
anxiety.
d. Handwashing helps to maintain the client in an active
state to resist the effects of depression.
2. Following the vaginal delivery of an 11-pound baby, the nurse
encourages the mother to breastfeed her newborn. What is the
primary purpose of this action?
a. To initiate the secretion of colostrum
b. To prevent neonatal hyperglycemia
c. To facilitate maternal-newborn interaction.
d. To stimulate the uterus to contract.
3. Client is admitted for a series of tests to verify the diagnosis of
Cushings syndrome. Which of the following assessment findings,
if observed by the nurse, would support this diagnosis?
a. Buffalo hump, hyperglycemia, and hypernatremia
b. Nervousness, tachycardia, and intolerance to heat
c. Lethargy, weight gain and intolerance to cold
d. Irritability, moon face and dry skin
4. The nurse is caring for a child with acute renal failure who is in
the intensive care unit. Which assessment finding would indicate
a sign of tonsialemia?
a. Seizure
b. ECG changes
c. Dyspnea
d. Oliguria
5. In planning care for a 7-year-old client with Graves disease, what
should the nurse do?
a. Encourage frequent rest periods
b. Encourage strenuous physical activity
c. Administer thyroid hormone replacement daily
d. Encourage a decrease caloric intake
6. The nurse recognizes which of the following as early sign of
lithium toxicity?
a. Restlessness, shuffling gait, involuntary muscle
movements
b. Ataxia, confusion, seizures
c. Fine tremors, nausea, vomiting, diarrhea
d. Elevated white blood cell count, orthostatic
hypotension
7. The nurse is preparing to do a shift assessment on a client who
was admitted with an upper gastrointestinal bleed. Which signs
and symptoms would indicate active bleeding? (Select all that
apply)
a. Blood pressure 80/52 mmHg
b. Stool black and tarry
c. Hemoglobin 18g/dL
d. Hematocrit 32%
e. Heart rate 128 beats/min
f. Respirations 32 and shallow
8. Mr. Rollins is a known alcoholic who is brought to the Emergency
Department by the police. He has severe ascites from his chronic
alcoholism and the physician prescribes spironolactone 50mg
orally now. The pharmacy dispenses spironolactone 25mg tablets.
How many tablets do you give Mr. Rollins?
a. 2 tablets
b. 0.5 tablet
c. 4 tablets
d. 1 tablet
9. A client is admitted with suspected pneumonia. The chest xray
reveals right middle and lower lunch consolidation. During
auscultation of the middle and lower lobes, which finding related
to the pulmonary system would the nurse anticipate?
a. Inspiratory and expiratory wheezing
b. Decreased breath sounds
c. Tympanic hyperresonance
d. Bronchovesicular sounds
10. Prior to electroconvulsive therapy (ECT) treatment, the patient
receives an injection of a medication that reduces secretions and
protects against vagal bradycardia. Which medication will you
administer?
a. Fluoxetine (Prozac)
b. Diphenhydramine (Bendaryl)
c. Atropine
d. Epinephrine (Adrenalin)
11. Patient with Alzheimers wandering in the hallway, which of the
following should the nurse do?
a. Place in soft restraints
b. Place in a restraint chair in the nurse station
c.
d. Ask relative to stay with the patient
12. Mrs. Robinson is a 38 year old woman being treated on an
outpatient basis for depression. Three months ago, her husband
revealed that he was having an affair with her best friend and
planned to file for divorce. Three weeks ago, Mrs. Robinsons 14
year old son (her only child) committed suicide on an inpatient
psychiatric mental health unit.in todays therapy session, Mrs.
Robinson reveals to her nurse therapist that she is seriously
contemplating suicide herself. What action should the therapist
take?
a. Arrange for voluntary hospitalization, if the patient is
willing
b. None, because people who speak of committing suicide
seldom do it
c. Arrange for immediate hospitalization
d. Request permission to speak with the husband to
suggest marriage counseling
13. A young adult client is scheduled for her first debridement of a
second-degree burn of the left arm. It is most important for the
nurse to take which of the following actions?
a. Assemble all necessary supplies and medications
b. Plan adequate time for the dressing change and provide
emotional support
c. Prepare the client and family for the pain the client
will experience during and after the procedure
d. Limit visitation prior to the procedure to reduce stress
14. The nurse is caring for a 67 years old man following a cardiac
catheterization. Two hours after the procedure, the nurse checks
the patients insertion site in the antecubital space, and the
patient complains that his hand is numb. The nurse should:
a. Change the position of his hand
b. Check his grip strength in both hands
c. Notify the physician
d. Instruct the patient to exercise his fingers
15. A client is to receive 1000mL of IV fluid over 10 hours. The IV
tubing set calibration is 15gtt/mL.how many drops per minute
would the nurse give?
a. 125gtt/min
b. 115gtt/min
c. 25gtt/min
d. 100gtt/min
16. Which intervention would the nurse anticipate for a patient who
is diagnosed with osteitisdeformans (Pagets disease)?
a. Biphosphate and recommended doses if calcium and
vitamin D
b. Calcitonin and vitamin A supplements
c. Estrogen and physical therapy
d. A low-phosphorus and aerobic exercise
17. The nurse has just received report from the previous shift. Which
of the following clients should the nurse see first?
a. A client who is receiving a blood transfusion and
complains of a dry mouth
b. A client who is scheduled to receive heparin and PTT is
70 seconds
c. A client who is receiving ciprofloxacin (Cipro) and
complains of fine macular rash
d. A client who is receiving IV potassium and complains of
burning at the IV site
18. Refer to the following list of drug indications, actions and side
effects. Which statement matches with simvastatin (Zocor)?
a. Lowers LDL level, increase HDL level, and slows
progression of coronary artery disease. Adverse effects
may include myopathy, and hepatotoxicity
b. Lowers LDL, triglycerides, and apolipoprotein B levels
by blocking absorption in the gastrointestinal tract.
Minimal adverse effects have been identified.
c. Lowers LDL cholesterol and VDL triglyceride levels;
raises HDL. May cause severe flushing
d. Reduces VLDL and increases HDL levels. Gastrointestinal
disturbances and an increased risk of gallstones may
occur.
19. A client is admitted with irritable bowel syndrome. The nurse
would anticipate the clients history to reflect which of the
following?
a. Pattern of alternating diarrhea and constipation
b. Chronic diarrhea stools occurring 10-12 times per day
c. Diarrhea and vomiting with severe abdominal distention
d. Bloody stools with increased cramping after eating
20. The nurse is preparing to do postoperative assessment on a 5 year
old child who has undergone tonsillectomy. During the
assessment, the nurse should be alert for bleeding. Which signs
and symptoms would indicate active bleeding? (select all that
apply)
a. Drowsiness
b. Dark red vomitus
c. Mouth breathing
d. Frequent swallowing
 e. Frequent clearing of throat
21. The nurseis preparing to administer carvedilol (Coreg) to a
patient. Which action should the nurse take first?
a. Find the results of the patients last blood pressure
measurement
b. Check the patency of the patients IV line
c. Assess the patients current pulse and blood pressure
d. Review the patients urine output as recorded by nurses
on the previous shift.
22. Who to see first?
a. Post colectomy with abdominal cramping
b. Patient with post bone marrow transplant with diarrhea
c. Patient with cast 30 minutes ago with muscle spasm
d. Patient chemo with n/v
23. A 47 year old woman comes to the outpatient psychiatric clinic
for treatment of a fear of heights. The nurse knows that phobias
include:
a. Projection and displacement
b. Sublimation and internalization
c. Rationalization and intellectualization
d. Reaction formation and symbolization
24. When teaching a client with myasthenia gravis about the
management of the disease, what advice should the nurse give to
the patient?
a. Prevent structured, active exercises at least twice a
week to prevent muscle atrophy
b. Protect extremities from injury due to decreased
sensory perception
c. Arrange a routine to accommodate frequent visits to
doctors office
d. Perform necessary physically demanding activities in
the morning
25. Client with paranoid thinks he is the son of the US president.
During interaction, he began to have hallucinations again, which
action should be done by the nurse first?
a. Ignore the hallucinations and proceed with the
interaction
b. Recognize the patients anxiety the proceed with the
interaction
c. Let the hallucinations be the center or topic of the
interaction
d. Ask for help
26. Your patient has been admitted in preterm labor and is receiving
magnesium sulfate as a tocolytic. You prepare her for the
common side effects of this medication, which include
drowsiness, lethargy, feeling warm and
a. Palpitations
b. Muscular weakness
c. Tremulousness
d. Tachycardia
27. A client has just been admitted after sustaining a second-degree
thermal injury to his right arm. Which of the following nursing
observations is most important to report to the doctor?
a. Pain around the periphery of the injury
b. Gastric pH less than 6.0
c. Increased edema of the right arm
d. An elevated hematocrit
28. Which drug would the nurse question?
a. Prozac for client with bulimia
b. Seroquel for patient with undifferentiated
schizophrenia
c. Olanzapine for OC
d. Buspar for client with anxiety
29. A patient with Raynauds disease should be taught to avoid which
environmental factor?
a. High levels of smog
b. Cold temperature
c. Exposure to secondhand smoke
d. Contact with pesticide
30. Which statement by a 7-year-old client would indicate an
understanding of when to take medication (via inhaler)?
a. After one puff, I can immediately give myself another
puff
b. I need to depress the top of the inhaler as I begin to
take a breath.
c. When I remove the inhaler, I can exhale through my
mouth.
d. I need to inhale the medicine and then hold my breath
to the count of 10.
31. To detect diabetic ketoacidosis (DKA), which of following would
you test for ketones?
a. Plasma
b. Feces
c. Urine
d. Sputum
32. A client has been diagnosed with metastatic cancer with a poor
prognosis. Recently, the client has complained of increased pain
and is less communicative, very irritable, and anorexic. Which of
the following nursing goals should be a priority at this time?
a. Encourage client to talk about the possibility of dying.
b. Provide pain assessment and effective pain
management
c. Manage nutrition and hydration
d. Verify that the physician has discussed the prognosis
with the family
33. A 60-year old man with a diagnosis of pneumonia is being
admitted to the medical/surgical unit. The nurse should place
the patient in a room with which of the following patients?
a. A 20-year-old in traction for multiple fractures of the
left lower leg
b. A 35-year-old with recurrent fever of unknown origin
c. A 50-year-old recovering alcoholic with cellulitis of the
right foot
d. An 89-year-old with Alzheimers disease awaiting
nursing home placement
34. A patient is hospitalized for severe pregnancy-induced
hypertension (PIH). Her hematocrit has increased two points
since the previous day. What is the probable cause of this
increase?
a. A shift of red blood cells from the fetus
b. A shift of fluid from the vascular compartment
c. Decreased red blood cell destruction by the spleen
d. Increased hematopoiesis in the red bone marrow
35. Lucy is a 34-year-old married woman with chronic low self-
esteem. Which action by Lucy demonstrates assertive behavior
and positive interpersonal relationships?
a. Lucy requests that her husband join her weekly sessions
to deal with the husbands use of alcohol and
extramarital affair.
b. Lucy cries for 28 minutes of the 30-minute therapy
session
c. Lucy says to the nurse, My husbands behavior gives
me headaches, so I sleep a lot.
d. Lucy says to the nurse, I am going to make other
peoples lives as miserable as mine is.
36. The nurse on a psychiatric unit of the hospital refuses to agree to
a 32-year-old patients request to organize a party on the unit
with his friends. The patient becomes angry and uses abusive
language with the nurse. Which of the following statements
indicates that the nurse has an understanding of the patients
behavior?
a. Allowing the patient to use abusive language will
undermine the authority of the nurse.
b. Responding in kind to a patient who uses abusive
language will perpetuate the behavior.
c. Abusive language is one the behaviors that is a
symptom of the patients illness.
d. The nurse should model acceptable behavior and
language for all patients.
37. You are caring for a 7-year-old client with a brain tumor. Which
observation would alert you to the possible development of
syndrome of inappropriate antidiuretic hormone secretion
(SIADH)?
a. Serum sodium of 130 mEq/L
b. Weight loss
c. Urinary output of 30mL/h
d. Peripheral edema
38. The nurse is preparing a client for a skin biopsy. Which of the
following client statements should the nurse report to the
physician?
a. Ive been taking aspirin for my sore knees.
b. Using lotion has helped my dry skin.
c. I went to the tanning salon yesterday.
d. I had a big breakfast this morning.
39. Endoscopic Retrograde Choliangopancreatography (ERCP) SATA
a. Check for gag reflex postprocedure
b. No discomfort post-procedure
c. Anesthesia will be used
d. No special prep needed
e. NPO prior to procedure
f. Will stay in hosp for a few days post op
40. The patient is taking ibandronate (Boniva) for the prevention of
osteoporosis. Which statement should be part of the patient
education provided by the nurse?
a. Take the medication with a minimal amount of fluid
just before bedtime.
b. Take the drug first thing in the morning with a full
glass of milk or juice.
c. Take the medication on a full stomach immediately
after meal.
 d. Take the medication in the morning with a glass of
water and then dont ingest anything for 30 minutes.
41. The nurse has administered sublingual nitroglycerin (Nitrostat) to
a client complaining of chest pain. Which of the following
observations is most important for the nurse to report to the next
shift?
a. The client indicates the need to use the bathroom.
b. Blood pressure has decreased from 140/80 to 90/60.
c. Respiratory rate has increased from 16 to 24.
d. The client indicates that the chest pain has subsided.
42. In planning care for a client with cirrhosis who was admitted with
bleeding esophagealvarices, to which goal should the nurse assign
the highest priority?
a. Maintain fluid volume
b. Relieve clients anxiety
c. Maintain airway patency
d. Control the bleeding
43. A client is admitted to the neurology unit for a myelogram. It
would be most important for the nurse to ask which of the
following questions?
a. Do you have any allergies?
b. Have you been drinking lots of fluids?
c. Are you wearing any metal objects?
d. Are you taking medication?
44. A nursing assistant is assigned to constant observation of a
suicidal patient, and the nurse overhears the nursing assistant
talking with the patient. Which of the following statements made
by the nursing assistant would require immediate intervention by
the nurse?
a. Lets put your clothes in the dresser.
b. Ill stay in the bathroom with you while you take your
shower.
c. Youre going to be moved to private room later
today.
d. Ill be right back with something for you to eat.
45. A patient diagnosed with angina is instructed to rest when having
an episode of chest pain. What is the best explanation for how
rest relieves the pain associated with angina?
a. Increased venous return to the heart decrease
myocardial oxygen needs.
b. Coronary arteries constrict and shunt blood to vital
areas of the myocardium.
c. A balance between myocardial cellular needs and
demand is achieved.
d. Coronary blood vessels dilate and increase myocardial
cell perfusion.
46. Twelve hours after a total thyroidectomy, the client develops
stridor on exhalation. What is the nurses best first action?
a. Hyperextend the client's neck.
b. Reassure the client that the voice change is temporary.
c. Call for emergency assistance.
d. Document the finding as the only action.
47. Which of the following is the first nursing action that should be
implemented for a 25-year-old woman after a vaginal delivery?
a. Check the patients lochial flow
b. Palpate the patients fundus
c. Monitor the patients pain
d. Assess the patients level of consciousness
48. The nurse is caring for a client receiving amphotericin B
(Fungizone) 1mg in 250cc of 5% dextrose in water IV over a 2-hour
period. The nurse should be most concerned if which of the
following was observed?
a. BUN 7.2 mg/dL, creatinine 0.5 mg/dL.
b. BP 90/60, complaints of fever and chills.
c. Complaints of burning on urination, thirst, and
dizziness.
d. AST (SGOT) 12 U/L, ALT (SGPT) 14 U/L, total bilirubin
0.2 mg/dL.
49. What equipment would be necessary for the nurse to complete an
evaluation of cranial nerve III during a physical assessment?
a. Tongue depressor
b. A pen light
c. A cotton swab
d. A safety pin
50. A G1P0 30-year-old patient at 38 weeks gestation is admitted
with heavy, bright red bleeding. The initial nursing assessment
should include all of the following except?
a. Fetal monitoring
b. Asking about the pain
c. Taking vital signs
d. A vaginal examination
51. A 12-year-old client has a right tibia fracture that is casted. The
client needs instruction regarding how to walk in crutches using a
three-point gait prior to be discharged from the Emergency
Department. Which instructions would be included? (SATA)
a. The hands and arms support the bodys weight
b. The body swings through and beyond the crutches
c. The right foot acts like a balance
d. Advance both crutches and swing both feet forward
e. Weight bearing is permitted on the right foot
f. Weight bearing is permitted on the left foot
g. The axillary area supports the body weight
52. Which patient is robust?
a. Pulse pressure of 40
b. BP of 90/60
c. RR of 8
d. CVP of 30cmH2O
53. What action should the nurse take when performing intermittent
nasogastric (NG) feedings in a client? SATA
a. Keep the head of the bed elevated at 15 degrees
b. Irrigate the NG tube prior to initiating feeding
c. Deliver feedings through a syringe barrel attached to
the NG tube
d. Deliver the feeding by pushing on the syringe plunger
e. Aspirate the stomach contents
f. Clamp the NG tube once the feeding is complete
54. A patient with chronic mental health problems has been making
progress with treatment. During the most recent visit to the
clinic, however, the patient tells the nurse he lost his job and
feels useless because he is unable to provide for the family.
Which nursing diagnosis would be most appropriate for this
patient?
a. Social isolation
b. Caregiver role restrain
c. Situational low self-esteem
d. Anxiety
55. To minimize the side effects of a DPT immunization for a six-
month-old, the nurse should instruct the parents to:
a. Give the child an alcohol bath for an elevated
temperature
b. Administer antipyretics for discomfort, irritability, and
fever
c. Place an ice bag on the childs leg for three days
d. Check the childs temperature every four hours for
three days
56. On admission, the vital signs of a client with a closed head injury
were temperature of 98.6F, blood pressure 128/68mmHg, heart
rate 110beats/min, respiration 26. One hour after admission, the
nurse observes that the client may be experiencing Cushings
triad. Which vital signs are indicative of Cushings triad?
a. Blood pressure 110/70mmHg, heart rate 120beats/min,
respiration 30
b. Blood pressure 130/72mmHg, heart rate 90beats/min,
respiration 24
c. Blood pressure 152/88mmHg, heart rate 122beats/min,
respiration 16
d. Blood pressure 150/70mmHg, heart rate 80beats/min,
respiration 14
57. A female client is diagnosed with human papillomavirus (HPV).
Which of the following client statements, if made to the nurse,
illustrates an understanding of the possible sequelae of this
illness?
a. I will need to take antibiotics for at least a week.
b. I will use only prescribed douches to avoid a
recurrence.
c. I will return for a Pap smear in six months.
d. I will avoid using tampons for eight weeks.
58. The nurse is caring for a client with a cervical spinal cord injury.
Vital signs and laboratory results for this client are as follows:
Blood pressure: 128/72 mmHg
Heart rate: 94 beats/min
Arterial pH: 7.3
Arterial pCO2: 60 mmHg
Arterial pO2:75 mmHg
Arterial HCO3: 35 mEq/L
Based of this information which nursing action would be the best
action?
a. Notify the physician, request an order for midazolam,
and reevaluate the client in 30 minutes
b. Evaluate airway patency, place the client in high
Fowlers position, and encourage coughing and deep
breathing
c. Notify the physician, inform the physician about the
clients metabolic acidosis and anticipate a sodium
bicarbonate continuous infusion
d. Evaluate airway patency, administer pain medication
and encourage coughing and deep breathing
59. A patient diagnosed with gout asks, Is there anything I can do to
decrease my uric acid levels? What is the nurses most
appropriate response?
a. Avoid strenuous activity, as it will cause muscle
breakdown.
b. Decrease the amount of liver, sardines, and shrimp in
your diet
c. Increase the amount of citrus fruits in your diet
 d. Drink at least 1 to 1.5 liters of fluid each day.
60. During the nursing history interview, a preschool clients mother
reports that the child has frequent bouts of gastroenteritis. It
would be most important for the nurse to ask which of the
following questions?
a. Are there other children in the family?
b. Does the child attend a day care center?
c. Does the child play with neighborhood children?
d. Is the child current on his immunizations?
61. A 9-year-old client is given his heparin injection on time, but it
was administered intravenously instead of subcutaneously. The
incident was discovered 2 hours after administration. Which plan
would be most appropriate?
a. Document the event on an incident report and notify
the physician
b. Hold the next scheduled heparin dose
c. Order a PTT and INR levels and notify the physican
d. Assess for evidence of bleeding and notify the parents
62. A client is diagnosed with lung cancer and undergoes a
pneumonectomy. In the immediate postoperative period, which
of the following nursing assessment is most important?
a. Presence of breath sounds bilaterally.
b. Position of the trachea in the sternal notch.
c. Amount and consistency of sputum.
d. Increase in the pulse pressure.
63. The nurse receives a phone call from a nursing assistant who
states that her five-year-old child has developed chickenpox. It
would be most important for the nurse to ask which of the
following questions?
a. Have your other children had chickenpox?
b. Does your child have a temperature?
c. Have you had the chickenpox?
d. Do you have someone to watch your child?
64. Mr. Holloway has just received his first dose of this antipsychotic
medication perphenazine (Trilafon) you know that the response
time to the medication for cognitive and perceptive symptoms,
such as hallucinations, delusions and thought broadcasting, may
take how long?
a. From 28-52 weeks
b. Up to 3 minutes
c. Up to 30 minutes
d. From 2 to 8 weeks
65. A patient who is 28 weeks pregnant complains of lower back pain.
What should the nurse suggest?
a. The patient take Motrin as needed
b. Lower back pain is part of being pregnant and there is
nothing the patient can do about the pain
c. The patient pay close attention to her body posture and
mechanics, as these are the cause of back pain in
pregnancy
d. The patient tell her provider immediately, because she
is in preterm labor
66. The nurse has collected the following data: client anger directed
toward staff in the form of frequent sarcastic or crude
comments, increased wringing of hands, and purposeless pacing,
particularly after the client has used the telephone. Based on this
data, the nurse should make which nursing diagnosis?
a. Impaired social interaction related to conversion
reaction
b. Risk for potential activity intolerance as evidenced by
purposeless pacing
c. Powerlessness in hospital situation
d. Ineffective individual coping related to recent anger
and anxiety
67. An adult patients prescription reads as follows, Infuse 80 mEq
of potassium chloride in 100 cc D5W over 30 minutes. Based on
the nurses understanding of potassium administration, what is
the most appropriate action?
a. Contact the prescriber about the order
b. Monitor the EKG during the medications administration
c. Switch the administration route to oral
d. Administer the medication
68. The nurses aide comes to take a woman by wheelchair for a
magnetic resonance imaging (MRI) scan of the head and neck.
Which of the following observations, if made by the nurse, would
require an intervention?
a. The woman removes her dentures and gives them to
her husband.
b. The womans vital signs are: BP 120/70, pulse 80,
respirations 12, temperature 99F (37.3C).
c. The woman has a nitroglycerine patch on her right
chest area.
d. The woman has red nail polish on her fingers and toes.
69. A middle-aged man is admitted to an inpatient psychiatric unit.
Over the last several months he has become convinced that his
brother is trying to steal his property. He is diagnosed with
paranoid disorder. The nurse knows that this client is
demonstrating which of the following
a. Delusions of persecution
b. Command hallucination
c. Delusions of reference
d. Persecution hallucination
70. A client returns to the unit from the recovery room following a
laryngoscopy. Which position would be most effective in helping
the client breathe?
a. Side-lying position
b. Sims position
c. Low fowlers position
d. Trendelenburg position
71. For the following herbal supplement, select the purported use of:
Black cohosh (Cimcifugaracemosa)
a. Used to relieve symptoms associated with benign
prostatic hypertrophy
b. Used to relieve symptoms of menopause
c. Used to relieve depression
d. Used to improve memory, sharpen concentration and
promote clear thinking
72. What is the highest priority in providing care to a client who is
admitted to the hospital with sickle cell crisis?
a. Insist the client rest instead of visiting with family
b. Administer prophylactic antibiotics
c. Initiate intravenous fluids to maximize hydration
d. Insert urinary catheter to measure accurate output
73. To maintain normalized blood sugars, Mr. Hernandez has the
following sliding scale insulin prescription:
Blood glucose < 130mg/dl: administer 0 unit of insulin
Blood glucose 130-160mg/dl: administer 2 unit of insulin
Blood glucose 161-190mg/dl: administer 4 unit of insulin
Blood glucose 191-220mg/dl: administer 6 unit of insulin
Blood glucose 221-250mg/dl: administer 8 unit of insulin
Blood glucose >250mg/dl: administer 10 unit of insulin and
contact the physician immediately
Mr. Hernandez blood sugar is 122. What is your intervention?
a. administer 2 unit of insulin
b. administer 4 unit of insulin
c. administer no of insulin and contact the physician
immediately
d. administer no insulin
74. A patient with Alzheimers disease doesnt want to take a bath,
what will the nurse do?
a. Call two staff nurses to help you bathe the patient
b. Attempt to bathe the patient slowly and calmly
c. Ask the patient the reason why she doesnt want to
take a bath
d. Document refuse to take a bath
75. Mr. Allen has psychosis and has been treated with haloperidol
(Haldol). You need to assess him for movement disorders as a side
effect of Haldol. What is another name for these movement
disorders?
a. Delusion etiologies
b. Extrapyramidal reactions
c. Autonomic dysreflexia
d. Biologic rigidity reactions
76. Identify the location on the chest area where the nurse would
take an apical pulse.
a. Right 5th intercostal space, midclavicular line
b. Left 8th intercostal space
c. Right 8th intercostal space
d. Left 3rd intercostal space, midclavicular line
77. A client with deep vein thrombophlebitis suddenly develops
dyspnea, tachypnea, and chest pain. What is the nurses initial,
most appropriate action?
a. Apply 100% oxygen via face mask
b. Obtain a 12-lead ECG
c. Assess the clients blood pressure and heart rate
d. Auscultate for abnormal heart sounds
78. The nurse is planning discharge for a group of clients. It is most
important to refer which of the following clients for home care?
a. A postoperative appendectomy client who is
complaining of incisional pain
b. A diabetic client who had a cardiac catheterization in
the early AM
c. A postoperative cholecystectomy client who is
complaining of incisional pain
d. A client with congestive heart failure who underwent
diuresis in the hospital
79. Which instruction would be given to a client who is receiving oral
methylprednisolone regarding when and how to take the
medication?
a. Once a day before bedtime
b. Consume 10-12 glasses of water per day
c. Once a day on an empty stomach
d. Once a day with breakfast
80. A patient with osteoarthritis has had hip replacement surgery.
What level of activity would the nurse anticipate for the first
postoperative day?
a. Paresthesia, rigidity, aphasia
b. Tremors, rigidity, bradykinesia
c. Spasticity, diplopia, paresthesia
d. Dysarthria, dysphagia, ataxia
81. A patient with acute coronary syndrome is administered
thrombolytic therapy. Which portion of the EKG tracing would the
nurse observe to determine the effectiveness of the medication?
a. ST segment elevation
b. PR interval
c. QT interval
d. Width of QRS complex
82. The nursing assistant reports to the nurse that a client who is
one-day postoperative after an angioplasty is refusing to eat and
states, I just dont feel good. Which of the following actions, if
taken by the nurse is best?
a. The nurse talks with the client about how he is feeling
b. The nurse instructs the nursing assistant to sit with the
client while he eats
c. The nurse contacts the physician to obtain an order for
an antacid
d. The nurse evaluates the most recent vital signs
recorded in the chart
83. An 18 month old client is admitted to the hospital with a fever of
104F, respirations of 56/min, suprasternal retractions and a pulse
oximeter reading of 85%; the infant is also drooling. Acute
epiglottitis is suspected. Which equipment would be important to
have at the bedside?
a. Tracheostomy tray
b. Intravenous infusion pump
c. Defibrillator
d. Code cart
84. Match the eating disorder with the correct description of the
disease. An excessive concern over gaining weight and a refusal
to maintain a minimally normal body weight.
a. Bulimia nervosa
b. Anorexia nervosa
85. Among the four patients, who warrants immediate attention?
a. Patient taking Glucophage with glucose reading of
185mg/dl
b. Patient who had a spinal injury and is complaining of
throbbing headache
c. Patient diagnosed with seizure who wants to change
medication time
d. Patient with osteoarthritis experiencing joint stiffness
86. Which drug would the nurse anticipate administering for the
treatment of inflammation of acute exacerbations of gout?
a. Allopurinol (Zyloprim)
b. Acetaminophen (Tylenol)
c. Probenecid (Benemid)
d. Colchicine (novocholchicine)
87. A client returns to the unit undergoing a right modified radical
mastectomy with dissection of the axillary lymph nodes. Which
measure is an appropriate intervention for the nurse to include in
the clients postoperative care?
a. Encourage the client to obtain a permanent breast
prosthesis upon discharge from the hospital
b. Instruct the client to watch the clock and use the PCA
pump every 10 minutes
c. Insist that the client examine the surgical incision when
the surgical dressings are removed
d. Post a sign at the bedside to avoid pressure
measurements or venipunctures in the right arm.
88. Patient with HIV states, I am so tired, my life is useless, I am
going to die anyway.
a. Refer to support group
b. Why are you tired?
c. What is the specific cause that makes you feel tired?
d. Do you think you are dying?
89. After receiving a total hip replacement, the client returns to the
unit with an abductor pillow in place. The client informs the
nurse that he would be more comfortable without the pillow.
What is the nurses best response?
a. The pillow is intended to prevent the inadvertent
movement of the left leg beyond the bodys midline.
b. The pillow is intended to prevent early ambulation if
you should wake up confused.
c. The pillow is intended to prevent the inadvertent
movement of the left leg too far way from the body.
d. The pillow is intended to prevent the contact of both
knees and reduce the risk that pressure ulcers will
form.
90. The triage nurse for a womens health center receives a phone
call from each of the following women. Which woman should be
directed to come to the health care facility immediately?
a. A multipara woman who is four weeks pregnant and
reporting unilateral, dull, abdominal pain.
b. A primipara woman who is seven weeks pregnant and
reporting increase in whitish vaginal secretions.
c. A primigravida woman who is five weeks gestation and
is having vaginal spotting and some cramping.
d. A multigravida woman who is six weeks pregnant and
reporting frank, red vaginal bleeding with moderate
cramps.
91. Erythromycin ophthalmic ointment 0.5% is given immediately
after an infant is born to provide prophylaxis against:
a. Chlamydia trachomatis
b. Syphilis
c. Both Neisseria gonorrhoea and chlamydia trachomatis
d. Neisseria gonorrhoea
92. Which food choice would be most appropriate for a patient with
osteoporosis who wants to increase calcium intake?
a. 1 ounce of cream cheese
b. 1 medium stalked of cooked broccoli
c. 3 ounces of beef
d. 1 medium apple
93. Which EKG tracing would the nurse recognize as an early
indicator of hyperkalemia?
a. Depressed ST segment
b. Prolonged QT interval
c. Shallow, flat, inverted T wave
d. Tall peaked T-wave
94. A 4-year-old has been admitted with second-degree burns and is
undergoing debridement of the wounds. Morphine 1 mg IV push
has been administered. Following administration of this
medication, the nurse makes the following observations:
Pulse: 96
Respirations: 28
Blood pressure: 84/62
Child sleeping quietly
Which nursing action is most appropriate?
a. Keep the code cart at the bedside
b. Allow the child to sleep quietly
c. Administer nalozone (Narcan)
d. Administer 100% oxygen
95. Individuals with diabetes mellitus can have a chronic
complication in which there is pain in the lower extremities due
to lack of blood supply. What is the complication called?
a. Retinopathy
b. Claudication
c. Stroke
d. Angina
96. The nurse is assessing an infant who had a repair of a cleft lip
and palate. The respiratory assessment reveals that the infant
has upper airway congestion and slightly labored respirations.
Which of the following nursing actions would be most
appropriate?
a. Elevate head of the bed
b. Suction the infants mouth and nose
c. Position the infant on one side
d. Administer oxygen until breathing is easier
97. Why is maintaining a thermoneutral environment essential for the
neonate?
a. A thermoneutral environment permits the neonate to
maintain a normal core temperature with increased
caloric consumption
b. Metabolism slows dramatically in the neonate who
experiences cold stress
c. The neonate produces heat by increasing activity and
shivering
d. A thermoneutral environment permits the neonate to
maintain a normal core temperature with minimum
oxygen consumption
98. A six-month-old infant has had all the required immunizations.
The nurse knows this would include which of the following?
a. Two doses of diphtheria, tetanus, and pertussis vaccine
b. Measles, mumps and rubella vaccines
c. A booster dose of trivalent oral polio vaccine
d. Chickenpox and smallpox vaccines
99. A 4-year-old child presents with possible rheumatic fever. Which
findings will the nurse observe in this patient?
a. Decreased antistreptolysin-O titer
b. Decreased erythrocyte sedimentation rate
c. Macular rash that is pruritic
d. Elevated C-reactive protein levels
100. The nursing evaluation of the respiratory status of a 3-year-old
client who is newly admitted with acute epiglottitis would
indicate the following findings:
a. Drooling, decreased pulse and stridor
b. Irritability, drooling and absence of spontaneous cough
c. Irritability, coarse crackles bilaterally and low-grade
fever
 d. Croupy cough, high fever and hoarseness
101. A client with necrotizing spider bite is to perform his own
dressing changes at homes. The nurse is aware that which of the
following statements, if made by the client, indicates
understanding of aseptic technique?
a. I need to buy sterile gloves to redress this wound.
b. I should wash my hands before redressing my wound.
c. I should keep the wound covered at all times.
d. I should use an over-the-counter antimicrobial
ointment.
102. A 22-month-old child is hospitalized for heart failure. During the
night, the child awakens crying and calling for the mother. The
nurse assesse the child and notes dyspnea, jugular vein
distention, crackles and pink, frothy sputum. After the nurse
begins oxygen by 40% face mask, which action should be taken
next?
a. Dim the lights and allow the mother to rock the child to
sleep
b. Continue to monitor the client frequently and increase
fluid rate
c. Place the child in a crib with a blanket and notify the
physician
d. Stay with the child and call for assistance to notify the
physician
103. An elderly patient has been prescribed aspirin for osteoarthritis.
What should the nurse teach the patient to ensure safe use of
this medication?
a. A prothrombin time should be drawn upon initiation of
therapy and every 2 months
b. The prescriber should be notified if the patient
experiences any unusual bruising or bleeding
c. The medication should be taken on an empty stomach
d. Enteric-coated tablets should be crushed to make the
medication easier to swallow
104. The nurse is caring for client in the outpatient clinic. Which of
the following messages should the nurse return first?
a. A mother reports that the umbilical cord of her five-
day-old infant is dry and hard to touch.
b. A mother reports that the soft spot on the head of
her four-day-old infant feels slightly elevated when the
baby sleeps.
c. A mother reports that the circumcision of her 3-day-old
infant is covered with yellowish exudate.
d. A father reports that her bumped the crib of his two-
day-old infant and she violently extended her
extremities and returned to their previous position.
105. Indomethacin is given as a treatment for preterm labor. What is a
potentially significant fetal side effect of this drug?
a. Premature closure of the ductusvenosus
b. Bradycardia
c. Decreased fetal movement
d. Premature closure of the ductusarteriosus
106. The nurse is caring for a client with internal radiation. Which of
the following actions, if taken by the nurse, is most important?
a. Restrict visitor who may have an upper respiratory
infection
b. Assign only male caregivers to the client
c. Plan nursing activities to decrease nurse exposure
d. Wear a lead-lined apron whenever delivering client
care
107. The nurse is caring for a client who sustained severe burns and
has an inhalation thermal injury. The client is intubated and on
the ventilator at 60% FiO2. The nurse notices that the client is
restless, thrashing, and attempting to cough, the respiratory rate
is 34. What should the nurses first action be?
a. Administer pain medication
b. Increase the FiO2 setting to 100%
c. Auscultate lung sounds and suction if needed
d. Notify the physician and prepare for immediate surgery
108. A 22-month-old client is receiving Nystatin 200,00 units via oral
swab every 6 hours. For which side effects should the nurse
assess the client?
a. Leukopenia
b. Oral thrush
c. Diarrhea
d. Thrombocytopenia
109. The nurse is performing discharge teaching on a client with
multiple sclerosis. It is most important for the nurse to include
which of the following instructions?
a. Ambulate as tolerated every day
b. Avoid overexposure to heat or cold
c. Perform stretching and strengthening exercises
d. Participate in social activities
110. A client is being prepared for surgical repair of an abdominal
aortic aneurysm. The nurse suspects complete aortic dissection
when:
a. The client becomes hypotensive and unresponsive
b. A bruit and thrill are palpable at the aneurysm site
c. The client becomes hypertensive and tachycardic
d. The client complains of sever leg and arm pain
111. The nurse is caring for patients on the surgical floor and has just
received report from the previous shift. Which of the following
patients should the nurse see first?
a. A 35-year-old admitted 3 hours ago with a gunshot
wound, 1/5 cm area of dark drainage noted on the
dressing.
b. A 43-year-old who had mastectomy two days ago, 23 cc
of serosanguinous fluid noted in the Jackson-Pratt drain
c. A 59-year-old with a collapsed lung due to an accident,
no drainage noted from the chest tube in the last eight
hours
d. A 62-year-old who had an abdominal-perineal resection
three days ago, patient complains of chills
112. Which of the following statements, if made by the parents of a
nine-year-old client with an ostomy, would indicate to the nurse
that they are providing quality home care?
a. We change the bag at least once a week and we
carefully inspect the stoma at that time.
b. We change the bag every day so that we can inspect
the stoma and the skin.
c. We encourage our daughter to watch TV while we
change her ostomy bag.
d. We only change the ostomy bag every ten days.
113. Nursing care in the first 30 minutes after a caesarean section
includes:
a. Fundal and lochial assessment
b. Ambulation
c. Vital signs every hour
d. Oral hydration and nutrition
114. Education about health promotion is often effective during
periods of role transitions. Which of the following is a role
transition?
a. Retirement
b. Buying a new car
c. Moving into a new house in the same neighbourhood
d. Going grocery shopping
115. An extremely angry patient with bipolar illness tells the nurse he
just learned his wife filed for divorce, and he needs to use the
phone. Which of the following responses by the most nurse is
most appropriate?
a. Allow the patient to use the phone
b. Confront the patient about his anger and inappropriate
plan of action
c. Do not allow the patient to use the phone because he is
an involuntary patient
d. Set limits on the patients phone use because he has
been unable to control his behaviour
116. A patients medicinal history includes the use of the herbal
medication garlic and the prescribed medication warfarin
(Coumadin). Based in the nurses knowledge of drug-drug
interactions, which problem could occur when a patient takes
both of these products concurrently?
a. Elevated blood pressure
b. Decreased immune function
c. Altered renal perfusion
d. Increased bleeding potential
117. Which statement by a patient would indicate that the patient is
adapting well to changes in functional status after experiencing a
spinal cord injury?
a. I tire easily when I use my wheelchair just around the
house. I know I would get tired if I tried to leave the
house.
b. "My wife tries to get me to go to the grocery store, but
I don't like to go out much."
c. "I have all the equipment to take a shower, but I prefer
a bed bath, because it is easier."
d. "I have been using the modified feeding utensils at
every meal. I still have spills, but I'm getting better."
118. A client is receiving plasmapheresis treatments for myasthenia
gravis. Which observation would the nurse identify as the desired
response for this treatment?
a. Increased ptosis
b. Decreased functional residual capacity
c. Ability to consume an entire meal
d. Need for frequent rest periods
119. A client is brought to the emergency room after a motor vehicle
accident that resulted in the client sustaining a head injury.
Which assessment should the nurse perform immediately?
a. Assessment of the respiratory status
b. Assessment of pupils
c. Assessment of short-term memory
d. Assessment of motor function
120. To promote safety in the environment of a client with a marked
depression of T cells, the nurse should:
 a. Keep a linen hamper immediately outside the room
b. Restrict eating utensils to spoons made of plastic
c. Provide masks for anyone entering the room
d. Remove any standing water left in containers or
equipment
121. A nurse is caring for a client with a spinal cord injury. Which
observation would indicate this client is exhibiting neurogenic
shock?
a. Heart rate of 52 beats/min
b. Temperature of 102.5F
c. Heart rate of 115 beats/min
d. Cool, moist skin
122. The nurse is preparing a teaching plan for a patient who is
visually impaired. Which teaching strategy should be included in
the plan?
a. Provision of written information
b. Use of captioned video materials
c. Auditory or tactile materials
d. Use of a slow, deliberate speech pattern
123. A 19-year-old patient has just been admitted to the
detoxification unit after drinking a quart of vodka every day for
the past 3 weeks. What is the most important nursing
intervention on the day of admission to reduce the risk of harm
to this patient?
a. Give the patient a meeting schedule for Alcoholic
Anonymous
b. Administer Librium as prescribed
c. Encourage the patient to attend group therapy sessions
d. Explain the addictive process to the patient
124. The physician informs the nurse that a client needs to be
intubated. In preparing for the physician to perform the
intubation, which equipment is appropriate for this procedure?
(SATA)
a. Laryngoscope
b. Sterile gloves
c. Uncuffed endotracheal tube
d. Oral suction
e. Face mask
f. Ambu bag
125. A 23-year-old man comes to the AIDS clinic for treatment of
large, painful, purplish-brown open areas on his right arm and
back. The nurse should instruct the client to:
a. Clean the area carefully with soap and warm water
every day and cover them with sterile dressing
b. Soak in a warm tub twice a day and rub the areas with
a washcloth before covering them
c. Shower daily using a mild antimicrobial soap from a
pump dispenser and leave the lesions uncovered
d. Clean the lesion twice a day with a diluted solution of
povidone-iodine (Betadine) and leave them open to the
air
126. The nurse is admitting a client to the unit from the postoperative
recovery area after abdominal exploratory surgery. After
determining the clients vital signs, which of the following
activities should the nurse perform next?
a. Position the client on her left side, supported with
pillows
b. Check the chart and determine the status of the fluid
balance from surgery
c. Check the clients abdominal dressing for any evidence
of bleeding
d. Monitor the incision and pulmonary status for the
presence of infection
127. A physician has written an order for an HIV-positive infant to
receive an oral polio immunization. Which of the following
nursing actions is most appropriate?
a. Wear gloves and gown when administering the
immunization
b. Administer the immunization as infant is being
discharged
c. Call the physician and discuss the rationale for the
immunization
d. Administer the medication in the same manner as you
would to any other infant
128. Mrs.Tungen, who has been diagnosed with bipolar disorder, is
receiving lithium and outpatient therapy.She now complains of
diarrhea, vomiting, thirst, and coarsening hand tremors. What
should the nurse's first intervention be?
a. Hold the lithium, and call for an order to obtain a
lithium level.
b. Administer an antidiarrheal medication.
c. Obtain a stool sample for culture.
d. Begin an intravenous drip of D5 NS with 20 mg
potassium chloride to infuse at 125 mL/h.
129. The nurse observes a client who is taking phenelzine (Nardil)
eating another clients lunch. After a few minutes, the client
complains of headache, nausea, rapid heartbeat, and begins to
vomit. The nurse anticipates administering which of the following
medication?
a. Buspirone (Buspar)
b. Fluoxetine (Prozac)
c. Prochlorperazine (Compazine)
d. Nifedipine (Procardia)
130. An infant born with spina bifida and is scheduled for surgery the
next day. Which nursing action has the greatest priority?
a. Preventing infection by supine positioning
b. Encouraging the parents to hold, cuddle and feed the
infant
c. Promoting range-if-motion exercises
d. Preventing rupture of the meningocele sac
131. The nurse is caring for a client admitted with acute
hypoparathyroidism. It is most important for the nurse to have
which of the following item available?
a. Tracheostomy set
b. Cardiac monitor
c. IV monitor
d. Heating pad
132. Which assessment finding indicates effective chest compressions
during CPR?
a. Pink mucous membranes
b. Palpable carotid pulse
c. Dilated pupils bilaterally
d. Sluggish capillary refill
133. A nasogastric tube is ordered to be placed in a client. Organize
the following steps in chronological order as they relate to this
procedure:
1. Lubricate the tube
2. Measure the tube for approximate placement length
3. Place the client in a high Fowlers position
4. Advance the tube downward and backward
5. Insert the tube along the base of the nose
6. Check the position of the tube, and secure the tube
a. 3,1,2,5,4,6
b. 2,3,1,5,4,6
c. 1,3,2,5,4,6
d. 3,2,1,5,4,6
134. A client has been receiving chlorpromazine hydrochloride
(Thorazine). When the nurse checks on the patient, the patient is
restless, unable to sit, and complains of insomnia and fine
tremors of the hands. The nurse identifies which of the following
as the best explanation about why these symptoms are occurring?
a. A side effect of the medication that will disappear as
time passes.
b. The reason the patient is receiving this medication.
c. Extrapyramidal side effects resulting from this
medication.
d. An indication that the dosage of the medication needs
to be increased.
135. A client has a right-side pneumothorax and a chest tube has been
inserted. Which finding would indicate that the chest drainage
system is functioning effectively?
a. Blood leaking around the chest tube insertion site
b. Constant bubbling in the water seal chamber
c. Absence of breath sounds on the right side
d. Bubbling in the suction chamber
136. Your patient, Mr. Lawrence, has been prescribed Mucinex
(guaifenesin) 300 mg orally daily as part of his treatment for
bronchitis. The pharmacy sends up Mucinex 600-mg extended-
release tablets. How many tablets doo you give Mr. Lawrence?
a. 2 tablets
b. None
c. 0.5 tablet
d. 1 tablet. None.
137. On the second day after a subtotal thyroidectomy, the client
informs the nurse that she is experiencing numbness and tingling
around her mouth. What is the nurses best first action?
a. Notify the physician
b. Order a thyroid-stimulating hormone level
c. Loosen the neck dressing
d. Offer mouth care
138. Select all self-care activities that persons should be able to
perform prior to discharge to home. (SATA)
1. Bathing
2. Banking
3. Dressing
4. Car oil change
5. Grooming
6. Hygiene
139. When to know if a 6 year old child has a dysfunctional grieving
after the death of a grandparent?
a. The child refuses to eat and stays in his room
b. The child re-enacts the funeral using his stuff toys and
pets
 c. The child asks when he can play with grandpa just after
visiting his grave
d. The child states that his grandpa is just sleeping and
would wake up soon
140. Mr. Koo is prescribed chlorpromazine (Thorazine) as an
antipsychotic medication. When he comes to the pill line in the
hospital, he reports that he has taken 2 days worth of the
medication as prescribed and is now experiencing dizziness. What
should your first nursing intervention be?
a. Obtain a complete blood count and serum ammonia
level as prescribed
b. Assess blood pressure with the patient In both the lying
and standing positions
c. Assess the optic chiasm using an ophthalmoscope
d. Obtain pulmonary function test, stat
141. A 9-year-old client is receiving one unit of packed red blood cells.
Which finding on assessment would indicate a possible haemolytic
reaction? (SATA)
a. Tightness in chest
b. Red or black urine
c. Shaking
d. Temperature of 97.6F
e. Flank pain
f. Bilateral crackles
142. The nurse is supervising the staff caring for clients on the
medical/surgical unit. The nurse observes the student nurse
enter wearing a gown, gloves, and a mask. The nurse determines
that the precautions are correct if the student nurse is caring for
which of the following clients?
a. An infant diagnosed with respiratory syncytial virus
b. A young child with a wound infected with S. aureus
c. A teenager diagnosed with toxic shock syndrome
d. A teenager diagnosed with rubella (German measles)
143. A client is admitted in sickle cell crisis and is receiving IV
morphine by PCA pump. The nurse makes the following
observations:
Pulse: 73
Respirations: 6
Blood pressure: 112/72 mmHg
Client is quietly sleeping
Which nursing action is most appropriate?
a. Allow the client to sleep quietly
b. Administer 100% oxygen
c. Administer naloxone (Narcan) as prescribed
d. Keep the code cart at the bedside
144. An autoimmune disorder attacks the myelin sheaths of nerve
fibers in the central nervous system and produces lesions called
plaques. This statement describes the pathophysiology of which
disease?
a. Amyotrophic lateral sclerosis
b. Multiple sclerosis
c. Alzheimers disease
d. Myasthenia gravis
145. The multipdisciplinary team decides to implement behaviour
modification with a client. Which of the following nursing actions
is of primary importance during this time?
a. Confirm that all staff members understand and comply
with the treatment plan.
b. Establish mutually agreed upon, realistic goals.
c. Ensure that the potent reinforcers (rewards) are
important to the client.
d. Establish a fixed interval schedule for reinforcement.
146. When completing discharge teaching for a patient who has
experienced a myocardial infarction, the patient asks the nurse
why aspirin has been prescribed daily. What is the nurses best
response?
a. The medication helps to maintain coronary blood flow
by decreasing platelet aggregation in the coronary
arteries.
b. Aspirin is used to prevent fever associated with the
inflammatory response in myocardial infarction.
c. The medication increases the amount of blood in the
coronary arteries.
d. Aspirin is used as prophylactic analgesic to reduce
pain.
147. Which immunization should be withheld if patient experiences
seizures?
a. Hepatitis
b. DPT
c. OPV
d. Measles
148. A 2-month-old infant is 2 days postoperative tracheoesophageal
fistula repair. A complete blood count reveals a haemoglobin of
8.6mg/dl and erythrocyte count of 2.5 million/mm3. Which
symptoms would the nurse most likely find on assessment?
a. Projectile vomiting after oral bottle feeding
b. Sluggish capillary refill and hypotension
c. Slight pallor and tires easily while crying
d. Tachycardia and flushing
149. The nurse is caring for a patient with acute coronary syndrome
who is receiving altaplase (tPA). Which side effects should the
nurse monitor the patient for?
a. Hepatomegaly
b. Fluid retention
c. Bleeding
d. Muscle pain
150. Lamotrigine is given to clients to relieve them from what?
a. Seizure
b. Joint stiffness
c. Blood pressure
d. Migraine
151. One of the goals the nurse and a client with posttraumatic stress
disorder (PTSD) mutually agreed upon is that he will increase his
participation in out-of-the apartment activities. Which of the
following recommendations, if made by nurse, will be most
therapeutic to achieve this goal?
a. Take a day trip with a friend
b. Take an eleven-minute bus ride alone
c. Join a support group and participate in a victim
assistance organization
d. Take a ten-minute with his wife around the block
152. The client is at risk for bleeding related to the Vitamin K
deficiency and the altered liver functions
a. Roasted chicken breast, baked potato with margarine
and chives and skim milk
b. Two eggs, two slices of toast with margarine and a glass
of whole milk
c. Baked fish, steamed broccoli with salt and pepper, and
a glass of iced tea
d. Grilled cheese sandwich, steamed vegetables with
butter and a cup of coffee
153. During a home visit, the nurse saw an old woman filthy and
unkempt in her childs house. What should you do?
a. Advise the woman to visit the hospital
b. Talk to the child of the old woman
c. Call the abuse center for the elderly
d. Perform hygiene care for the old woman
154. A patient has a subcutaneous terbutaline (Brethine) pump for
treatment of preterm labor. Which of the following findings
warrants a call to the physician?
a. Fetal movements are fewer than 12 per hour
b. The patient feels nervous and jittery
c. The patients pulse is 124 beats per minute
d. Fetal movements are more than 12 per hour
155. The nurse is teaching a client how to perform self-monitoring
blood glucose (SMBG) using a blood glucose monitor. Which of the
following actions, if performed by the client indicates to the
nurse the need for further teaching?
a. The client lets her hand dangle before sticking her
finger with the lancet
b. The client sticks her finger on the side of the distal
pharynx
c. The client touches the strip with a large drop of blood
from her fingertip
d. The client milks her finger after sticking it
156. A bipolar patient refuses to put down the mop that he is swinging
to threaten other patients and staff. What information is most
important for the nurse to consider before administering a PRN IM
dose of lorazepam (Ativan)?
a. The patient is harmful to himself
b. The patient is psychotic
c. A restrictive intervention failed
d. The patient is harmful to others
157. A client is admitted to the burn unit with a third-degree burn to
the chest, face, and upper extremities. During the acute phase
(i.e., first 48 hours) of a major burn injury, which assessment
findings should the nurse report immediately?
a. Temperature of 100F
b. Edema of hands
c. Decreased sensation in the extremities
d. Urinary output of 200 ml over 8 hours
158. A 19-month old child weighs 22 pounds and has an order of 200
mcg digoxin to be given intravenously. You have a vial of digoxin
at a concentration of 0.1mg/ml. how many millilitres of the
solution will you need to deliver the ordered dose?
a. 0.22 mL
b. 0.002 mL
c. 2.0 mL
d. 0.2mL
159. Mrs. Langley has hyperosmolar nonketotic coma with
hyperglycemia. She begins to experience CNS dysfunction. What
is most likely source of this dysfunction?
a. Adrenal gland tumor
b. Cellular fluid loss
c. Fever
 d. Hypoxia
160. The nurse is supervising a care given to clients on a
medical/surgical unit. The nurse should intervene if which of the
following is observed?
a. A nurse and client wear masks during a dressing change
for the central catheter used for total parenteral
nutrition
b. A nurse injects insulin through a single-lumen
percutaneous central catheter for client receiving total
parenteral nutrition
c. A nurse applies lip balm to his/ her lips immediately
after performing a blood draw to obtain specimen
d. A nurse wears a disposable particulate respirator when
administering rifampicin to a client withtuberculosis.
161. A patient is in 8 cm dilated, 90% effaced and -3 station when her
water breaks. Immediately thereafter, the fetal heart rate
decelerates in the 60s. the nurse knows:
a. This could be a sign of uterine rupture
b. This could be a sign of cord prolapse
c. This is a normal fetal heart pattern
d. This is a normal fetal heart pattern
162. Which statement by a patient with a history of major depression
indicates that he is not maintaining good health in his current
environment?
a. Going back to work, well, its not bad; its okay.
b. I just dont like going to the movies like I did before.
c. I cant wait to go to my sons wedding next weekend.
It will be nice to have the whole family together.
d. I had a great trip to the Smokey Mountains. It was
fun.
163. The nurse knows that which of the following mood altering drugs
is most often associated with an increased risk for HIV infection
related to intravenous drug use?
a. Benzodiazepines
b. Marijuana
c. Barbiturates
d. Narcotics
164. A 7-year-old child is diagnosed with insulin-dependent diabetes
mellitus. The child and parents are being taught what should
occur if the child presents with signs and symptoms of
hypoglycaemia. Which statement if made by the parents would
indicate an understanding of the teaching?
a. It is important to decrease the amount of long-acting
insulin.
b. It is important for the child to rest in bed until the
symptoms subside.
c. It is important to increase activity prior to insulin
administration.
d. It is important for the child to eat 4-6 lifesavers
candies or drink orange juice.
165. A urinalysis has been obtained on a client who has been
complaining of dysuria, urinary frequency, and discomfort in the
suprapubic area. After evaluating the results, the nurse should
order a repeat urinalysis based on which of the following
findings?
a. Negative glucose
b. RBCspresent
c. No WBCs or RBCs reported
d. Specific gravity 1.018
166. The client is to have EMG. Which of the following is the correct
instruction?
a. Ask the client for allergies to seafoods
b. Tell the patient that he may experience discomfort
because of the needles to be used
c. Put the patient on NPO 6-8 hours
d. Ask the patient to empty the bladder
167. Indicated use of magnesium sulphate in pregnancy is:
a. To prohibit preterm labor
b. Both prohibit preterm labor and prevent seizure
c. To trigger breast milk letdown
d. To prevent seizures
168. The nurse is caring for a client with perforated bowel secondary
to bowel obstruction. At the time the diagnosis is made, which of
the following should be a priority in the nursing are plan?
a. Maintain the client in a supine position
b. Notify the clients next of kin
c. Prepare the client for emergency surgery
d. Remove the nasogastric tube
169. Which action would be the first priority when caring for a client
in anaphylaxis?
a. Administer an antibiotic
b. Administering oxygen via face mask
c. Obtaining vascular access
d. Preventing future antigen exposure
170. The home health nurse is performing a follow-up visit for a 76-
year-old man receiving isoniazid (INH) 200 mg every day for 6
months. The nurse would be most concerned if the client made
which of the following statements?
a. I have blurred vision at times.
b. My legs and knees hurt.
c. My hands and feet tingle.
d. I think I had a migraine yesterday.
171. The nurse is obtaining a history on a client just admitted to the
unit. The client informs the nurse that any information shared
with the nurse during the interview is to remain confidential.
Which of the following responses by the nurse is best?
a. Ill share any information you give me with staff
members only.
b. If the information you share is important to your care,
Ill need to share it with the staff.
c. We can keep the information just between the two of
us.
d. I have an obligation to maintain nurse/patient
confidentiality about anything you tell me.
172. After abdominal surgery, a client is admitted from the recovery
room with intravenous fluid infusing at 100cc/hr. One hour later,
the nurse finds the clamp wide open and notes that the client has
received 850cc. The nurse would be most concerned by which of
the following?
a. A CVP reading of 12 and bradycardia
b. Tachycardia and hypotension
c. Dyspnea and oliguria
d. Rales and tachycardia
173. What is the cause of blindness due to diabetic retinopathy?
a. Haemorrhage
b. Tiny lesions in the tear ducts
c. Acidosis
d. Scar tissue
174. A staff member informs the nurse that his six-year-old child has
head lice. It is most important for the nurse to take which of the
following actions?
a. Inspects the staff members head for louse and nits
b. Inform the staff member that he cannot care for clients
until further notice
c. Request that the staff member contact the physician
d. Instruct the staff member about how to use Kwell
175. To help prevent polypharmacy interactions in a client who is
taking multiple prescriptions, what instruction would the nurse
give to the client?
a. Use a dispensing system as a reminder to take
medications on a schedule
b. Inform a family member of the names and uses of all
medications
c. Bring all medications, including supplements and herbal
remedies to the doctors appointment
d. Abstain from taking any over-the-counter medications
in addition to the medication you are already taking
176. A 7-year-old client is scheduled for a cardiac catheterization.
Which priority nursing assessment finding to report to the
physician?
a. The child has an allergic reaction of hives to shellfish
b. The child insists on taking a stuffed teddy bear to the
procedure
c. The child has cool lower extremities with brisk capillary
refill bilaterally
d. The child has diminished palpable pedal pulses
bilaterally
177. A 6-month-old infant has returned to the unit from surgery. Which
assessment finding would indicate that the infant was
experiencing pain?
a. The child cries steadily and kicks
b. The child points to the area producing the pain
c. The child has a rating of 6 on the Faces Pain Rating
Scale
d. The child sleeps soundly, with an increased pulse rate
and decreased blood pressure
178. Which of the following would the nurse see first?
a. Psychotic patient with delusion
b. Severe depression with suicide ideation
c. Patient with anxiety who is agitated
d. Patient with bipolar manic phase
179. A client presents with hypoparathyroidism. Which assessments
will the nurse make with this client?
a. Nephrolithiasis
b. Serum calcium level of 6.8 mg/dL
c. Positive Chvosteks sign
d. Serum phosphorus level of 5.2mg/dL
180. In which situation is the patient most likely to experience
anticipatory grieving?
a. The patient experiences traumatic amputation of an
extremity in an industrial accident
b. A patient is brought into the Emergency Room and
declared brain dead
 c. After diagnostic testing, a patient is diagnosed with
metastatic liver cancer
d. A patient finds out that her symptoms were from an
ectopic pregnancy
181. A nurse notices ventricular tachycardia on the cardiac monitor at
the nurses station and goes to the clients room. What is the first
action the nurse should take in assisting this client?
a. Start cardiopulmonary resuscitation
b. Check the patients airway
c. Establish unresponsiveness
d. Alert the physician on call
182. The clinic nurse observes that a ten-year-old child with leukemia
has a large bum on her arm and the bum appears to be oily. The
client states that she touched a hot pan and her mother put
cooking fat on it so it would not blister. The nurse should:
a. Document the findings in the chart
b. Call the physician immediately to report the injury
c. Teach the client that oil holds germs and makes
infection more likely
d. Wash the burn with soap and water to remove the oil
183. The nurse is caring for a client postoperatively following removal
of a pituitary tumor. Which observation would alert the nurse to
the possible development of diabetes insipidus (DI)?
a. Weight gain
b. Peripheral edema
c. Urinary output of greater than 200mL/hr
d. Serum sodium of 150 mEq/L
184. The nurse is making a home visit for a client with an abdominal
wound. When irrigating the draining wound with a sterile saline
solution, which of the following sequences would be most
appropriate for the nurse to follow?
a. Pour the solution, wash hands and remove the soiled
dressing
b. Wash hands, prepare the sterile field and remove soiled
dressing
c. Prepare the sterile field, put on sterile gloves, and
remove the soiled dressing
d. Remove the soiled dressing, flush the wound and wash
hands
185. A client underwent a cerebral angiogram through the right
femoral site. Which post-procedural nursing assessments would
justify calling the physician? (SATA)
a. Equal, bilateral radial pulse
b. Bilateral pink, warm toes
c. Blood pressure of 88/52 mmHg
d. Pulse 122
e. Right pedal pulse weaker than left pedal pulse
f. Respiration 22
g. Intact dressing that needs reinforcement due to bloody
drainage
186. Which factor may contribute to the development of
osteoarthritis? SATA
a. Excessive use of alcohol
b. 20 to 20 years of age
c. Obesity
d. Caucasian or Asian ethnicity
e. Regular strenuous exercise
f. Family history of osteoarthritis
187. An adult client is brought into the Emergency Deparment in
cardiac arrest. Cardiopulmonary resuscitation (CPR) is being
performed. Name the area where the pulse should be checked.
a. Ulnar or radial pulse
b. Dorsalispedis pulse
c. Brachial pulse
d. Carotid pulse
188. A client has a nasogastric tube in place after extensive abdominal
surgery. The client complains of nausea. His abdomen is
distended and there are no bowel sounds. The first nursing action
should be to:
a. Administer the PRN pain medication and an antiemetic
b. Irrigate the nasogastric tube with normal saline
c. Determine if the nasogastric tube is patent and draining
d. Check the placement of the nasogastric tube by
auscultation
189. Which emergency medication should the nurse initially administer
to a client in pulseless electrical activity?
a. Lidocaine 4mg/min IV infusion
b. Atropine 1.0mg IV push
c. Epinephrine 1.0mg IV push
d. Amiodarone 400 mg IV push
190. The nurse knows which of the following would have the greatest
impact on an elderly clients ability to complete activities of
daily living (ADLs)?
a. Perseveration
b. Aphasia
c. Mnemonic disturbance
d. Apraxia
191. The nurse is administering furosemide (Lasix) to a patient who
has edema associated with congestive heart failure. What is the
most appropriate parameter for the nurse to monitor regarding
effectiveness of this drug?
a. Urine specific gravity
b. Serum potassium level
c. Daily weight
d. Abdominal girth measurement
192. A 30-year-old woman is admitted to the hospital with dry mucous
membranes and decreased skin turgor, the womans vital signs
are BP 120/70, temperature 101F (38.3C), pulse 88, respirations
14. Laboratory tests indicate the serum sodium is 150 mEq/L and
Hct is 48%. The nurse expect the physician to order which of the
following IV fluids?
a. D5NSS
b. 0.45% NaCl
c. 0.9% NaCl
d. Lactated Ringers
193. Which of the following condition are associated with impaired
glucose tolerance (IGT)?
a. Hypoglycaemia and prostatitis
b. Obesity and hypotension
c. Obesity and syndrome X
d. Hypotension and hyperlipidemia
194. You are teaching a patient who is newly diagnosed with diabetes,
how to choose healthy snacks. Of the following foods, which is
the best choice for your patient?
a. Chocolate chip cookies with nuts
b. Ice cream
c. Buttered popcorn
d. Baked chips and salsa
195. The clinic nurse is obtaining a throat culture from a client with
pharyngitis. It is most important for the nurse to do which of the
following?
a. Quickly rub a cotton swab over both tonsillar areas and
the posterior pharynx
b. Obtain a sputum container for the client to use
c. Irrigate with warm saline and then swab the pharynx
d. Hyperextend the clients head and neck for the
procedure
196. Which measures should the nursing care of a client with
hypothyroidism include?
a. Planning frequent rest periods
b. Providing cool environment
c. Encouraging the use of heating pad
d. Provide a low-calorie, high-protein diet
197. The nurse is drawing up a vitamin K injection for a newborn.
What should the dose be?
a. 1-2 mg
b. 0.5-1 mg
c. 10-50 mg
d. 12 mL
198. Which statement by a nurse in response to a patient would be an
example of a reflective question or comment?
a. How do you feel when you take the medication?
b. Tell me what occurred first- did your symptoms occur
before or after you took the medication?
c. What time do you take your medication?
d. Youve been upset about your blood pressure.
199. A patient undergoing hip replacement surgery who is at risk for
the development of deep vein thrombosis is receiving dalteparin
(Fragmin). Which statement correctly describes the
administration technique for the medication?
a. Use an 18-guage, 1 inch needle to administer the
drug
b. Inject the medication into the muscle within 2 inches
of the umbilicus
c. Aspirate prior to administering the medication
d. Administer the medication by subcutaneous route
200. The nurse is caring for patients in an acute renal care facility.
The nurse would identify which of the following patients as a
likely candidate for developing acute renal failure?
a. A young female with recent ileostomy due to ulcerative
colitis
b. A middle-aged male with elevated temperature and
chronic pancreatitis
c. A teenager in hypovolemic shock following a crushing
injury to the chest
d. Child with compound fracture on the right femur and
massive laceration of the left arm

ANSWER
1. C. Compulsive behavior is an unconscious attempt to control
and/or relieve the tension and anxiety the client is experiencing
It is not a manipulation on the clients part. Client is not subject
to depression but to high levels of anxiety.
2. D. Infant suckling cause the posterior pituitary to release
oxytocin, which is a hormone that contracts the uterus.
3. A. Options B&D are symptoms of hyperthyroidism. Option C are
symptoms of hypothyroidism (myxedema).
4. B. ECG changes can indicate potentially lethal arrhythmias such
as ventricular fibrillation, which can occur in hyperkalemia.
5. A. Graves disease results from an increased production of
thyroid hormone. It is state of hypermetabolism. The increased
metabolic rate generates heat and produces tachycardia and fine
muscle tremors. Patients are encourage to have frequent rest
periods, and are advised to avoid strenuous physical activity.
Management include the use of antithyroid drugs
(propylthiouracil or Tapazole), radioactive iodine, or surgical
removal of a portion of the gland.
6. C. Early signs of lithium toxicity are Fine tremors, nausea,
vomiting, diarrhea. Late signs include Ataxia, confusion, seizures
7. A, D, E, F. The presence of frankly bloody emesis (hematemesis)
suggests moderate to severe bleeding that may be ongoing,
whereas coffee-ground emesis suggests more limited bleeding.
Melena may be seen with variable degrees of blood loss, being
seen with as little as 50 mL of blood. Hematochezia (red or
maroon blood in the stool) is usually due to lower GI bleeding.
However, it can occur with massive upper GI bleeding, which is
typically associated with orthostatic hypotension.
8. B.
9. B. Consolidation will result in diminished breath sounds over the
lobes involved. Wheezing results from constricted airways such as
in asthma. Bronchovesicular breath sounds are normal lung
sound. Hyperresonance results from percussing an excessively air-
filled lung or pleural space.
10. C. Atropine has a vagolytic effect as well as blocks muscarinic
responses and has selective depression of central nervous system.
Benadryl is an H-1 receptor antagonist and antihistamine with
anticholinergic activity and does not protect against vagal
bradycardia. Adrenalin is a catecholamine that constricts
bronchioles and inhibits histamine release, and Prozac is a
antidepressant.
11. D.
12. C. The suicide of her son puts this patient at high risk of suicide.
This risk is exacerbated by the betrayal of her husband and best
friend.
13. C. *
14. C. Notify the if there is arm or hand numbness, coldness,
tingling, swelling, or pain
15. C.
16. A. Four main methods of treatment exist for a patient with
Pagets disease, pharmacological therapy using either
bisphosphonates or calcitonin; pain management using
analgesics; surgery; and non-pharmacological therapy (focusing
mainly on physical therapy as a means of improving muscle
strength to help control some types of pain).
17. C. Fine macular rash during ciprofloxacin administration indicates
hypersensitivity reaction, should stop medication and notify the
physician. Option A does not warrants an immediate concern.
Option B, PTT is within normal limits, should give medication.
Option D, should decrease rate to prevent irritation of the vein.
18. A.
19. A. Condition is often called spastic bowel disease. Options B & C
refer to inflammatory bowel disease such as ulcerative colitis or
Crohn's disease. Bloody stools do not occur.
20. D, E. Clots or fresh blood in the nose or throat, frequent
swallowing, clearing of the throat, and vomiting of dark blood are
indications of possible bleeding. Check the back of the patient's
throat with a flashlight for trickling of blood. Decreased BP,
tachycardia, pallor, and restlessness are hallmark signs of
hemorrhage and should be reported to the surgeon immediately.
21. C. Carvedilol is a nonselective beta-adrenergic antagonist that
blocks the action of beta1 receptors in the heart and the action of
beta2 receptors in the lung, smooth and skeletal muscles.
Blocking the beta1 receptor leads to deacreased heart rate,
contractility and velocity of impulse conduction in the
atrioventricular node. Beta2 receptors blockade can result in
bronchoconstriction and inhibition of glycogenolysis. Because of
this drugs effect on the heart, the nurse should assess the
patients current pulse and blood pressure before administering
carvedilol. The prescriber should be contacted if bradycardia or
hypotension is identified prior to administration of the drug.
Carvedilol is administered orally.
22. B. First signs of acute rejection are usually a rash, burning, and
redness of the skin on the palms and soles. This can spread over
the entire body. Other symptoms include nausea, vomiting,
stomach cramps, diarrhea (watery and sometimes bloody), loss of
appetite, yellowing of the skin and eyes (jaundice), abdominal
(belly) pain, weight loss.
23. A.
24. D. Muscles are generally strongest in the morning, and activities
involving muscle activity should be scheduled then. There is no
decrease in sensation with MG, and muscle atrophy does not
occur because muscles are used during part of the day.
25. B.
26. B. Magnesium sulfate is a central bervous system depressant and
relaxes smooth muscles. Adverse effects include flushing,
depressed respirations, depressed deep tendon reflexes,
hypotension, extreme muscle weakness, decreased urinary
output, pulmonary edema and elevated serum magnesium levels.
27. B. Stress ulcers or Curling's ulcers are acute ulcerations of the
stomach or duodenum that form following the burn injury.
28. C. Olanzapine (Zyprexa) is an atypical antipsychotic drug given to
patients with schizophrenia. Key treatments for obsessive-
compulsive are benzodiazepines and SSRIs. Fluoxetine (Prozac)
and other SSRIs are given to patients with bulimia nervosa.
Seroquel is an atypical antipsychotic. Buspar is an anxiolytic
drug.
29. B. Raynauds disease is characterized by attacks of vasospasms in
the small arteries and arterioles of the fingers and sometimes the
toes. The disease primarily affects young women and can be
triggered by exposure to cold.
30. D. Utilization of an MDI requires coordination between activation
and inspiration; deep breaths to ensure that medication is
distributed into the lungs, holding the breath for 10 seconds or as
long as possible to disperse the medication into the lungs,
shaking up the medication in the MDI before use, and a sufficient
amount of time between puffs to provide an adequate amount of
inhalation medication.
31. C.
32. B.
33. C.
34. B. The pathology behind PIH is a fluid shift that occurs from the
vasculature to the tissues, which causes edema and leads to an
increase in hematocrit.
35. A.
36. C.
37. A. SIADH is a condition in which the client has excessive levels of
antidiuretic hormone (ADH) and cant excrete the diluted urine.
Therefore, the client retains fluids. This disorder causes a
dilutional hyponatremia.
38. A.
39. A, C, E. An endoscopic retrograde cholangiopancreatography is
anendoscopic test that provides radiographic visualization of the
bile and pancreatic ducts. Postprocedural care after the ERCP
include monitoring the vital signs and maintaining an NPO status
until the gag reflex returns. The client probably received
sedating medication before the procedure; consequently,
lethargy is expected. A local anesthetic is sprayed into the
clients throat, so it is possible that the gag and cough reflexes
will not be present. The client should be monitored for signs of
cholangitis and perforation, which include fever, abdominal pain
(especially in the RUQ), hypotension and tachycardia.
40. D. Ibandronate (Boniva) is a bisphosphonate drug. In giving such
drugs the nurse should instruct the client to swallow the whole
tablet, it should not be chewed. It should be taken in the
morning on an empty stomach with large glass of water (6-8oz)
and wait at last 30 minutes before eating or lying down. Make
sure the client has adequate intake of Vitamin D. Instruct the
client to report any signs and symptoms of gastric reflex or pain.
41. B.
42. C. The airway is compromised by the bleeding in the esophagus
and aspiration easily occurs.
43. A. Dye is injected into subarachnoid space before an x-ray of
spinal cord and vertebral column to assist in identifying spinal
lesions; if client is allergic to dye, there is a major safety issue. It
is important that client drink extra fluids AFTER the test to
replace CSF lost during test and to flush out the dye. Option C is
appropriate for MRI.
44. D. Client is under constant observation; must not be left alone
for any reason
45. C.
46. C. Stridor on exhalation is a hallmark of respiratory distress,
usually caused by obstruction resulting from edema. One
emergency measure is to remove the surgical clips to relieve the
pressure. In some settings, this may be a nursing action; in other
settings, this is a physician function. Emergency intubation also
may be necessary.
47. A.
48. B. Option A & D, reveals normal values: BUN 718 mg/dL;
creatine 0.61.2 mg/dL; AST (formerly SGOT) 820 U/L, ALT
(formerly SGPT) 820 U/L, bilirubin 0.11.0 mg/dL . Amphotericin
B causes renal and liver toxicity. Check liver and renal function
studies weekly, notify the physician if elevated. Option C are not
side effects of the medication.
49. B.
50. D.
51. A, C, F.
52. A. Robust means strong and healthy. Pulse pressure of 40 is
normal. All other options reveal abnormal assessment.
53. C, E, F.
54. C. This patient has experienced a loss (job) that is contributing to
his feelings of uselessness to his family. The diagnosis of
situational low self-esteem is the most appropriate diagnosis for
this patient. The North American Nursing Diagnosis Association
(NANDA) definition for the nursing diagnosis is the development
of a negative perception of self-worth in response to a current
situation.
55. B. Antipyretics relieve the combination of side effects. Ice bag is
dangerous to both skin integrity and overall temperature control.
Option D is unnecessary unless indicated for another reason.
56. D. Cushing's triad is systolic hypertension with a widening pulse
pressure, bradycardia with a full and bounding pulse, and slowed
respirations. The rise in blood pressure is an attempt to maintain
cerebral perfusion, and it is a neurologic emergency because
decompensation is imminent.
57. C. Several strains of the human papillomavirus (HPV) are
associated with cervical cancer. Antibiotics are not used for viral
infections. Douches will not prevent recurrence of the disease.
Tampons would not be a problem as in toxic shock syndrome.
58. B.
59. B.
60. B. Environments with increased numbers of children (day care)
more likely to promote infections due to close living conditions
and increased likelihood of disease transmission. Option A & D do
not pose a problem or solution regarding gastroenteritis.
Neighbourhood is a possible source of infection, but not as likely
as a day care center.
61. A.
62. B. Position of the trachea should be evaluated; with a tracheal
shift, an increase in pressure could occur on the operative side
and could cause pressure against the mediastinal area. On the
surgical side, breath sounds will be absent. Sputum is important
to observe but not as high a priority. Pulse pressure does not
relate to the situation
63.
64. A.
65. D.
66. C.
67. D.
68. A. Potassium chloride must be diluted and administered at a rate
no faster than 20mEq/hr
69. C. Nitroglycerin patch should be removed before the test.
Dentures are removed removed before the test. Option B, results
are within normal limits. It is unnecessary check capillary refill.
70. A. Delusion of perseceution is a strongly held belief that is not
validated bu reality, for example, the idea that his brother is
trying to steal his property is not validated by reality. Delusion of
reference is a false belief that public events or people are
directly related to the individual.
71. C.
72. A.
73. C. During a sickle cell crisis, increasing the transport and
availability of oxygen to the body's tissues is paramount.
Administering a high volume of intravenous fluid and electrolytes
to help compensate for the acidosis resulting from hypoxemia
associated with sickle cell crisis is one way to accomplish this.
Fluid administration also helps overcome dehydration, a possible
predisposing factor common in clients with sickle cell crisis.
74. D.
75. C.
76. B. Extrapyramidal reactions include movement disorders such as
dystonia, tardive dyskinesia, and pseudoparkinsonism.
77. A.
78. A.
79. D.
80. D.
81. B.
82. A. ECG monitoring of acute coronary syndrome: features that
increase the likelihood of infarction are: new ST-segment
elevation; new Q waves; any ST-segment elevation; new
conduction defect. Other features of ischaemia are ST-segment
depression and T-wave inversion.
83. A.
84. A.
85. B.
86. B.
87. D.
88. D. The patient is at risk for lymphedema and infection if blood
pressures or venipuncture are done on the right arm. The patient
is taught to use the PCA as needed for pain control rather than at
a set time. The nurse allows the patient to examine the incision
and participate in care when the patient feels ready. Permanent
breast prostheses are usually obtained about 6 weeks after
surgery.
89. C.
90. A. After a total hip replacement, it is important to maintain the
hip in a state of abduction to prevent dislocation of the
prosthesis. Use of an abduction pillow or splint will not prevent
the formation of sacral pressure ulcers. An abduction pillow may
also be used to keep the legs shoulder width apart and to prevent
rotation of the hips, and avoid crossing the leg beyond the
midline of the body (e.g. not crossing the leg over the other leg).
91. A. Among the 4 women, the least stable patient is the patient
experiencing unilateral dull abdominal pain. The pregnant woman
needs to be evaluated immediately for ectopic pregnancy. Option
B is expected during first trimester of pregnancy. Option C is
symptomatic of threatened abortion, should be instructed to
decrease activity. Option D symptoms suggest of spontaneous
abortion and should be instruct client to pads. Ectopic pregnancy
needs more emergent intervention as compared to abortion.
92. C. Instillation of erythromycin into the neonates eyes provides
prophylaxis for opyhalmia neonatorum or neonatal blindness
caused by gonorrhoea in the mother. Erythromycin is also
eefctive in the prevention of infection and conjunctivitis from
Chlamydia trachomatis. The medication may result in redness of
the neonates eyes, but this redness will eventually disappear.
Erythromycin ointment is not effective in treating neonatal
chorioretinitis from cytomegalovirus. No effective treatment is
available for a mother with cytomegalovirus.
93. B.
94. D. EKG changes in hyperkalemia: Peaked T waves; Widened QRS
complexes; prolonged PR intervals; Flat P waves
95. B.
96. B.
97. C.
98. D. The temperature range during which the basal metabolic rate
of the baby is at a minimum, oxygen utilization is least and baby
thrives well is known as 'Thermo- neutral range of temperature'
or 'Neutral Thermal Environment'. For each baby, this range of
temperature varies depending on gestational age.
99. A. first dose of the DPT may be given at two months, the second
is given around four months. MMR is given at 15 months. Polio is
given at two and four months and again at 12 to 18 months.
Smallpox vaccine is no longer recommended.
100. D. Diagnosis of rheumatic fever is based on the Jones criteria and
positive laboratoty tests for: Increased erythrocyte sedimentation
rate; positive C-reactive protein; positive antistreptolysin-O titer;
positive throat culture for group A beta haemolytic streptococci;
prolonged PR and QT intervals, revealed by ECG.
101. B. The absence of spontaneous cough and presence of drooling
and agitation are cardinal signs distinctive of epiglottitis.
102. B. Hallmark of aseptic technique is handwashing. Client should
use only the prescribed medications on the wound.
103. D.
104. B. Take the drug with food or after meals if GI upset occurs. Do
not cut, crush, or chew sustained-release products. Report
ringing in the ears; dizziness, confusion; abdominal pain; rapid or
difficult breathing; nausea, vomiting, bloody stools, easy
bruising, gum bleeding (related to aspirins effects on blood
clotting).
105. B. Fontanelle should feel soft and flat; fullness or bulging
indicates increased intracranial pressure. Umbilical cord falls off
within 1 to 2 weeks; no tub baths until the cord falls off. Normal
healing of cirucmcision, don't remove exudate; clean with warm
water. motor reflex is normal; disappears after 3 to 4 months.
106. D.
107. C. Principles for radiation therapy are time, distance, shielding;
nurse should decrease the time spent in close proximity to the
client. All visitors are restricted with regard to the distance they
should be from the client. Appropriate shielding (lead aprons) is
to be used when the nurse has to spend any length of time at a
close distance, not just for routine care.
108. C.
109. C. Nystatin is given for candida infections such as oral thrush. A
common side effect is diarrhea.
110. B.
111. A. Signs and symptoms of abdominal aortic aneurysm include:
diminished femoral pulses, lower back and abdominal pain,
pulsatile abdominal mass, bruit over site, BP difference between
extremities, peripheral ischemia.
112. D. Patient is at risk for peritonitis, and should be assessed for
further symptoms of infection. Option A reveals small amount of
bleeding and does not indicate acute bleeding. Option B suggests
expected outcome. Option C indicates resolution.
113. A. Ostomy bags should be changed at least once a week or when
seal arpunf stoma is loose or leaking; during change of bag isa
good time for stoma and skin to be closely inspected. Client
should be encouraged to participate and should foster
independence.
114. A.
115. A.
116. A. Patient has not lost civil right to use phone. Patient is able to
use phone unless otherwise indicated by court order or
physicians order.
117. D. Garlic, a lipid lowering-agent, increase bleeding potential with
aspirin, NSAIDs and warfarin.
118. D. A goal when caring for patients with spinal cord injuries is to
promote their adjustment to the injury and their independence.
A patient who is using modified feeding utensils at every meal is
demonstrating an attempt at independence for the functional
activity of eating. The patient's statement recognizes that the
activity is one that requires continued work, but progress is being
made toward the goal of developing as much independence as
possible with eating.
119. C. Other options suggest exacerbation of the disease.
120. A.
121. D. Water should not be allowed to stand in containers, such as
respiratory or suction equipment because this could act as a
culture medium.
122. A. Neurogenic shock is characterized by areflexia. In neurogenic
shock, vasodilation occurs as a result of a loss of balance
between parasympathetic and sympathetic stimualtaion. The
patient experiences a predominant parasympathetic
stimulationthat causes vasodilation lasting for an extended
period. It is manifested by hypotension, due to a reduction in
systemic vascular resistance and venous return; warm, dry skin;
bradycardia, due to dominance of the parasympathetic system
 (vagus nerve); flaccid paralysis, including bowel and bladder;
hypothermia, due to vasodilation.
123. C.
124. B. By administering Librium, you will prevent delirium tremens
that can possibly harm during the process.
125. A, D, E, F.
126. A. Open Kaposis sarcoma lesions should be cleaned and dressed
daily to prevent secondary infection. Warm tub bath is not done
because of risk of secondary skin infection. It is important to
keep the skin clean to prevent secondary skin infection but
should be covered due to open areas. Diluted povidone-iodine is
the treatment for herpes simplex virus abscess, not Kaposis
sarcoma.
127. C. Assessment of the dressing should be checked on admission to
the room and frequently for the next several hours. Option A is an
Implementation, complete assessment first. Option B is an
assessment but determine what is happening to the patient now.
Option D is an inappropriate assessment, it is too soon for
infection to occur secondary to surgery.
128. C. Polio vaccine contains live virus and should not be given to
children who are immunocompromised.
129. A. Unsteady gait, slurred speech, nausea, vomiting, diarrhea,
thirst, and coarsening of hand tremors indicate lithium toxicity.
130. D. Hypertensive crisis, an adverse effect of this medication, is
characterized by hypertension, frontally radiating occipital
headache, neck stiffness and soreness, nausea, vomiting,
sweating, fever and chills, clammy skin, dilated pupils, and
palpitations. Tachycardia, bradycardia, and constricting chest
pain may also be present. The client is taught to be alert to any
occipital headache radiating frontally and neck stiffness or
soreness, which could be the first signs of a hypertensive crisis.
Hypertensive crisis is treated with (Nifedipine) Procardia.
131. D.
132. A. Tracheostomy set is the most important for the client's safety
due to risk for laryngospasm.
133. B.
134. D.
135. C. Extrapyramidal side effects resulting from this medication
include akathisia (motor restlessness), dystonias (protrusion of
tongue, abnormal posturing), pseudoparkinsonism (tremors,
rigidity), and dyskinesia (stiff neck, difficulty swallowing). The
dosage may need to be decreased because of side effect of
medication; antiparkinsonian drug such as Cogentin may be
ordered. Option B is not accurat, Thorazine is an antipsychotic
medication.
136. D.
137. B. You should not cut extended-release tablets in half.
138. A. The patient may be experiencing hypocalcemia.
139. A, C, D, E.
140. C.
141. B. Postural hypotension can be a result of dizziness owing to the
use of low-potency antipsychotics such as chlorpromazine or
thioridazine.
142. A,B,C,E. Hemolytic Reaction is a type of complication of blood
transfusion is caused by infusion of incompatible blood products.
Assessment include Low back pain (first sign). This is due to
inflammatory response of the kidneys to incompatible blood;
Chills; Feeling of fullness; Tachycardia; Flushing; Tachypnea;
Hypotension; Bleeding; Vascular collapse; Acute renal failure.
143. D. Droplet precautions used for organisms that can be
transmitted by face-to-face contact, door may remain open.
Option A&B require contact precautions with no mask. Option C
requires standard precautions.
144. C. Naloxone is a narcotic antagonist that can reverse the effects,
both adverse and therapeutic, of opioid narcotic analgesics.
Morphine is an opioid narcotic analgesic that can depress
respiration.
145. B.
146. A. To implement a behavior modification plan successfully,
all staff members need to be included in program development,
and time must be allowed for discussion of concerns from each
nursing staff member; consistency and follow-through is
important to prevent or diminish the level of manipulation by the
staff or client during implementation of this program.
147. A.
148. B
149. C.
150. C. Alteplase is a tissue plasminogen activator which induce
fibrinolysis that causes bleeding.
151. A. Lamotrigine, marketed in the US and most of Europe as
Lamictal by GlaxoSmithKline, is an anticonvulsant drug used in
the treatment of epilepsy and bipolar disorder. It is also used off-
label as an adjunct in treating depression. For epilepsy, it is used
to treat focal seizures, primary and secondary tonic-clonic
seizures, and seizures associated with Lennox-Gastautsyndrome.
152. C. Support groups of people who have suffered similar acts of
violence can be helpful and supportive to teach clients how to
deal with the traumatizing situation and the emotional
aftermath. Other options are reasonable recommendations to
begin using in a systematic desensitization program after the
crisis is alleviated.
153. C. Vitamin K food sources are green leafy vegetables, cauliflower
and cabbage.
154. C. The nurse must immediately call and report the suspected
abuse. Failure to report abuse is a misdemeanor.
155. C.
156. D. Milking forces interstitial fluid to mix with capillary blood and
dilutes the blood. Dangling helps facilitates venous congestion.
Sticking on the side is less painful that the center of the
fingertip. Blood should sit on the strip like a raindrop, smearing
alters the reading.
157. C. Use the least restrictive interventions in ascending order.
158. D. Acute phase of burn injury occurs from beginning of diuresis to
the near completion of wound closure Characterized by fluid shift
from interstitial to intravascular. Urinary output of less than
30ml/hr should reported to the physician.
159. C. 1 milligram = 1000 mcg
160. B. In HHNS, CNS depression, disorientation or mental confusion,
seizures, and coma are caused by intracellular dehydration and
hyperosmolarity. CNS dysfunction worsens as serum osmolarity
rises.
161. C. Applying lip balm or handling contact lenses is prohibited in
work areas where exposure to bloodborne pathogens may occur.
Option A demonstrates appropriate procedure, prevents airborne
contamination. Insulin is the only medication that can be given,
compatible with TPN. Use airborne precautions for TB, private
room with negative air pressure, minimum of six exchanges per
hour.
162. B.
163. B. Anhedoniathe loss of interest and pleasure in activitiesis a
sign of depression.
164. D. Narcotics are most often used intravenously
165. D. Candy or another simple sugar is carried and used to treat
mild hypoglycemia episodes.
166. C. With the clients complaints, WBCs and RBCs should be
present; WBCs are a response to the inflammation process and
irritation of the urethra; RBCs are increased when bladder
mucosa is irritated and bleeding. Glucose increases during the
inflammation process; it is not a primary component in
determining urinary tract infections.
167. A.
(B.) Electromyography (EMG) assesses electrical activity
associated with nerves and skeletal muscles. Needle electrodes
are inserted to detect muscle and peripheral nerve disease. You
should inform the patient that pain and discomfort are associated
with insertion of needles. There is no risk of electric shock with
this procedure.
168. B. Magnesium Sulfate is used to reduce preterm labor
contractions and prevent seizures in Pre-Eclampsia
169. C.
170. B.
171. C. Isoniazid/INH can causes peripheral neuritis. Vit
B6/Pyridoxine is given.
172. B. The nurse is obligated to share client information with
personnel directly involved with the clients care. The nurse must
never agree to keep information confidential without knowing
the content of the information. The nurse is not obligated to
report information that is not relevant to the clients care or
well-being.
173. D. Indicates cardiovascular fluid overload.
174. A. Diabetic retinopathy leads to development of microaneurysms
and intraretinal haemorrhage.
175. A. Observe for movement (louse) or small whitish oval specks
that adhere to the hair shaft (nits); treat with gamma-benzene
hexachloride (Kwell). Confirm the presence of lice before
excluding from duty; if lice present, exclude from patient care
until appropriate treatment has been received and shown to be
effective. Assessment should be done first. Apply Kwell shampoo
to dry hair and work into lather for 45 minutes
176. C. Polypharmacy means that multiple medications have been
prescribed.
177. A. People who have an allergy to shellfish or iodine may
experience an allergic reaction to the contrast dye.
178. A.
179. B.
180. C.
181. C. Grief can be classified as acute, anticipatory, or pathologic.
Anticipatory grief is associated with the anticipation of a death
or loss that has yet to take place. A patient who is newly
diagnosed with liver cancer is most likely to experience
anticipatory grieving when anticipating death.
182. C.
183. D. Because leukemic clients are immunosuppressed, they are
more susceptible to infections; cooking fat applied to an open
wound increases the possibility of infection; burns should be
rinsed immediately with tap water to reduce the heat in the
burn. Documentation is done later, and does not address the
immediate problem of cleansing the wound. Reporting the
physician is unnecessary unless signs of wound infection is noted.
184. C.
185. B. Handwashing should be done prior to beginning any procedure,
especially irrigating a wound. Using sterile gloves to remove the
dressing would contaminate them.
186. D,E,G.
187. C,D,F.
188. D. During CPR, the carotid artery pulse is the most accessible and
may persist when the peripheral pulses (radial and brachial) no
longer are palpable because of decreases in cardiac output and
peripheral perfusion.
189. C. Should first assess if the tube is open and draining to
determine if there is a problem with the nasogastric tube; if it is
patent and draining it does not need to be irrigated. Option A &
B, may be carried out after the patency of the tube is
determined. Patency should be checked first by aspirating
stomach contents, not by auscultation.
190. C. The mainstay of drug therapy for PEA is epinephrine 1 mg
every 35 minutes.
191. D.
192. C.
193. B. Hypotonic solution, shifts fluid into intracellular space to
correct dehydration. Hypertonic solutions are contraindicated in
dehydration. Isotonic solutios are not best with dehydration.
Lactated Ringers is an isotonic solution used to replace
electrolytes.
194. C.
195. D.
196. A. To obtain a throat culture specimen, the nurse puts on clean
gloves, then inserts the swab into the oropharynx and runs the
swab along the tonsils and areas on the pharynx that are
reddened or contain exudate. The gag reflex, active in some
clients, may be decreased by having the client sit upright if
health permits, open the mouth, extend the tongue, and say "ah,"
and by taking the specimen quickly.
197. D.
198. B.
199. D. The statement "You've been upset about your blood pressure"
is a reflective comment that describes the patient's feelings. A
reflective comment repeats what a patient has said or describes
the person's feelings. It is used by the nurse to encourage the
patient to elaborate on the topic.
200. D. Dalteparin is given by subcutaneous (under the skin) injection,
usually in the lower abdominal area.
201. C.